284 JEFFERSON AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
i
i\hissaehiINcl Ls State Building Cade(BO C\1R)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building permit Number: Date Applicxt: -_ Building Official:
SECTION 1: LOCATION(Please indicate Block N and Lot p for locations for which a street address is not available)
i20 -TEFFE2SON AVE' 5141 '=M OL970 _
No. ant. Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED W014K
Edition of CIA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration Addition❑ 1 Denudition ❑ (Please fill Out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction d'x'unents being supplied as part of this permit application? Yes ❑ No ❑ —
Is an Independent Structural Engineering Peer Review required? Yes- ❑ NO Q�
Brief Description of proposed %VOrk:-_ 1 RI P(4r — DL-'C/C P7RC PV NEFp"g %D
P1K�S M/ 6LLO xwo QE/jUZI5 AlGf)207N/!9 rO 7H68UILD/1V
CtgbE,�,a4 dpEf,-Ui.f)-�n�iS .
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 760 CNIR 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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Fluard H-1 ❑ H-2❑ H-3 ❑ 1-1-i❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ I-1❑ NE Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: i
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA Cl IB ❑ HA ❑ 118 ❑ IIIA ❑ 11113 ❑ IV ❑ 1 VA ❑ VB ❑ -
SECION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply:. flood Zone Information: Sewage Disposal: French Permit. Debris Removal:
Public❑ Check if outside Hood Zone❑ Indicate municipal❑ A trench will not be LRVIISVd Disposal Site M
required❑or trench or specify:
Pricdlc❑ or indrntily Lune:"- - or on site system ❑ permit is enclosed ❑ _ ___
Railroad right-of-way: [lizards to Air Navigation: V h I ir.Ila 1 ' .,.m,n' ,., .. _�
,Not applicable❑ LC Structure within airport aplhmarh area? Is their rev icw completed?
or Consent to Build enclosed❑ Nes❑ or No❑ Yes❑ No ❑
SECTION A:CONTENT OF CERTIICA'FE OF OCCUPANCY
FdiHon of Code: __._ L'se Group(s). — I%pe of Construction: . _. _. Occupant Load per Ilno r:
Does the building cotitain in Sprinkler System.': ___ __.-Special Stipul,uions:
SECTION 9: PRonjurY OWNER AU'I'IIORIZA'1'ION
Name and Address of Property Owner
MIRoSLflfn) J4,,,Wk 05P 2914 eT - u
Nanm(Print) No.and. treet City/Town Zip
Property Owner Contact Information:
ef-74 II- 3Lf 77 -
Title Telephone No. (business) Telephone No. (cell) e-mail address
If opplicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all natters relative to work authorized b V this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 33,000 cu.ft.of enclosed space and/or not tinder Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
MlICML 5zY0L0PSP _I/- Vr�- 2-(916 szNdt".I cl M1,AA2jW-I A 319
Name(Re•istrnnQ Telephone No. Ve-mail address R%istration Number
450 Vtt1J Sr_ `7KILL fh 0(970 LS 00 4/II�2p12
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
P1oNffaCN
Company Name -
MICHRL 5zY0t,0WSK! HIC 160001
Name of Person Responsible for Construction License No. and Type if Applicable
4h0 SI R( Af}(Y1I LToA/ ffkt 0/9R2
Street Address City/Town t State Zip
Z-4/ - 2616 -- 5zuC/10WA M/Aa.Pb7&4v,coin
Telephone No. business Telephone No. cell a-mall address
SECTION 11:1b,Caai;r.S( M \_I NFIj1,ANC) Al lit IAe'It M.G.L.c.152.§25C6
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 13
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item b)=S_
I. Building S Z( 000.00 Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)-5
3. Plumbing $
1. Mechanical (HVAC) $ Note: Nlininmmt fee-S j(COnt,10 mm�icip,rlily)
5. Mechanical Other S &tclose check payable to
6.Total Cost $ Z11000-CO I (Contact municipality)and write chef number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering nw name below, I hereby attest under the pains and penalties of I rjury, tall of the i donuation Contained in this
appliattion is true and accurate to the best of my knowledge and understand ng.
Please print and sign n•une LL Title rlepho�ne. No. Date
tilreet Address CilviTown St, to Zip
Municipal Inspector to fill out this section upon application
None Date ���TTT
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.I.u:. It:l Y:IMIN I'I I
11:NVAH4l1,411u•%ilaekT a i.ul•N, hf.\U.tt.11t V I IS.;1'7J:
1'"' 774?lip/i8 a 1'Ix v7x-?4C•'4Y46
Workers' Cumpensatlon Insurunce A1Oduvit: Builders/Cuntracturs/E(ectr(clyns/Plumbers
\ 1 )Ill:ant In nnnuflon
M - It I P Int La—my
VaIn011/nurlclil)raanvninNleJlvuluull: /'/I L'�/ir}L �y�Qfls'k�
Address: L U
City.Srarc.%ip /'Y/� I0 q Phune it:_ 4/-9/3 1
IAre nu in empfeyer! Chuck the appropriate box;
I.❑ l ;ten a cmpluyer wish 4. Q 1 an a gunural coulractor and 1 1 SPe°/pfO/uut(rcyulrrJ):
Liler
lu)ecs(full und/ur part-time).• have hired the vuh-cunoracturs rl' ❑new cun%tructiun
,1 sole prnprieta or partner• listed on theanaehed.cheat. ) � Q Relnedeling
and have no empluyees These subcontractors have
ing hir me in any capacity, workers' comp• Insurunce Q Demolition
orkers'comp. insurance J. ❑ We are a cal 9. ❑Building additiunJ.) pontinn and itsoMccrs have excreisc•J their 10.QElectrical repairs or additions
halrteuwner Joing all work right of exemption per MCI I I.❑Plumbing rcpuirs ter additions
f. (Ko workers'comp. e. 132,v`I(4),and we have no
nce reyuired.l t cmpluyeux. (No workera' 12•Q Ruufrepairs
rnmp, insuranca nyuimi.J 12•Q Other
•any,,;gala'+1a]Jimrhevb Oae nl muW alau lift uw Ilw.cebuu Ixluw awwuq'heir rurkWF vunlyeeaWlan Isaivy nlru olli,, w
'I lumwlrfwn wha n1In,#this ollld ill illJiulina Ihey+w auine ten.lurk told Ihm Airy uwsidg ruefnerpe mwl.uhna a new URJevis imlia•Wi11e�1vh,
r,minabin IhW tMvk Ihie koe m1W allaahrn.Ie aeairitioll d1.ot A...ine ON Ir3111e Or the rrrl►eantrarrary"d,hfN 4waete'nYllo,p111vy IIIt1M111a1111e.
/atn ten eutployrr that 1r pruvldlgr Ivarkurs'cutnpenrnNon httunmeajur my crop/tepees. Be/uw la the pu//ay and/u1 aiq
injururulGna
Incurancc C'umpany Vmne• _
Policy 4 or Sulf-ins. Lic.H:
Expirolwn Date:
Iola,Site-Wdresc:
Attach it cu cily'slatavZlp:
yy of f he worker'cumpunxatlun pulley JuelaruUun page(showing the policy number and usplratfue data).
I allure w.wcuro cocclogs as required under Section?JA u1'.�IGL c. 132 eau lead to the imposition orcriminal Penn, of a
Ii ti uti m S0.00 4M y dlur Idaitune•year unpri.runmunr, as wall an civd pcnuhlu in the form ufa STOP WORK ORDER and a fine
�crup m i'J0.(M a Jay �Iyuinat Ill violator. Ile advi.k•d shut a copy ufihis afalcmwlt may be IurwarJeJ lu the Offleo ter
Igrv.h�anrins ur;he UL1 19r ul.arancc coverage ccrilicapun.
/du 7tereby t ertijY undav the p,tinr,ufd pine/tier ufprr/ury that the in unnrNon
n p III�- / pruvided abuve is true fund rorrvet
:I._„11rrr. _ �`tYIA),L aAf7fGr (D,,r
r1r, . . 1
0114-iu1 foe wn/y, /7u,nor,vrirr in thdr urea, ro be cuntplclyd by city ter town a//1ciuL
Jrit,vur,lblrn: _
Icvuing .\ufhurify (cin'la nl,cl; Pemni17l.1cvnce 0
I.6. Other
n1IhvlUt 1. Ihuhhu� UgLlrtnlvnt 1. ). orin Clerk a. Llcclric x
.11 faycfur 3, l'hnnbing Invyccror
n er
I
.__ I'hnne Y•
Information and Instructions
v n+o1 m the service Jf mother un,kr any eJmnct of hire.
�Lusadlu:cus licnenl Laws chapel I s2 tcywrcs all employers to proviJe workers cotnpensler'I for heir ct ofhir .
11unu.ult to tius aatute, an rmples'ee is Joined as"._e cry {ri
:.pleas or 14T, , oral or written." or an two or more
uMersl -.IYYJc1a1Wa,corporation or other legal cjstj lu cr or he
�n ctnplupar 1+de tined as"an mJividual, p employing.m Ioyces. Hc*,;vcr the
�t he toregJing engage) m a lumt enterynsa, and incluJing the legal reprcseatatives of a Jeceax emp Y
ecmver Jr trussed of.m iudivldual, parmcrshnp, a{apenaJ ailments
or other legal a resides
ty, h ' P
e r+han to three
tnaintenunce,cunsuuction or repair work un such dwelling house
owner of a dwelling house having not more hoa threevpartmenu and who resides herein,or the occupant of
.IwOlmg house of another who employ. pa
or ,m the vrounds or building appurtenant theretOrs o shall not because of such employment be deemeJ its be an empWyer.'
\IGL chapter 152, 425C(6) also states that"avary state or local 1lcansing)agaeey shall withhold the th for
issuance or
ce of Uaaee with the Insugancs covaraae required.'
renewal of a Incense or permit to operate■huslnass or to construct buildings In he�om overage
I sulrequi i any
+hall
upplleantwho has not produced 15CePtable)Braes-,Neither he otnmonwcalth not any of its p
AJditionally, MGL ohuper I5_, i-
ener into any contract for the performance of public work until acceptable evidence ol'cmupli;ulce w ith the ulsuranc
requirements of this chapter have been presented to the contracting authority."
ApplicatorsApply
p to our situation and if
hone numbric(s)along{with their cartificate(s)of
Plc:l:ur lilt out the workers' compensation atltdavit completely,by checking)the boats that u p Y Y
necessary, supply sub contractors)nama(s), uddteLimi)And p with
insurance. Limited Liability Companies(LLCworke 1, con gsensa oted Liability o insurance.(t an)LLC or LLP no Blocs haveoyees r
than t
members or partners. are not required to carry be submitted to the Department of Industrial
employees,u policy is required Be advised that this Affidavit stray artmeat of
hcuien for he pannif or license is beings requested,not the Lhp
\ccidenre for contlnnation of insurance coversas. Also be sure to slaa anJ data the afddnvlt Tu affidavit should
he rctltmed to tlla city or town that the apD uesriaos regarding{the law or if you arc required to obtain u workers'
Industrial Accidents. Should you have any 4
compensation policy,please call the Department at flu number listed below. Self•insunJ companies should enter then
self-insurance license number on the approatillill line.
City or'rown Omelets Ivil IicanL
rPthe affidavit rhor you W till lotsintthe event he 011ka mplete And printed of InvesrivatiDonh as to c ntact you rcgardina the app provided a spud at the bottom
fleas: Suva to fill m the permlt/IICCIIaO Ilulllber Which will be used as a reference Ilulllbcr. in addition,an applicant Jr
Ace
chat must submit multiple pennit'INteltt applications
AJdresegiven
theyear.
applicant d houlJ only writemit uaall IJcu una in rovideJ w th Y ne iffidavit indicating set
policy inl'ormution lif necessary) ed or marked by the city or town nnay be p
town)." \copy Jf tilt affidavit that has been Offfile
for
future
stamp'
Applicant as proof that a wags) affidavit is use file for futon Permits or licenses. A now atliJavit must be filled nut esc
tart KR ens or permit o, bum leavesctc.)laid per.nos NOT required o related mpleto anyte the affidav ebusiness or mnlereial venture
I he >(ticc ou in advance fur your cooperation anJ shoal)you halo.uly yuesuons,
of itivertigatiuns Iwuld like to thank y
plead. do net hesitate to give us a call.
fhc Ucp:uuncnr's addle+.a, telephone aTh ait number:
Commonwealth of Massachusetts
Department of Industrial Accidents
Olflea of Invesdgadans
600 WilthinBton Street
Boston, MA 02111
'fen. p 617-727-00 6ext l7 702 Or 1.817-MASSAFE
4 if, fis wwvt.mass.giov/die
CITY OF S.u.ENfj AASSACHUSETTS
BLLLDLNG DEPARTNONT
110 W.UHLNGTON STRM, Ya FLOOR
IIEL (978) 745.9599
KI3C3ERLEY DESCOLL F.Vt(978) 740-9846
,MAYOR TRo.�Na ST.Pzzu&
DIRECTOR OP PLBLIC PROPERTY/KaMOIG CONMISSIONER
Construction Debris Disposal AlVdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 11.5
Debris, and the provisions of MGL a 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
G_/hEc( o coP(P
(name of hauler)
The debris will be disposed of in :
�ECC,J TR IUS R sf�}-ZoN
(name of facrlit )
i y
�� `J(
�.O ST MIN
Ri=El"
(address or facility)
signature of perrojt applicant
nS I lKall _
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h hr,..ir,j.
Tt-o)a iz�
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