28 LEAVITT ST - BUILDING INSPECTION GK LJ(3'� 3 t256'2'
ti TITJ- / (4 — / 28 3 RECEIVE t SERVICES
The Commonwealth of Massachusetts W
Department of Public Safeq��MAUG -" A �61assachusells State Building Code(7517 R)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: _ Building Official:
SECTION 1:LOCATION(Please indicate Block B and Lot N for locations for which a street address is not available)
, Sj :1.Q,eA, C3/7 76)
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 in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix tl
Change of Use ❑ Change Of Occupancy ❑ 1 Other ❑ Specify: i
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering P per view required? Yes ❑ No ❑
Brief Description of Proposed Work: _ n A �..r f 2 '��' --e
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 CMR 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❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ IL- Hi h Hazard H-1❑ H-2❑ H-3 ❑ EI-3❑ H-5❑
1: Institutional I-I❑ 1-2❑ 1.3❑ 1-4 CIM: Mercantile❑ R: Residential R-l❑ R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
[A ❑ IB ❑ IIA ❑ 1190 IIIA ❑ IIIB ❑ 1 IV ❑ 1 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❑ A\trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: 11azards to Air Navigation: MA I_li k ri-l onm 4r m I },iro I nkrs:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes Cl or No❑ 1 Yes❑ No ❑
SECTION g:CONTENT OF CERTIFICATE OF! CCUPANCY
Edition of Code: Use Group(s):_ TYpe of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
Sev-r S l S -I-ID MG M ns-pem
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nome and Address of Property Owner
vld c t,
Name(Print)e ,-I A - No.and Street City/Town Zip
t!
Property Owner Contact Information:
'title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable, the property owner hereby authorizes yv
N64i6vel "*?,n7 o" A;501 oC4a
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
f �- Fs6 /9�
t he jRc�yistmnt)�� e,Ng. e-mail a��d��d,r,ess ri k� Registration Nutnbe� y 6G
10
Street ess ity/Town S Zip Discipline Expiration Date
10.2 General Contractor
Company Name
at�me of Person Responsible for Construction License No. and Type if Applicable r., �^
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:4VORKFKS'COAIPENSAI[ON INSUHANC.E AITIDAVI I' 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 ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ �
1. Building $ Building Permit Fee-Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=S
3. Plumbing, 5
Note:blinintum fee=$ contact municipality)
4. �fechaniril (HVAC) $ (� �V+ Y)
5. Mechanical Other '6 Enclose check payable to C
Y'
6.Total Cost S CrL, (contact municipality)and write check number sere
SECTION 13:SIGNATURE OF BUILDING PERNirr APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip Q //
Municipal Inspector to fill out this section upon application approval: ft7ZiiO ( O T
Name Date
CITY OF SALEM, AksSACHUSEITS
a
E)I;ILDING DEP3RT>lL-.\T
120 WASHLIIGTON STREET, 3'D FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
IU.\i3ERt F_Y DRISCOLL
�",M'tYOR T HoNw ST.P1FRAE
DIRECTOR OF PUBLIC PROPERTY/BUILDMG CMMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print 1 eBihiy
Nainc (0usiues;,Orgvl i raI ill mindi vi(1ual): 4b4i entin I�A�� =pea At
��Address: S• 0, .5! raatr� �r�^
City/Stat&Zip: �.7iU/LJ _ Phone ft: 1�66'— 3s-Ss-A _ ..,-. ._...
Arc you an employer?Check the appropriate box: 'Type of pr7) ,
I.❑ I am a employer with 4• ❑ I am a general contractor and t
employees(full and/or part-time).
+ have hired the sub-contractors 6. ❑New
2.❑ lama soic proprietor or partner- listed on the attached sheet. t 7. ❑ Rem
F .hip and have no employees These sub-contractors have U. ❑ Dem
working for me in any capacity. workers'comp. insurance. 9. ❑ Buil
[No workcn•' camp. insurance 5. ❑ We are a corporation mid its
required.) officers have exercised their 10.❑ Electrical repairs or additions
}.❑ I ant a homeowner doing all wok right of exemption per MGL I I.[] Plumbing repuirs or additions
myself.[No workers'comp. C. 152, §1(4),and we have no 12Roof repairs
insuraneerequi«d.) t employees. [No workers' (}, Other r
cutup. insurance required,)
Any applwaal aml checks boa Of must also fill out the ucGom below showing their worken'compensation policy inlltrmatlun,
'I Iummrwncn who submit this slAdnvit indicating thcy ore doing all work and then hire putslde cuntracton mml suhmit anew ailidavil indicsuu a such.
$'amractun that cheek this box mmt attached in:uldidima ehnt showing the name,of the subwentnctota and their workers'camp.put icy inWmtation.
l unr can employer that is pruviding worAers'ewrlpen,sadun hrsurance for my erupluyees. Beluly Is the policy sold fob,sih,
h1farmudaut.
Insurtmce Company Name: /}
Ptdicy it or Self-itm Lie, d: — --- 1 Expiration Date: -
Job Site Address: City/State/Zip:
Attach a copy of the workers,compensation policy declaration page(showing the policy number and expiration date). .
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
or up to S25o.00 a day against the violator. Ile advised that a❑opy of this statement may be forwarded to ilia OI'lice of
Inve',ligutiutm of the 01A for insurance coverage verificatiun.
/du hereby certify under the pain ud penalties of perjury that the htfurnmtlon provided ubuvr j.s true surf correct.
Si •t nose' 4 l2, �g Date:
Phone i, T-2S-
Official use wily. Donut write in this area, to be completed by city ur twvn nfJirful
City nr'Ibwn: Permitil.lcenyc 4
Issuing Authority (circle one):
I. hoard of Ileallh 2. Iluildlnq Oepartnieut .1.Cityfrnnn Clerk d. F:Iectriul Ltspectur 5. Plumbing ttapectar
6, Other
Contact Person: Phone ran 8:
J CITY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
120WASHINGTONSTREET,3mFLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THomAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 betransported by:
(name of hauler)
T is will be disposed of in:
(name of facility)
(address of facility)
Signa ure of applicant
Date
e rOo�nmzoiuoeazowyaaaacfueaoCta _free of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to only
egistration:_1.j8786 Office of Consumer Affairs and Business Regulation
Expiration:=m I,2o18. TYPE 10 Park Plaza-Suite 5170
NATIONAL MANAGEMENT,TEAMjNC. Supplement�:ard Boston,MA 02116
EDWARDS RICHARDS
P.O.BOX �JWt�C
TOPSFIELD,D,MA 01983
Undersecretary Not vali�/}d without signature