15-17 LEAVITT ST - BUILDING INSPECTION (3) - 5 5 "I CY0S 13S
C RECEIVE
A -I 2S 1 INSPECTiONAL SERVICES
The Commonwe �0)Vs cbUb3ttS
qDepartment Ali fic Safety
➢� klassachusctLs State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Onl ) in
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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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 to the two rows below
Existing Building RepairviAlteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change ofUse ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes IN No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No I$
Brief Description of posed Work:
Pro
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SECTION 3:COMPLETE TF11S 311L I'ION 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 Gruup(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)h Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-!❑ A 5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ If: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
L Institutional 4l ❑ 1-2❑ 1-3❑ 1-4❑ NI: Mercantile Cl R: Residential R-10 R-2❑ R-3❑ R-1❑
S: Storage S•l ❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
L\ ❑ 18 ❑ IIA ❑ If8 ❑ IfIA ❑ 1118 ❑ 1 !V ❑ 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
Private❑ or indentify Zane: or on site system❑ required ❑or trench or specify: Nr
Permit is enclosed❑
Railroad right-of-way: [lizards to Air Navigation: \I_\_I In n rn innud si m It . ��. I_pw;,•s;
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:
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SECTION 9:t,PROPERTY OWNER AUTHORIZA"PION
NameandA/ddressofProperty'Otvned
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Name(Print) t Np.whd,Suy� City/Town Zip
Property Owner Contact Information:
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Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
JoHn/ pAtil-Ap& PL7• /3Cy_ L/a6S- &,q(�0 ✓f1/��l�G/
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)
If building is less than 35,000 cu.ft.of enclosed space anJ or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional-Responsible for Construction Control
Gr' i^'�
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Name(Registrint) Telephone No. a-mail address Registration Number
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Street Address City/Town State Ztp Discipline Expiration Date
10.2 General Contractor
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Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/T n State Zip
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Telephone No. business Telephone No. cell a-mail edc ress
SECTION 11:t 7RKER5'COMPENSA IION INSURANCE AFFIDAVIT M.G.L.c.152.9 25C 6
A Workers'Compensation Insurance Affidavit from the NIA 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? Ye9jK No Cl
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
I. Building SS SO 6 Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=$
3.Plumbing 5
d. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) Enclose check pa able to
SS y
6.Total Cost S 0a '� (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true,rod accurate to the � t of(tny kn lee ge am understanding.
P4 P A>vr Iq
Please print and sig n n ame Title Telephone No. Date
�% Ior.,rIi ; , P� QfCO� jt74 0/ °6-0
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
r CITY OF SALEM, iANSSACHUSETTS
4
r� BUILDING DEPART>IE.\T
120 W."HCVGTON STREET, 3w FLOOR
TEL (978) 745-9595
F.A-X(978) 740-9846
KI.%IBERLFY DRISCOLL
MAYOR InOh1A5 ST.PI ARE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informatinn nn Please Print [ e ib1Y
--]� /✓
V;Itnc(Rosiness Organiralion,'Individual): L/B Al✓ll yy rn/'T� /'•�f`
Address: P O gaX L71063_
Pgm?( -O-,0� t/Vl v4
City/State/ZiP: �,�� Phone It: 'O/— 7;46j- '
Arc you on employer?Check(he appropriate boar: Type of project(required):
I.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. New consWetion
antpinyees(full anrVorpart-time).• have hired the subcontractors I�t
2.� Ian a sole proprietor or partner- listed on the attached sheet. 1 7., Remodeling
ship and have no employees These sub-contractors have t1. ❑Demolition
working litr me in any capacity. workers'comp. insurance. 9. ❑ Building addition
INo workers' camp, insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
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, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' I3.❑Other
comp. ;.......ante rcyuircd.)
•Any upplie:u t our rlwuks but so mwr alsu fill uur tilt ocean below showing their worken'campensaiiun policy ineumallon.
'I L+m¢nwncn whu whmit this smdnvir indicating they arc doing all work and then hire ouitide conlmcton trial suhmit a new aMdavil indinring such
l'mtrwmn thin uhmIt this box mast aaachal an nddoiurul.heel showing IN route of the subaonrnciun and their wnrkon'camp.pulley inrumiarion.
/uns an employer that is providing lvorkers'conrpensadun insurance jot my eurployers. 13elury is file policy and fob s11e
inlornrution.
Insurance Company Vame: __.-_
Policy it or Self-inn. Liu. 0: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation pulley declarlitlon page(showing the policy number and explratlon date).
Failure to sccuru coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties Life
line up to S1,500.00 und/or ate-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a lino
of up to S2i000 a day against rile violator. 13e advised that a copy of this statement may be 1'urwarded to the 011ice of
invest 1gali uns of[lie DIA for insurance coverage veri Creation.
/do hereby cerrij raider the pain nd penalties ojperjury that the btfuralutlun provided above is true and t-orrecr.
1- 7')O y�— JJ__
F601�)
l use only. Do not write in thi.v area,to be completed by city or to ova elgiviaL
r'1'mvn: PermiuTicensc q
,luthurity (circle one): —_ _— --- --- i
d of health E. Ruildlm„ Department .t.City/town Clerk 4. Electrical lu.prctur 5. Plumbing Innpee tar
r
Contact Person: Phone!t:
CITY OF SALEM MASSAQHUSETTS
+ Stk ITj BUILDING DEPARTMENT
\emsr sir 120 WASffiNGTONSTREET,3AD FLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THomAS STTIERRE
DImcroR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
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:
v /
(name of hauler)
The debris will be disposed of in:
_PFA°3orr,, i rws �
(name"of facility)
!/o �� ST S/ ✓�Ey9 �ioyJ�� y�
(address of facility)
ignature of applicant
Date