39 LEACH - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
V➢V bfassachusetts State Building Code(780 CNIR)
Building Permit Application for any Building other than a One-or Two-P mily vellin
,(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official
.}.. SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for whit a street address is not available)
J Le.e.ck Scn
No.and Street City/Town Zip Code Name of Building(if applicable) _
110 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 O Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix t)
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 required? Yes ❑ No ❑
Br' f Descr Lion of Proposed Work:
l o�a �` f.i , fir+ ,Fk J oa
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 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 a PH ble)
A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I❑ F2❑ H., Hi h Huard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I•t❑ [-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-l❑ R-2❑ R-3❑ R-0❑
S: Storage S•1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ Ill ❑ IIA ❑ IIB ❑ I IIIA ❑ IIIB ❑ I IV ❑ I 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 Rood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required El or trench or specify:permit is enclosed❑
Railroad right-of-way: Ilazards to Air Navigation: ��A Ili t n l�nnnu i n on;o-1 ...r,.:
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:_
Dues the building contain an Sprinkler System?: _ Special Stipulations: ____
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner t
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) a-mail address
If, plicable,the roper owner hereby authorizes
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jayj d 3 3 S�✓l t.^ �� —yy�/��,¢� 6 �t�,�
Name Street Address City/Town Statb Z
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 butldin is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here O and ski Section 10.1
10.1 Re istered Professional Responsible for Construction Control
Name(Registrant) Telephone N0. o-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cum any Name
W fi /75rr-t-(,I;oti C.S - n&zas-�
Name of Person Responsible for Construction License No. and Type if Applicable
C
`J( Street Address �� / City/Tos� State Zip
-XZ-30- 114 q
Telephone No. business Telephone No. cell a-mail address
SECTION 11:WORKERS'COMPENSAIION INSUNANCE AFFIDAVII M.C.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 ❑
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) 'iota!Construction Cost(from Item 6)_$
1. Budding $ Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Mini rmm fee=$ (contact municipality)
5. Mechanic, Other
Enclose check payable t0
6.Total Cost �� (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
i�y{t',lication is 17me and accurate to the best of my knowledge and understanding.
Pl :u prinl,.myl sign name Title Telephoyto,N�.� Date
x erer o� nt
Street Address City/" uwn State Zip
Municipal Inspector to fill out this section upon application approval: -`ice-i L//i4
Name Date
Q-I-Y OF Si1LEM, 1�wsS CHL;SE-ITS
gf i
BL'ILDNG DEPARTMENT
3 ) • y r 1 120 WASHINGTON STREET, 3w FLOOR
TEL (978) 745-9595
F.ALX(978) 7a9846
Kl)IBEAL F-Y DRISCOLL TrIORIAS ST.PtFxRs
`.MAYOR
DIRECTOR OF PUBLIC PROPERTY/BUQ.DING CMMISS(ONER
Workers' Cornpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibl
/ Y
Nanne(0usinssOrganiratippnro lndividuall/:�`� ' 141 41 ( 211
Address: 33 nS�)l�t
City/State/Zip: I�a✓,ern& 0!� Phone N: �—oT — 31" (,f L f
Arc you an employer'.'Check the appropriate bolt 'Type of project(required):
i.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors;
2.� lain a sole proprietor or partner- listed on the attached sheet. I T• (�Remodeling
ship and have no employees These sub-contractors have B• ❑Demolition
working for me in any capacity. workers'comp. insurance. q• ❑ Building addition -
(No workers•'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.) officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself(No workers'comp. c. 152, 91(4),and we have no 12•❑Roof repairs
insurance required.) f ` ' employees. [No workers' 13.0 Other
comp.insurance required.)
•Anv uppfic:un gut checks boa Of most also fill out the"di,n below showing their wurkeril eompensadon pulisy info matron.
'I lam,nwr6Ta echa submit this atndnvit indicating obey are doing all work and rho hire omsidecontmctms mint submit a new aoldavil indioing such•
$lonraewn shut chak NO boa most mmchal on additional:howl showing the noun,of rho rubwentraa,ni and Ihelr workea'romp.policy inr°rmation.
l unr un employer that is providing Ivorkers'compensation htturmrcefor my employees. Below is the pollcy and jab rile
inforrnatian.
Insurance Company Name: —._--_--
Policy it or Sclf-ins. Lie. d: Expiration Date:
Job Site Address: City/State/zip:
,mach a copy of the workers'compensation pulley declaration page(showing the policy number and explratlon date).
Failure to secure coverage as required under Section 25A of,IIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to SI.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
cf up to 5250.00 a day against rile violator. Ile advised that a copy of this statement may tau furwarded to the Office of
hnvcsligaliun.c 01'I11e DIA for insurance coverage verification.
l da hereby re y seder the papas and pearIsles ojperjury that the hifunaatlon provided ubuve is true and c arrreL
tt ///� /
Sienalure: f � � �ln E&ViT—
Phone
R
D/jiriul use wily. Do not write is this area, robe campleted by city ur lanves ojjielal
Citynr'fuavn: _-- -- PermltfHcenscq__..____. . .--- .
Issuing Aulburity (circle one):
1. hoard of Health 2. Building Department .s.citymmi,Clerk J. Efectrical hnpectur 5. Plnnlbing Inspector
6, Other
Comet Perm,: Phone 'I:
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QTY OF SALEM MASSA
CHUSETTS
BUILDING DEPARTMENT
120 WASIBNGTONSTREET,3ftDFLOOR
TEL(978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMM ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BunDING COMRSSIOMR
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:
G, 1 [ I I Cr
(name of hauler)
The debris will be disposed of in:
(name of facility)
(a dress of facility)
Signature of applicant
Date