200 JEFFERSON - BUILDING INSPECTION f
-RECE�I l SERVICES
!� The Commonwealth of Massachys S
qDepartment of Pq '2 ;/�1 `►0
ru Massachusetts State Builti !i!`1!(�78 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Onl )
Building Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block M and Lot If for locations for which a street address is not available)
7
No.and Street City/Torun Zip Code Name of Building(if applicable)
SECTION2.PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply 1 inthe two rows below
Existing Building,♦' Repair�i' Alteration ❑ Addition❑ Demolition ❑ (Please fill ut and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Libber ❑ SPdY�Specify: fo
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 ❑
Brief Description of Proposed Work:
J �•
SECTION X COMPLETE TEAS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if anad
stigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use C Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No,of Floors/Stlevels)&Area Per Flax(.sq.f[.)
TO6il Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a liable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-I❑ A-5❑ B: Business ❑
F: Facto F-1❑ F2 E: Educational ❑
❑ If: Hi h hazard H-1 ❑ H-2❑ H-3 ❑ FI-•4❑ H-5❑
1: Institutional 1-I❑ I-2❑ 1-3❑ 14❑ Ml Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-I❑ S-2❑ IU: Utility❑ Special Use❑and please describe below:
Special Use:
4 SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ HA ❑ fill ❑ IIL\ ❑ IIIB ❑ IV ❑ 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 trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right- -way: Hazards to Air Navigation: \L\Ili+l ru l nmi sir+n I �tcw 1 r>;�s:
Not Applicable d� Is Structure within airport a proacI area? Is their review completed?
Or QMSCIIt to Build enclosed❑ Yes❑ or N Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Consfructiun: Ocn,pant Load per f-loor
Does tine Lillfill illy,contain an Sprinkler System?:__ Special Sf ipulations: —
1 S
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name.lid Address of Proper t .Ownei '�
lvi -2
Name(Print) No.and Street City/Town Zip
Property O vner Contact I{u rmtt' c GUA Ii1Z
p 'o� �yS 8�-7V '��- a, //7
Title V Telephone No.(business) Telephone No. (cell) e-mail address
If a rlica le,th property owner hereby authorizes
B1�170
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 ae2lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
U building is less than 35,000 cu.ft.of enclosed s ace and or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
L sus i
Name(Registrant) Telephone No. e-mail address Registration
NuumSber
p/Sr
Street Address _ City/Town State Zip Discipline Exp rats n Date
10.2 General Contractor
Name of Person Responsible for Constru tion License No. and Type if Applicable
/y �1��o� � 7 shy a � ,
Street Address / City/Town State Zip
Telephone No. business Tele hone No. cell e-mail address
SECTION 11:Vvo1:KERs CONiPENL XVl0N INSURANCE AFFIDAVff 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 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Libor
and Materials) Total Construction Cost(from Item 6) $
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert 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 $ pp , 1 (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
applic ' ni true juid accura`ttee to the best of my knowledge and understanding.
` o) 37'n `?
Please print a n tgu mm�e Title Telephone No. Date
Street Address City/Town /State Zip
Municipal Inspector to fill out this section upon application approval: ✓
Name Date
QTY OF SALEM, MASSACHUSETTS
3
BUILDING DEPARTMENT
120 WASHNGTON STREET,3AD FLOOR
TEL. (978) 745-9595
F
KIMBERLEY DRISODLL FAX(978) 740-9846
MAYOR THomAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMSSIONER
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:
(name of hauler)
The de wi b po ed of in:
(name of cility)
(address of facility)
Signdttire of p licant
Dat
r
<'T CITY OF Sm Emtl NL- ssi: CHLSE1fiS
BUILDING DEPART\IL\T
120 WASIiLNGTQN STREET, 3"FLOOR i
'��a•`� TEL. (978) 745-9595
F.kx(978) 740-9946
!U\tBE'IILEY DI ISCOLL
�'Z YOR THo&wST.PIERRE
F DIRECTOR OF PUBLIC PROPERTY/BUILDING CO-NNISSIONER
+
M)rtcers' Compensation insurance Affidavit: 13uilders/Contractorv/Electricians/Plumbers
A T Tlieaai►finformatinn Please Print Le ihI
V;IInC:lnminuss Organiratiom'Individual):
Address:
City/State/Zip: Phone It:
" Ar .gnu.an ployer:'Check the appropriate box:
Type of project(required):
m a employer wish 4. ❑ I um a general contractor and I
enlplayees(full and/or part-time).* have hired the sub-contractors 6' ❑New construction
2.0 1 am a sole proprietor or partner- •listed on the attached sheet. 7, ❑ Remodeling -
ship and have no employees These sub-contractors have M. C] Demolition
working tar me in any capacity. workers'camp. insurance. ,
(No warken•'comp. insurance 5. ❑ We are a corporation and iu 9. ❑ Building additiun
required.) officers have exercised their IBE Electrical repairs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers'Gump. C. 152, §1(4),and we have no 12.C] Roof repairs
insurance required.) I cmpluyecs. (No warken'
cotnp.insurance.:suited.) 13•❑ Other
•Any applicant eon checks but rl must also fill out the secl:un below shpwing their wotken'cempenaatiun policy inlurtnmiun.
'In"no'M en.eho.uhmir this atTldnvit indicating they m doing all work and then hire oatlideraNmeton policy Must hmh a new aff!davil indiaaling ruck
1'ontnctun that check this box met inachat an adduiunul sheet shuwing 11u mute ofthe subaomncton and their warken'camp.policy inin"a ins
!•our an employer that is pruviding workers'eampeasatlan iosurauee for my earpluyees. Beluty is tha pu/lry and fob.ri/a
irtformulioa.
Insurance Company Naine: M C CA^-k
Policy it or Sclf-ins. Lic, d: Expiration Date:
Job Site Address: a U e *, e k`a. S sa.., pvwv�
City/State/Zip: SAt t�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and explr2don date).
Failure to secure coverage as required under Section 25A ofbfGL c. 152 can 'cad to the imposition ofcriminal penalties of
line up to S1.500.00 und/or one-year imprisonment,as well as civil penafties in(he loan of u STOP WORK ORDER and a tine
of up to S'_S0.00 a day against the v' • mr. Ileac that a copy of this statement may be fur-warded to the Office of
hnvcstngutiuni ul'the Dlr r ins ane cos age v• ticaliun. -
/ f hereby rrrd cr!/t poi pens/lie ,lhu!!hr fnfunnullan pro vidud above r)true and correct
�i •n t re' f2 1 14
I�anc t z1�7 7
011h iul use may. Do not write its this area, to be completed by city or tatvrr oJJiciut
I
City or Tutrnc Permit/l.iccntc,q
issuing Authority (circle one): - ----- --- - "--
I. Ituard of Ileahh 2. Dui(din"I I)epartmcn[ 1. City/town C'Icrk J. F.Icetrieal htspcctor 5. Plunthing fnspcdor G.Ilthcr _ _.. �
('unlact l crtnn: �I