16 HOLLY ST - BUILDING INSPECTION (3) $s 5 Oro
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Z' The Commonwealth of MjAllttsSERVICES
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Department of Public Safe
Massachusetts State'Building Cudet� ) pj� ee
Building Permit Application for any Building other than a.O�-o!fwAinty2livelling
_(This Section For Official Use Only)
Budding Permit Number. Date Applied: Building Official:
SECTION]:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
Ib \40114 5 t Stele .. okelt ? 0
r No.and Street City/Town Zip Code Name of Building(if applicable) _
SECTION 2 PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 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 Yes O No ❑
Brief Description of Proposed Work: r aired? �
o
2 S
SECTION 1 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 ChIR 34) O
Existing Use Group(s): - Proposed Use Group(s):
SECTION4:BUILDING HEIGHT AND AREA
.. ... - Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor.(ey,ft.). ,
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑- A-3 O A---1❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑. H-2❑ H-3 ❑ H4 O H-5❑
L• Institutional f-I D 1-2❑ 1-3❑ I4❑ M: Mercantile❑ R.- Residential R-1❑- R-2 O R-3❑ R4 O ,
S: Storage S-1 ❑ - S-2❑ U. Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable) -
IA ❑ III ❑ IIA ❑ fill O IIIA ❑ [fill ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 ChIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outsiale Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentity Znne: or on site system❑ permit is enclosed❑
Railroad rightof-wa : Hazards to Air Navigation: y:\Itistnri.Gingtiissi�m It,_,neg�_['nn,'}=.•
Nut Applicable Is Stricture within airport approach area? Is their review completed?
or Consent to Budd en lased❑ Yes❑ or Nu Yes❑ No ❑ /\
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Lo,le: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building Coneain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION "
Name and Address of Property Owner
QgrYK-Gc�( :.t5 L'—'Z .I�o
\g w( h 1 Sk' I C� 2ltie� Ok l '
Name(Print)e •e 44 " !'-`l• '"No.and Street City/Town Zip ,
Pro erty Owner Contact Inforrpetion:
5 1r s t p7L- 9 G-327 —_ J�iJ>c2r5� L?✓errwzlho
Title Telephone No.(business) Telephone No. (ced) e-mad address
If applicable,the property owner hereby authorizes
N.une Street Address City/Town State - Zip
to act on the property owners behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUC ION 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
/ /Jy - ram' LJ C'A.4)S e " `Z0__3e7n
Name(Re` trant) Telephone No e-maif address Registration umber
Street Address City/Town State Zip Discipline Expiration Date
.. 10.2 General Contractor - -
Company Name
:05"CCW_' 0s/l3s
Name of Person Responsible for Construction License No. and Type if Applicable
2\ed Vrtn��.r GA&2UL -L ice. _
Street Address City/Town State Sip
7PI-!O ldD/ / - �0327 ��1<[���15GLc�✓e1iZe✓,�2d
Telephone No. business Telephone No. cell e-mail address
SECTION 11:FVORKFR.S'COAIPENSA IION INSURANCE AFFID, V11 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 budding permit.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
I. Budding $ Building Permit Fee-Total Construction Cost x—(insert here
2.Electrical $ - appropriate municipal factor)_$
3. Plumbing $
d.btechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
S. Mechanical Other - $ Enclose chk aY able to
p'
6.Total Cost $ �� (contact mueenicipality)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 accurate to the best of my knowledge and understanding.
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P17print an tgn name Title Telephone No. Date
ZI�� ��nZ T ✓ &k�L � ng
Street Address % City/Town State Zip ?
Municipal Inspector to fill out this section upon application approvak �' ✓/�
014�-
Name Date
µ CITY OF SALE4 MASSACHUSEM
j BUILDING DEPARTMENT
120 WASH NGTONSTREET,3'm FLOOR
TEL.(978)745-9595
FAX(978)740-9W
gIIvIBERLEYDRISO)LL
MAYOR THOMAS STYIERRE
DIRECTOR OF PUBLICPROPERTY/BLuDING 00MMISSI0NER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
I
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:
(name of hauler)
I
The debris will be disposed of in:
;
Lti
(na a of facility)
30 2
(address of facility)
Si ure f applica t
Date
I
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the Wh edition of the
Massachusetts State Building Code, 780 CMR, Section 107.6.2 .
Project Title: Holly Street Tenant Renovations Q of 4 units) Date: February 29 2016
Property Address: 16 Holly Street Salem MA
Project: Check(x)one or both as applicable: _ New construction x Existing Construction
Project description: Interior modifications to first floor right hand side unit Renovation to including new kitchen and
bathroom renovations new mechanical electrical plumbing fire alarm and sprnrkler systems.
I Craig R.Bosworth MA Registration Number: 20030 Expiration Date: August 30, 2016, am a registered
design professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning:
_ Entire Project X Architectural Structural Mechanical
Fire Protection _ Electrical _ Other:
for the above named project and that such plans, computations and specifications meet the applicable provisions of the
Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I
understand and agree that I(or my designee)shall perform the necessary professional services and be present on the
construction site on a periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents. Such review shall not diminish or
relieve the Contractor of its submittal and other responsibilities.
2. Perform the duties for registered-design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code. The Contractor shall be responsible for performing the work in accordance with
the contract documents and shall be exclusively responsible for its construction means,methods,sequences and procedure,
and for the construction safety.
4. The performance of the services shall not require any special testing or inspections unless specifically stated in the Code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official
Upon completion of the work, I shall submit to the building official a`Final Construction Control Doc
ARC
BOS�oTFc
Enter in the space to-the right a".wet'or j
electronic signature and seal: t o No. 20030 =
MARBLEHEAD,
Phone number: 781-631-4949 Email: craiongramd-ovelleco.co �o MASS.
OF N,P�
Building Official Use Only
Building Official Name: Permit No.: Date: