11-13 LIBERTY HILL AVE - BUILDING INSPECTION V
R
The Commonwealth o 9Hhc 9u!PEs
Department of P bl'iLc SMaAfety T
YU kiassachusetts State Build��NotWt�8HaffA b.- 3�,
Building Permit Application for any Building other than a One-or Two-Family Dwelling
n (This Section For Official Use Only) Ili
Building Permit Number: Date Applied: IBuilding Official:
� ) SECTION 1:LOCATION(Please indicate Block If and Lot ff for locations for which a skeet address s not available)
1 L ✓y//Ar/e S3c�•• og7o
and Street City/Town Zip Code Name of Building(if applicable) _
SECTION 2:PROPOSED WORK
( Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below
QD Existing Buildin _ Repaidlj , Alteration ❑ Addition❑ DemolilimCH:(-Please fill out and submit Appendix t)
Change of Use ❑ 1 ChangeofOccupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ N011141
Is an Indep PndentStruct ral Engineering Peer Review required? ` Yes ❑ Nu
Brief Description of Proposed Work: ��i.-+ofo., P.Yi5 .9w /J�APrn uro S ��✓mLy.:u
gy
i
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check hoe 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 Flours/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-I❑ A-2❑ Nightclub ❑ A-3 ❑ A--I❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-I❑ F2❑ fL• High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
h Institutional 1-I❑ I-2❑ I-3❑ f-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-I ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ ❑A ❑ IIB ❑ IIIA ❑ IIIB ❑ I IV ❑ 1 VA Cl 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:
Publi A trench will not be Licensed Disposal Site❑
ell-_ Check if outside Flood Zun Indicate municipn
required❑or trench or specify:
Private❑ or inJentify Zune: or on site system❑ Imnuit is enclose) ❑
Railroad right-of-way: Hazards to Air Navigation: T \I•\f li,,l ii u. mnih,i n I v;o.1 r .,:p:v;
Not Applicable Cl Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 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,con Lain an Sprinkler System?: _ Special Stipuldtions:
(v��f27b
SECTION 9: PROPERTY OWNER AUTHORIZATION n
Name and Address of Prop•rty.O�v,ner, _
Gbh/s /3 L;�11 see
Name(Print) " _ No.and Street City/Town Zip
Property Owner Contact Information: �,•t :j'i
1jr r V
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
m act on the property owner's behalf, in all matters relative to work authorized by this building permit a pplication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.R.of enclosed space and/or not under Construction Control then check here 13 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:1VURkER9'COAIPENSAIION INSURANCE AFFIDAVFI 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 0 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)=5
3. Plumbing $
4. Mechanical (FIVAC) $ Note:Minimum fee=3 (contact municipa )
5. Mechanical Other $ /•
Enclose check payable to
6.Total Cost S �d (contact municipality)and write check num er here
SECTIO 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
Application is true and accurate to the best of my now d e and understanding.
g2e S2 r� Dwnei- -6SS7 - gZro
Please print and sign name Title Telephone No. Date
Street Address City/Town Sr Zip /
.Municipal Inspector to fill out this section upon application approval: r2d'� �/�
Name Date
F
QTY OF SALEK MASSAaR SE TTS
B
UIIAING DEPARTMENT
` f 120 WASHINGTON STREET,3AD FLOOR
,� TEL.(978)745-9595
KIMMRLEYDRISOOLL FAX(978)740-9846
MAYOR TfiomAs ST.PIERRE
DIRECroR OF PUBLIC PROPERTY/BUIIAING CONSUSSIONER
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:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Ignature of applicant
3//s
Date
CITY OF SALEM, MASSACMETTS
BUILDING DEPARTMENT
' 120 WASHINGTON STREET,31O FLOOR
\'" vsc• TEL. (978) 745-9595
FAX(978)740-9846
KINIBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECI'OROF PUBLIC PROPERTY/BUILDING COM&IISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location
Home Owner Address 50 e_
Present Mailing Address ` thz , e.
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner' shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements. /
HOMEOWNER'S SIGNATURE `
APPROVAL OF BUILDING INSPECTOR �i w