19 HERSEY ST - BPA-14-1765 ADD OFFICE & 2 BATHS The Commonwealth of Massachu"MrLCTIONAL SERVICES
Department of Public Safety
yU, + 61assachusetts State Building Code(780 CMR) ������h� yp��VV //���
Building Permit Application for any Building other than a One-or 4�tVb� Iti�tI n%30
t .(This Section For Official Use Onl )
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block It and Lot#for locations for which a street address is not available)
iy -rsry , Slerl A 0ay76 frt- inlsew
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration 0, 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ff�
Is an Independent Structural Engineerini;-X-eer Review ret wired? 'L Ycs ❑ / No4
Brief Description of Proposed Work: Ae'9� �i O'u� ��t�-�3 e9'nr✓I _5"W
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 CNIR 34) ❑
Existing Use Group(s): I Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)8r Area Per Floor(sq. ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-t❑ A-5❑ F B: Business ❑ E: Educational Cl
F: Facto F-1 ❑ F2❑ FL• High Hazard Ff-1❑ H-2❑ H-3 ❑ F[-4❑ H-5❑
1: Institutional 1-1 ❑ [-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ IIB ❑ 1112%, ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or in lentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: %I t I h l one C m wi .jon,l: , n I nglti<:
Not Applicable❑ Is Structure within airport approach area? Is their reviety completed?
or Consent to Build enclosed ❑ 1 Yes❑ or No❑ I Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: _Use Group(s): Type of Construction: _ Occupant Load per Floor:_
Uaoe-+s the
�building,contain an Spr inkllerrsSysste�m?: ._ Special Stipulations:.
C-f]-t. L-e-0 11 14S LA)1 LL Q U . wits-0 N I t
1
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner .-I
7-rick if (1 4d,,211W-5 /f Ile rsr-y s s4 /�a a/Y78
&-u`ie•(Mnt) JA$10 IJ.J`L'.iil No.and Street City/Town Zip
Property Owner Contact Information:
0 E * Q 0 1 V 00 $I I I
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this bU ding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control -
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor /
ar/I /ten (," Z-rva4a 7
Company Na re
2 rl,n,r x .
Name of Person Responsible for or}struction Lice No. and Type if Applicable �Q
Street Address/ City/Town�2r D �/ State Zip
�,r -9MO -t<� __ /"r c 1t.4 c h`4 cfl 0 7.�/9✓�9""O rG i't
Telephone No. business Telephone No. cell a-matriddress
SECTION 11:FVORKBIS'COMPENSAI 10N IIVSUR:\NCkS:VI'IM1.11 r M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No ❑
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE-
Item Estimated Costs: (Labor
and Materials) "Total Construction Cost(from Item 6)_$
1. Building $ z:> Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ f',O'b appropriate municipal factor)=$
3. Plumbing $ oZ .
4. Mechanical (FIVAC) $ Note: Minimum fee=$ (contact municipality)
5. i'vIechanicrl Other - 1i a e Enclose check payable to
6.Total Cost S e5 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application/Is true and acrr to to the best of my knowledge anti understanding.
lr�C 2c�/
Ple p t• n name Title Telephone No. Date
reet Address City/Town State Zip
o'ure �/ d
Municipal Inspector to fill out this section upon application approval: ' /b
Name Date
CITY OF SALEM MASSACHUSETTS
BUILDING DEPARTMENT
J' 120 WASHINGTON STREET,31D FLOOR
TEL. (978)745-9595
FAX AX(978) 740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING 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 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
G e
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signat re olf applicant
Date
CI-I-Y OF &M-EM, 2NL-1SS:ICHL;SETTS
_ BL'ILDLNG DEPARTTIEINT
120 \Y MIALVGTON STREET, Sao FLOOR
TFL (978) 745-9595
Fn.x(978) 740-98.36
KI\LBERLEY DRISCOLL
`&L-%YOR THont is ST.PIFraRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\L\IISS(ONER
liVorkers' Cmnpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbero
Applicant Information /Please Print Le Ibiy
Name lNminessOrgm,iratinm'Individual):_/T4,P-y- , if.ov 7`f'J'/tr
Address: T/ 9c kh,d(y /7/47 0/ 0
City/State/Zip: Phone N: 5pl� _!?/6)
y
T
re you an employer:'Check the appropriate box: Type of project(required):
1.It I am a employer with 4, ❑ I am a general contractor and 1 g. ❑New construction
employees(full and/or part-time)." have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7• Q Remodeling
ship and have no employees These sub-contractors have V. C] Demolition
working Yor me in any capacity. workers'comp. insurance. 9. ❑Building addition
(No workers'comp. insurance - 5. ❑ We area corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.❑ i am a homeowner doing all work right of exemption per M I 1 I.[] Plumbing repairs or additions
myself.(No workers'comp. C. 152, §I(4),and we have no 12.❑ Roof repairs
insurance required) t employees. (No workers'
comp.insurance required.) 13.Q Other
-Any applteant that e111Ykt box Of most also fill out the section belowshowing their walked compensation puliry inG,mtatlon.
'I b.muowm"who submit this nndavit indicating they am doing all wort and then hire moside comramom mint suhmit a new allldavit indicating such.
:(*....o otoo that chsck this box most anachd an addittunul shoal showing the name of the subavntncton and their woken'comp.pulley Inf°tmatien.
font an rurpluy er drat 6 pruvidlnK,vorlrers'rumptnradun hisurance jar my employees. Below/s the pol/ry and fob silo
fujunnurian. f
Insurance Contpa ny Vane: L� U-ara/ .-__-_ /C75� yYgnG
�
Policy it or Self ✓iin. Lic. if: ��/l � 6 S 7S- i2 Expiration Date: 5 8 /
Job Site Address: �y /7��s�y l�71`Y City/State/Zip: �et /� m �!r' o f F 70
:Attach a copy of the worl(cn'compensatlon pulley declaration page(showing the policy number and expiration data).
Failuru to secure coverage as required under Section 2JA arXIGL e. 152 can lead to the imposition of criminal penalties of a
line up to 51,500.00 und/or one-year imprisonmcn4 as well as civil penalties in the forth of a STOP WORK ORDER and aline
of up in 5250.00 a day against the violator. Ile advised that a copy of this statement may b: forwarded to the Ofrice of
Investigu,ions ul'the DIA for insurance coverage verification. -
l da hereby certify it Or the L I nahles u/perjury that the fnjunnullan pruvir/¢d ubuvr i-v true and corr"L
aLIL t e: Dale: //Z/D�/x
Phone,!• _,2 '
nfficlal use only. no not evrire in this area, to be completed by city or town offleiut
City ne'I'uwn: - -- -- PermidUcensep--
Lssuing Autpurity(circle one):
1. hoard of ileahh 2. Ruilding Oeparttuent J.Cityfrnen Clerk I. F.lectrieai htspecfor 5. Plumbing Inspector I
b. Other
l Contact Tenon:
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