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62 JEFFERSON AVE - BUILDING INSPECTION (7) The Commonwealth of Massachusetts (t' Department of Public Safety 1�11Q 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 street address is not available) 'a No. eye, APWL o oa rs 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❑ I Alteration W' I Addition❑ 1 Demolition Cl (Please fill out and submit Appendix"I) 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 J;}— Is an Independent Structural Engineering Peer Review required? Yes ❑ No M� Brief Description of Proposed Work: . an/' �• n'o.. Ph� ovo,�i�-ate i 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): SECTION 4:BUILDING HEIGHT AND AREA - Existing Proposed No.of Floors/Stories(include basement levels)&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-4❑ A-5❑ B: Business E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ 1-2❑ I-3❑ 14❑ M: Mercantile El : 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 applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ - IIIB ❑ 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❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: \tn .t ru c'uq,n, Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: - Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: J SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property 6 Owned If nVy 9 v n L- to v q4 uV 2 Jf�G(_P,0 - S 41-en, ✓{,---- Name(Print) 'No.and Street City/Town Zip Property Owner Contact Information: 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 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 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control VCC,aal-�! gI?g _3�b - 2ys3 cj>_J 2- 4_ �m (Registm" p Telephone N�j e-mail address Registration Number Wtn P l�Lw/ © !S Street Address City/Town State Zip- Discipline Expiration Date 10.2 General Contractor r co ©Se Pni any nL\ MC— Name of Person Responsible for Constru tion License No. and Type if Applicable Street Address City/To n State Zip �8 _ - _? Co�lwr��� ✓n C Q4,2,- C&, Telephone No. business Telephone No. cell e-mail address SECTION 11:W0RKFRS'CONdPFNSAl10N INSURANCE AFFI1MVl'f 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❑ No Er— SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor �'h ,. and Materials) Total Construction Cost(from Item 6)_$,200''y� 'OO 1. Building $ Building Permit Fee=Total Construction Cost x (hhsert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ C70�.�� (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 informatioFined outapplication is true and accurate to the best of my knowledge and understanding. os �6h m�2Lj �s�-Please printand sign name Title Telephone Street Address City/Town A State Zip Municipal Inspector to fill out this section upon application approval: Name ate CITY OF SALEM // [PUBLIC PROPRERTY DEPARTMENT " nII r ,nIH,91 11u,w _ I�� 1VA HOAI•IU.\jl:Itk)' • j,1l l'N, IA1.11A.161 It y.I 11 Workers' Cumpenfatlon InJUra)ICO Uflduvit UullderUCuntnctorst/Ele tNclanyplumbery \ 1 illcant Infilrinallo -(� PI ' in Le 'AI V,rf11d I ILn1,IY,yt)r�yt,rJtinlelnJl�uluull: �J(> .IO r I t �. C�`✓Z. City,.5f:ue.%ip• I'J3c y?� G) M.+ niGic ne Ihunrilr (q17 .\ry)jai It' cngrloyer:'C h"ll the;glpropriaIs box.1 am i :mpluyvr with 4. Q I aln i gcnvnl"1111ecf0f and 1 I)Pe ofprn/ecf(rvyulrrd): _/�niPluyccs(IuI1,nJ/ur huvuhired the.vuh-cunfractors Ov4 I'Im u iota prnprit:uw or partner• lifted vn the anached.hv 7' Rem P 7 Q em delincumi uctiun xhip and hiva no empluyvvs Thefe cub eonrrseron have aeling Aurking raw my in any capacity, worker'comp, Insurance, g' ❑�emoliriun 1 Nn workers'comp, insurance J. Q we are a cruporlinn and its 9 ❑Ouikling addition J.Qnyuind) a)/ears hive their 1 ant i hnmcowncr doing ill work right of vrent lion 11.0 Electrical repairs or ,ldili ors myfclf, iNo lvnrkvn'cum P par h1( 6 I LQ Plumbing npuirs or aJJitiory P• C. 1 Jl, 01(J),and we hnva nn "Muranca rcyuired.1 r cmpluyvvs.(No work ara• 12•Q Ruul'repairs .nln p; in..urincu reyuind.l 1].Q Uther'1").'IglAuua Ilya eArcee ft"At mull.11w Tilt uw Jimwcltun WOW aWwale,AYw nwINO'cum 'I luny„rnn wlw.I,tx,ut tAie elTl,l�vll inakuine Ir„/r.IO auin all„w 4,.mrwh,n IAr11 Md IAq tra m,rl m>A /,n'tWlwr 1�icy u,rurlr,utiut► re,,n r uuiuW. o `""r IMw Afro N Ilia ru I'ft mwl.u1w 4 a nwr.1RJOvi1 inalaYln fr,Yt Juwin IIy na11N Of IM 1,1'YtMeraeAtte aM IAfa wuArre' a vn,0, /urn un vnrrleyn that lr prvvlJ/nr IrurAen'evrnpaem/!on Gr.runtnee�br tar Orn u, 'ntlKy Inllnnl�nua in/u/IIIYIIII/4 p/J rra 9r/err!s rAo Jsu/lfy unsl�ul pile Inaurumv C'unipaoy I'ulicy 4 ur SOr•ins. Lie.re; — --� — _l Eapirution Dnie:),A) 5iry dddn..r: ---� l"\ftu.•A a cosy of the worksn'cumpenwtlua pulley duelarullun page(shovel MI the Policynumber and vcpl►atlue daU), : t ru o I RO'iffe v)indlu s i required privy inunt,n:JA vl'.\IGL a. 132 eats lead to attr impufition ot'eriminal Penalties airs nnv till ro I JaO,tM Jnd/ur uue-year nnprivnnmcnr, Jn ,vcll J.t card fw"Jl11ut in Iha farm of a STOP 4YUlt i up m j?113 l ,I guy Ig;6r the rL1lJtar. Ile fdvLad rhur i copy ofIhtA..tutemcnt may by IarwirJvJ a the nOEillwo ul' Ia1,oli�Ju,nu ul ;hu UTA ibr m"it lrca a,AcrJgv %cl nikilmn. h URDER and a Rne /,lu/r:rrby t,rnh nn,/.v dir pwint,rnJprvndNrr u /,vrr/rlry Ilto, /bf"Mit, w rrvr11/ed abut r it uue un,/correct AIL r)//Iciu/,nr u„/y. /)u„nI,.tart in that yrcu, ru Ar ruury/i•IrJ b ( irr or L.uin - PAnniul.leenta • y .\urharity (cirelo'n1Yh I IL,.u'd 9r llr.illh G, ILher !. Ihullhn;• 111 p.Ir nnc nt 1. Cal t.'ron11 Clerk t. uvtfrival In 1per lur i. Plumbing Imycctar 1'.. u.let Information and Instructions �Lusu:huseui GcnarJl Lucas chiptet I i2 iegtures JII eutplo`e+on �n iha"sarvua of anotherenuler nny:ontnet of hire.s. every P' I•unu.utt w aus "atut+, Jn r,eplet'r+ is JclineJ as of Illy rose or more spress or ❑nphcJ, oral nr written.' oranun ur,that legsl cnnry, lu tr of the �e e,npluper is JclincJ U"an inJtvidual, Purtnanhip,assuctanoo,Corp «!. However the :J �n a Jwnt enterprise' Ind utcluJing the legal repretmualeTs IuYtng en Ployemp Y ' , „t the to or enbag sttnenhtp.Jssothe asuoa or other legal¢nary. D i ecery to or uustce ul'.us individual, p air workers such dwelling house owner r a awaiting house having not tots on!to do vain+nun e,and ion o�ep or the occupant of .lose Ian I houi+ of another who a play.4 Persons o shall net becauN of such employment be deg ad to b+ in empluyar." or,m rha¢rounds or building aPD state or local Ileenslag ag+aay shad withhold the bwaacr or �IGL chapter 152. 625C(6) also stntpe rate"wary ulred.' renesvu1 of s license or prrmlt to operate s basin,s or to construct Nltlh thwlnsuraaa�oreragingos as produced aee+plable+vldraee of camp ny of"political subdivisions shall ryplle+M w ho has not P , , C171,tat+e"Neither the conunanweahh not ';q 1JJitiunully, %iGL clwptar 15., i-5 ,bile work until acce table evidence ul'cuntyliwws with the insuranea enter inn any:ontroct for the parfortance of p I requirarlwnn ul'this dtupt+r have been presented to the contracting authority." �yyllcuua checking the boxes rhos apply to yuur situation and, if as)and phone nuntber(s)along with then canillcutels)of Plo,tar rill,art the workers' wot($) M MA( ), davit emnplatsly,by Partnerships(LLP)with no employu,ts other than the na.ass try, supply sub contractor(!) name(!),adJreW LLF have m carry workers' corttpansatiborny omitted to the Depurotma t o�Industrial insurance'e. Limuad Liability Companies(LLC)or Limited Liability inetstbM or partners, era not required entpinyars,a policy is requlted. f'!e advised rant this affidavit ituy arttncnt of Also be Gyre le 71{M anal data the YlOdavlt. Ttr affidavit should heaven for the permit x licertas is being requestted't it o obtain of the u workers' ucidenu too the city or to of ithat the eo coverage. the law err if you an cey ha reutnted to der airy or town that have re euuny questions regarding anies should enter their Industrial,\ecidanta. Should y ¢Amer st the number listed below. Sdf-insttraJ comp cotnpensution policy,please call the Dep self•insurance license number on the a ro riute line. ary or•rows Offlelsts W ruvided u spu a at the bottom rioted legibly. 'the De «mint has p the applicant. please he sure that the affidavit is n the e n and p beam wed only subtrt one alfldnvit indicating (citycurrent nniNicense nwnbeo which will be mad as a reference number. In addition,an aPP ,i dta JifiJuvil iur you n till ,err.in the avant the 011la of Investigations has to career you regsr n Please be sure to till in this De lieuti ins in any given year, Y :it err tlrrt must iub nit tnultiPts pannittlicmue app hunt shaUIJ write ,;all lucutiuns in (city of the utliduvit that has basis officially stamped err markad by rha city or town tray bar eroviduJ n the policy inim ntation lit necassary) and under"Job Site Address"theor I census. A new atNJun ay b,just be tilled nut coca town)."A copy business err eommareial venture JPplicant as proof that a valid affidavit i is on file far Nttun P ennit not related Many coon is NOT reyuired to eampten thi.t altldsvit. year. i0'hers a awn r owner or c urn is obtaining i license of uasl W ttl. l i ,. a Jog license ,r permit to burn to etc.) sal p ea,)oil not hesitan to tgtve us J all• io drunk You in JJv;wce rut your:oup+ralion and ihuulJ you ha,u.,ny 4 f he Uepanincnt'e Jddra,s, telaphune and fJ►number. The Com+aanweolth of Massachuseft7 Department of Industrial Accidents Of[fee of[svestigsdons 600 washiagton Street Boston, MA 02111 tad, p 617-727F 6 1 7 7 9 00 02 o77t9"-MASSAFE ,,1 i5 Nwar.mus.gov/dia CITY OF SALEN(I >, us.wFiUSETTS ©LLLDLNG DEP.IRT\IF,\T 120 W-tS-4LNGTON STREET. )"FLOOR rEL (978) 745-9599 KIMBERUY DROLL FAX(978) 740-9946 ,tiIAY01! THomu ST.PtERRit DIRELTOI<Or PCBLIC PROPERTY/BLMDLNG CO-%OIISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code. 780 CMR Debris, and the provisions of MGL a 40, S 34; section I 11.S 11Building Permit 4 is issued with the condition that the debris resulting from , S I SOA.work shall be disposed of in a properly 1 1 licensed waste disposal facility as defined by,blGL c The debris will be transported by: C 19 ti i- —1 (name of hauler) The debris will be disposed of in -" � 5 -(name or fuditY) (iddrgs of rujhty) 1 iynJrore afpermft �pplw.tnt L