282 JEFFERSON AVE - BUILDING INSPECTION l /� �
The Commonwealth of Massachusetts
\' I Department of Public Safety
to State Budding Cudv(.780 C\IR)Svventh Edition
City of Salem
Building Permit A lication for an Buildin other than a I- or 2-Family Dwelling
(rhis Section For Official Use Only)
budding Prrmtt Numiwr: Daty Applied: Budding Inspector: MT
SECTION t: LOCATION (Please indicate Block 0 and Lot 0 for locations for which a street address is not available)
rx t:H� "TAMEA508) /tom _&4L6M.it PT4 r•s/9)0 /)s dge rs'TbD/D
.No. and Street City /Town Zip Code Name ut Budding(if applicable)
SECTION 2:PROPOSED WORK
It New Construction check here❑or check all that apply in the two rows below
Existing Building Repair Alteratiun ❑ Addition O Demolition ❑ (Please fill out and submit Appendix 1)
.,Change of Use ❑ lChangwofOccupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents bring supplied as part of this permit application? Yes ❑ No
Isan Independent Structural Engineering Peer Review required? � � Yes ❑ No M,"
Brief Descri Lion of Propatsarl Work: e!O �il I517A6 Qii15/�f.,C /s Qad¢` �r SR7SA o/"DEd.2/S. 1AJ•57a7 1
/Z,. jd( ( etVklt Jl OA4WZ bDisw!Ua a W,'TZZ,4VZ t/ Me-
! .�4�.O�yrdcr�ihlbs
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) D
Existing Use Group(s): Proposed Use Group(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Fluors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area (sq. ft.)and Total Height(ft.)
SECTION 3:USE GROUP(Check as app, "
cable)
A: Assembl A-1 ❑ A-2r ❑ A-2nc❑ A-3 O A4❑ A-5❑ 0. Business ❑ E: Educational ❑
F. Facto F-I ❑ F2❑ H: Hi Hasard H-t ❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional 1-1 ❑ 1.2❑ 1-3❑ 14❑ M, Mercantile❑ R: Residential RAC( R-2❑ R-3❑ R4❑
Sr Stara Bar 5-1 a S-2 O U: villity❑ Special Use O and please describe.brlow:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IAO ISO IIA ❑ Ilea IIIAO IIIBO IV ❑ I VIA ❑ VBO
. SECTION 7: SITE INFORMATION frehr to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
PLlbhc A trench will nut be Licensed Oi.panti bite❑
(9' C heck tl uuGtde Fhs.al Luna•❑ Inalicatr mun:rtpal ❑
required❑or trench ur,pax:de•:
I'nvatr❑ ar indcnitA Zuni: or on,rtr se,tpm❑ permit is enclose) ❑
Railroad right-of-way: Hazards to Air Navigation: \L\ I h,h•n. ( ••nuns„o•n Itrt i.a I'n v,,:
\nl \ppl:caWle 0 1,Structure tc rthut airiv.rt.tpprnach area.' I.their rat tvac annpluted.'
a'l nt,avtt 6.11u d.1 cne L.val ❑ Ye.❑ ur.No❑ 1'rn 0 \\r ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I .hom.d ('•ode. __-- L,e CimiPl,v rt pr.4 C'.nt,iructom: - Ckcopant Load per l h,or
17•v, Ihcbud.hnt;annainan9pnnkler?t,tem' �pa•c:el?tipulahuns:
'la-W , La
r .
SECTION 9: PROPERTY OWNER AUTHORIZATION �f
.V.J eIf)').N nJ,{JGII)Fol I llrojwrtv Owner Aw '11 /•Ki014'
.Name(Print) .No.and Street City/ Town Ztp
I'm x•rN'the nee l•ontact Inlormabun:
Title Trlephonr Nu. (business) Teiephone No• (cell) a-mad addrv,.%
I(appbcable, the propsrle osc ner hereby authortz"
Name Street Addrew City/Town State Zip
to act on the •ru+erl% otcnvr'+behalf. to all matter%rel.uice to work authorized by this building permit a + +hcatitin.
" SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix'211
(If building is less thin 35'Lwcu.It.of enck,wJ.pace and/ur not under Construction Contnrl than check hen O and ski 8edwn I0.1)
10.1 Registered Professional Responsible for Construction Control
7 /C<(�uz„t: r1�,�311(� �aa wt►,t Gry lox,/. 6677y
Name(Registrant) Aphorist No. e-mail address Registration NumberJunDate
Street Address City/Town State Zip Discipline E10.2 General Contractor
Cum
siblr for Construction n I License No. and Type ifteabl�/�GB
Street Add'
� �'f /3yCity/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WOR V (M.G.L.c. 132§ 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 O No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) =f
1. Building f Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical f appropriate municipal factor)-f
1.3. Plumbingf
4. Mechanical (HVAC) f Note:Minimum fee=f (contact municipality)
5. Mechanical (Other) f Enclom check payable to Z�/ w
6. Total Cost f QQr (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
11y entering my name below, I hereby attest under the p•unx and penalties of perjury That all of the information cun6uneJ to this
appiiall on p true and accurate to the besl of my knowledge and understanding.
C��NJ mCyu� 971 /I;6f 7 ,6
1•Ieaprml and sign name rill rot.-phone No. Dale
:�trecl .Wdre,, Crts i Town ' ate Zip
Municipal Inspector to fill out this section upon application Approval:
Name Date
s
CITY OF SALEM
N t -_ ,, j PUBLIC PROPRERTY
DEPARTMENT
-'a..
"Wit;al.Y.Y DKNCOIA1
".I.,Yt'it 12C WASHING ION STItELT• SALEM,MsSSMA If SE I IS rJ197^.
11:1.:978-745-9595 0 1-:%X.978.740-984G
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information rl / b Please Print Leeiblv
Nime (Busincssi()rBanizatimVnlndividuab: �Wg �— �� C� anurd►�S
Atldress: — 'c W
Af�_Aa �� p
City%St:ua/.ip: U Phone i:: 97
Are you an employer'.'Check the appropriate box: 'Type of project(required):
. ❑ I :fill a general contractor and I
I.L]d 1 am a employer with 4
� G. ❑ New construction
employees(full and/or part-time).' have hired the sub-contractors 7. Remodeling
2.❑ 1 :fin a sole propricaar or partner-
listed on the attached sheet.
ship and have no mnployccs These sub-contractors have 8. ❑ Demolition
Working ror me in any capacity. workers' comp. insurance. 9. ❑ Building addition
'No workers'comp. insurance 5. ❑ We are a corporation and its
officers have exercised their III.[] Electrical repairs or additions
required.] a
3.❑ I um a homeowner doing all work right of exemption per MGL I I.❑ Plumbing b repairs or additions
myself. [No workers' comp. C. 152, ¢1(4),and we have no 12.0 Roof repairs
insurance required.) r employees. LN'o workers' I3.0 U(her
m cop. insurance required.]
-Airy applicant tlmt checks box dl must alsu fill out the section Wow showing their w'urkery cumpcnsariun policy inf,rmution.
T I lomcownco who submit this a17davit indieuing Ihc-y are doing all work and then hire outside conuacton ntur auhmir a new affidavit indi"int;such.
-Contmcmn that check(his box mtut atach%d an addiiional sheer shuwing the name of the sub-contru(om and their workers'comp.frol icy inform ad on.
l am fin einplayer that it providing workers'eomrpeiicatian htcurance fur ray employees. Below is the policy and job site
iufurinutiom y�
Insurance CompanyNatne: j_-f/SC.CTt/ `J'I_ U'/tJ,_1�4� lthlS, Co...----
Policy a or Self-ins. Lic. ti: 0315 to /t0�' _..-..._.._. Expiration Date;_ /
5r9GlCr� �s/f rJ/S7�
Job Site Address: a9� C\IEGIEw"YZA) V City/Stale/Zip: r yr
Attach it copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
I.,ailurc to secure coverage as required under Section 25A of NiGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 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 if day against the violator. Be advi,cd that a copy of this statement may be forwarded to the Office of
Investigaiiuns of the DIA for insurance coverage verification.
l dr,herchy certii under the pain.• rid penalties of perjury that the information provided above is rue and correct.
Simawre: _ Date- l�
?$ -.53/- 9
Official use mdy. Do not write its this area, to be completed by city or town aJJiciuL
City or Town: . . Permit/License X__--- -
Issuing Authority (circle one):
1. Board of l(caith 2. Building Department .3.Citylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Ofher _- -
Contact Person: Phonc S:
f '
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursumit to this statute,an errrpft yee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the.
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally, hIGL chapter 152, §25C(7)states"Neither the commonwealth nor`any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) name(s), address(es) and phone nunrber(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
.Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he Sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to cotiiact you regarding the applicant.
Please be.cure to till in the pennittlicense number which will be used as a reference number. in addition,an applicant
that must submit multiple permiu'licetse applications in any given year,need only submit one affidavit indicating current
policy information iif necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town tray be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he Oft ice of investigations would like to thank you in advance for your cooperation and should you have ;ny questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Oltice of Investigations
600 Washington.Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
acviscd ;-'_6-vs - www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
`-` - DEPARTMENT
I_'C \r.\;1 II m0N.,I'itl:I T # S.\I I \I, %1. 11 \t !I' <I I -
'I'I:1 974?45`)595 ♦ I\x: 9-8 .'4;-')S4t,
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
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit N - is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
ldks�"-
(name of hauler)
The debris will be disposed of in
(name of laahty)
(A-dress of facility)
6
s ¢nature of permit: It)[ CA[it
Ie --