12 LINDEN ST - BUILDING INSPECTION a _
�T
The Commonwealth of Massachusetts
I I j Department of Public Safety
..\lass,ichusctts State Budding Coale(780 C:YIR)Seventh Edition
City of Salem 1
Building Permit Application for any Building other than a 1- or 2-Family Dwellin
(rhis Section For Official U.se Only)
Budding Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION I Please indicate Block a and Lot t for locations for which a street address is not available)
J 01 57 4 /ek-t (Vl Iq 0
No. and Street Cih' /Town Zip Catde Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Conslructiun check here❑or check all that apply in the two rows below
Existing Building RepaiX I Alteration C3 I Addition O 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No ❑ _
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O
Existing Use Group(s): Proposed Use Group(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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 S:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business O E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 O H-2❑ H-3 ❑ H-4 O H-5❑
1: Institutional 1-1 ❑ 1.2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 R-3❑ R4 ❑
S: Storage SI O S-2 ❑ U: Utility❑ Special Use O and please describe below: �h/lj
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as ap licable)
IA ❑ IB ❑ IIA ❑ 118 ❑ IIfA ❑- IIIB ❑ IV ❑ VA ❑ VS O
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 FI.wJ Luna•❑ Indicate municipal ❑ A trench will not be Licensed Disia wtl Site ❑
Pnc.tty❑ or mda•nt de Zone: or on air system❑ required O or trench or s1aYil v:
permitisendosed O '
Railroad right-of-way: Hazards to Air Navigation: \L\ I h,1--m n•n..I H.,w. 1'r,,,,
\.-1 \ppliiablvE3 htilruilu«•tailhm atrpurt api•ru.tih area.' 1, their rev tecv cuntplch•al.'
a(' at�a•nt to ltudd vniluval ❑ - Yc.O ur No O 1'es❑ \u ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I:.hu.m r( Jr: ___ L�r(�r.niplsl: It pc ul fund«iiUun: lkiupant Luaalper tluuc
11w, the building iontain.nt<pnnkler;%,tem': �pvcial>hpulanone
y
SECTION 9: PROPERTY OWNER AUTHORIZATION
Namv and Address of Property Owner
.Name(Print) Nu. and Street C ih•/Town zip
I'TF+vrh' Chrner C-onlact Information:
Title Telephone No. (business) Telephone No. (cell) a-maul addrass
If applicable, the prupern• owner hereby.utthortze%
Name Street Address City/Town State Zip
to act on the properti, o%%ner's behalf, in all matter%relative 10 work authorized by this building permit a p plicatiun.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is ltti%than 15,001.1 cu.tt.Uf enck,1. %f s pace and/or not under Coastmctian Cuntrul then cheek hm Cand,kip Smijun I0.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
azAk-6 /ice f vG ST
Cowry Name: /
YiL-t9H /Mc t �, e� /, Cru ks'-}. �✓p�y S-I' �/ Z �w
Name of Person Responsible fur/Cunstructiun License No. and Type if Applicable t�
Street Address City/To n State Zip
Telephone No.(business) Telephone No. cell). - e-mail address
SECTION 11:WORKERS'COMPENSATLON INSURANCE AFFIDAVIT(M.G.L.c.152.9 2506))
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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) =$
1. Building S Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=S
3. Plumbing $
�! 4. Mechanical (HVAC) S Note:Minimum fee=S (contact municipality)
5. Mechancal (Other) I S Enclose check payable to
6. Total Cost I S �� (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I herebv attest under the pains and penalties of perjury that all of the information aonluned in this
application is true and accurate to the best of my knowledge and understanding.
/�.an /e-- " 6-way 9176 .5:-78- PS-8/1 rZ
Ilea. print an );n name/ fitly Ft4,vphoneNo. Dale
r \ �U'ca•1� Ufvi Topvn a i p'
pU ti I L c.�
(
Municipal Inspector to fill out this section upon application approval: ' ZSr' co
Name Date
•
' - CITY OF S.Uxmg MOWS XCHUSEM
8L'QD6VG DEPART11EAiT
120 W.%jHMTON ST Rmm. )"FLOOR
TIL (978) 743.9599
F.ut(978) 71495td
KIM®EA"Y DRISCOLL nw"ASST.FUUM
%4AYOR D,RgCTon oP 1R SLIC MWVgRTY/IK ILDNG CoaaBsu0.%ER
Workers' Compenstion Insurance Allldslait. guilders/ContractonlElectriclsnslPfumben
%nollcant Infmrmatlan Phase Pero Ledblst
valve IeeannwOrSa^rrallMtrrbvrde.11: /1nia 2G/-fL GC � �' a oV S7
Address'
Cily/StatdZipr. 91 A. Phone
F
wplsyf!Cksk tAs apprepslase kam Type of project(rprlre/jc
mplayw with s. ❑ 1 am a gild eeasgelm ad1 ❑New coosaucdos
�(Am�Wre'dme6t have hired do at►esttrnesom
IiatN see tM asacha/sl6tet 7. Q Remodeling
ole prepriator ors•panutan have no o nplayas Them rt►eantteaaere hove s. ❑ryamolitiem
forma in any capsity. workers'comp`fnwusaea 9. Q Building addhios
rk::'comp` ittarrrattce !. Q We am•capsn:das ad it I0.❑Electricalnpeirs or additionsnquirarL) :7ksm have aaadad their
).❑ 1 as a haatanwnr doing aB work ^tild d�^P�Pr IMOL 11.❑Phunkky tepatts or addkloreg
myself.1N0 workers'comp. e. 13%#1(41 and we bM no 12.0 Roof elapsing
insurance requiradl t c'"pl°3 1146 wo bms' 13.0 Odw,
comps istuar4a tlagekd.i
•nq ygMar nor attarae 6ts rl eeae a6w ns yr ter rw:6rlw A..I.g rkJr aesaaa'ranea�eree valley irrarrtttetra
't hrs.srwerse eks.u6tae atk sle+ee idtd4 deny s tlsire d wtA aae wee Eke arraitYeseuarriw rrae rrrAN•w a1lfrlrvk iMleeiq.r.►
'f...r.�res r6r1 c6�Y rW r n^r+aerYa a ad8iwr deer.6erlq rAe rerae drag wAtwaertre rrre rtrrb wararre'ta*/rM1 i�rrrreL
/sew law rw/byo►rAwr b pretr//bR ewAM'rrwpewrerlra/wawswaJir q eaepAryses S/Alee b nwpati ewl�else
in/wars&&
In%urance Company Vamr.
Policy Our Salf--ins.Lie.AF Etpirallem Darr.
)ub Siu Arhhrac Ciq/Slagal
.glnack a copy of tie workers'composadem pallet'tlockrelles pop In'glektg lkg pelky gamber sad esplrulen daAajr
YvIun to sacure coverage w rcquirad under lectles MA of JtOL a. 132 can lead to the imposition of criminal pertalMe of a
fine up to S l.)00.00 arul/or onager itnprimrtnwtw.at wall as Civil panahiee is the fans of a STOP WORK ORDER ad aline
Of up eo 3210.00 a Jay ryaiest this violator. IN a@M.*W that a cupy of this rauemenl may be rwwrtrded to the 0171ee of
ptiurta ur rho nlA far insurance covaraee v%olkatiot►
/Cis herway err`d'/jr/rnnAw/AlOriwa Yw_/pennrd/as tj/tr/uq#Aar rye infMMdM proeilW ubw is mw nwI a wrrd
:i.•n Hurt' �T/� _ � 'vim` Dote: �/� ��/(>
c o
P`ut:a a•
t7arkid ne u..//a As lad r.Wty is this Wore*to Air.utwp/rM/lap ciy w/aiew a/Ikw
City or ruwn: errmit/r.leeneel__
Iwuarts Aulhortty (circle rrnel:
I Iluird ul11rJUk 1. Ruddlny Mp.64,11,19vat i. Citltrowe Clerk 1. flecirical lntpcclor 1. Plumbmt Impeetor
6. thher
l•,ntrcl Person: _ _ Phone 0.
`\ CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
ta tl'T •5•,I1\I, fit.\��\I I11 J 1.`�t'1•�
rrl:'/ 1•N4$ys �1°\1:)7t♦•iJJ'IMM,
construction Debris Disposal Affidavit
(required 1'ur all demolition and renovation work)
In accordance with the sixth edition of the State building Colt, 780 CMR section 111.5
Debris, and the provisions of MGL c 4U, S 54;is issued with the condition that the debris resulting from
Otnilding Permit H�—
this work shall be disposed of in a properly licensed was Disposal facility as defined by MGL c
S 150A.
The debris will be trunsportcd by.
Inattta of hauler)
The debris will be disposed or in
(namaul ul ny
taddre34 of 11acllity)
„mature o twrmir rpylicanr
Date