19 HERSEY ST - BPA-13-332 SEPARATE BAYS t�
4� The Commonwealth of Massachusetts
Department of Public Safety
�ftl VUu�� Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: . Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
j1 hersel Sf. 1, ALPtm 01CO7
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used 2111 If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ 1 Alteration Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 0�
Brief Description of Proposed Work: Seop-y ATi n.J n T to dr 11 �AV S u.l I f h (U (_I_. FL oo 2
1°-o ce IjNG ND euo to e,,:/1 u, 'T7•, com Mud 4d —.,S®, .x as
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s): 6
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 5600 ,SOO O
Total Area(sq.ft.)and Total Height(ft.) 1600 s000 od aI
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A=4❑ A-5❑ 1 B: Business E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
L Institutional l-1 ❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA Ill ❑ IIA ❑ IIB ❑ IIIA ❑ 1111313 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply. Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 0 Check if outside Flood Zone❑ Indicate municipal A trench wit r trench or specify:not be Licensed Disposal Site❑
Private❑ or inaientify Zrn,c: or on site system❑ required opermit is enclosed❑
Railroad right-of-wa Hazards to Air Navigation: T9A I Inh n._( )nun wv.....1. .i 1 i >cc s:
Not Applicable Is Structure within airport appr iach area? Is their review completed?
or Consent to Build enclosed ❑ Yes❑ or No 0 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code:_?77�, Use Group(s):_A 'TVpe of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?:11/12_Special Stipulations:
r
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Preowo.e0 Aare, ealset SA&rn O/970
Name(Print) 9NnJ'�
City/Town Zip
Property Owner Contact Information: p �.
Ta�kfaDe, >7s / OAwR2oc�f5 7- - ZGG� �A 42 �tq/
Title Telephone No.(business) Telephone No. (cell) e-mail address _
If�ap-plicable„the property owner hereby authorizes
�los-pl� horeec i,1 (e ro re S IU Aiv vt/l hnA MM2-3
TName Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not.under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
M 0 R2 ,S C_ht` Co.
Compally Name -
J C73P.rD/l Ltf mo 2Esc l„I C S - 0 5,S51I 1 C0"5. y
Name of Arson Responsible for Construction License No. and Type if Applicable
lP r00L2Sl si , Atjwi S _jar[}• 0197.3
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-W address
SECTION 11: INSUGAN(T Al 1DAVI'r M.G.L.c.152.§ Z5C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ 7,300, 00
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ 3 p p, po appropriate municipal factor)_$
3.Plumbing $ -
1. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $
n Enclose check payable to
6.Total Cost $ / 8 00, OQ I (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to thbes of my knowledge and understanding.
pp q
J o 5 �j-�/8/'[JC1 C A r i>eATfP 60 aSy6 /0'2'/2,
Please pn t a(n? ud sign name itic Tel hone No. Date
Street Address City/Town Sta Zip t`
Municipal Inspector to fill out this section upon application approval: /O
*N>h%\,YDate
i
it
CITY OF S.U.ENI, NL-�sSACHliSETTS
Bt:1LDING DEP 9RTME.NT
t Jr< 130 WASHIINGTON STREET, 3ie FLOOR
TET_ (978) 745-9595
FA.e(978) 740-9846
KINBFRT F.Y DRISCOLi
MAYORTHOMAS ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BCIIDING CON11MISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
t
Narne(Businas&orginiizatiorvindividual):_ TA-,PA) � 0 RA2.5G 1
Address: (Q 1—o2e6t 5+
City/State/Zip: 0 IN M Ut k- S 4. QJ_ga3 Phone #: q 7 8 — 3 6 0—oR SS/(o
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with 4. 0 1 am a general contractor and 1 6. ❑N w construction
ployees(full and/or part-time)." have hired the sub-contractors
2.21 am a sole proprietor or partner. listed on the attached sheet.t' 7• Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
workingfor mein an capacity. workers'comp. insurance.
Y 9. [:] Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its
officers have exercised their t0.❑ Electrical repairs or additions
required.) of
3.0 1 am a homeowner doing all work right of exemption per MGL 1 LCI Plumbing repairs or additions
myself. (No workers'comp. C. 152, q 1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. LNo workers' 13.0 Other
comp. insurance required.)
•Any applicam dmt Omki box 91 must also fill uut the soctiou blow,showing their wofku ,'compensation policy information
{I weowners who submit this a0ldnvit indicating they are doing all work and then hire oetsidebontmctoo must submit a new affidavit indicating such
:Cemraewo thug check this box must anach d an additional short showing the name of rho mb.:omtaeton and their workers'comp.policy information.
1 am an employer that Zr providing workers'compensation insurance for my employees Below is file policy and Job site
information.
Insurance Company dame: _
Policy#or Sclf-ins. Lic. 4: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA ror insurance coverage verification.
1 do hereby Gerdy lard r tird p\fains an lenuldes of perjury that r/re infuriation provided above is true and correct
.l' I Date' - 0 Z
phoned:
OfJiciul use only. Do not write in tints urea,to be completed by city or town official
City or"town: PcrmitR.lcense
Issuing Authority(circle uric):
1. Board of Health Z.Building Department 3.Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other.--- ----..._._
Contact Person: Phone#:
A
CITY OF SALEM, iNLksSACHUSETrS
BUIMIING DEPARTNMNT
p• 130 WASHLIIGTON STREET, 3P0 FLOOR
T EL (978) 745-9595
F&v.(978) 740-9846
KI\IBERLSY DRISCOLL
MAYORT'HOAIAS ST.PIERR&.
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 t 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(..JAAe dY&lu44P Me.N�71
(narffe of hauler)
The debris will be disposed of in
_ 0 m
(name of facility)
(address of racility)
siliiiriture of permit applicant
/D — _:9-012�
date