2-4 LORING AVE - BUILDING INSPECTION (2) eo
The Commonwealth of Massachusetts
Department of Public Safety
JVV��
•}; i;, NIassaChuseIts Slatr Building Code(7811ChIR)
""r + Building Permit Application for any Building other than a One-or Two-Faotily Dwelling
(I his Section For Official Use Only)
Building Permit Number: Date Applied: _ __ Building Official:
SECTION 1:LOCATION (Please indicate Block B and Lot It for locations for which a,street address is not available)
No. and Street Cih, /Mown Zip Code Name of Building(it applicable)
Sli IION 2:PROPOSED WORK--, ,-,
Edition of NIA Stale Code used I,!T'cw=lstruction chock here❑or Check all that apply in Iho two rows below —
Fmsting Building Repair EelAlteration Addition❑ I Denxtlilion ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: — _
Are building plans and/orconstruction documents being supplied as part of this permit application? Yes ❑ No - --
IS an Independent Structural Engineering Peer Reviewrequired? Yes ❑ No V
Brief Description oI Proposed Work: S�(13P +- d-Ht.E S`LD"�'UCr' O!J t S`- 17'C 'f-�PsA•2. OF
cM$.�(y _
r
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 CKIR.14) ❑
Existing Use Grrxlp(S): -r. - Proposed Use Group(s): -
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) 3 Of
Told Area(sq.ft.)and Total Height(it.) soo fQ
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-I ❑ A-5❑ 1 B: Business ❑ E: Educational ❑
17: Facto F-I ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ 1-1-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-'10 R-2❑ R-3❑ R-I❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 18 ❑ IIA ❑ 11130 IIIA ❑ IIIB ❑. 1 IV ❑ 1 VA VB ❑
SEC"TION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water SupP Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
;r A Irench,% not be Licensed Disposal Site❑
Public Check if outside Hoed 7_one Indicate numicip.d ❑
required or trench or spt.CifyR;QWM__—
Priyatr❑. or indentily Zuno:_ or on site system ❑ ,ennit is vnc lased❑
Railroad right-of-.va Ilazards to Air Navigation: �i t i,.i,n„ , "�n..........
Nut :\pplieahlr Is Structure tciIh in eirpnrt ap+ ach aroa? Is their crylew contpletv'l f
or Consrnt h+ fiuilJ onClosrd ❑ Yes❑ ar:Vo ),.So No a
SECTION B:CON'1'IiN,r OF CFRTll:lCA'rE OF OCCUPANCY
Hors Ihr bui�ldJiJng contain an Sprinklrr System?:_—._____SPrcial Slipulali+nts: .__
SECTION 9: PROI'FRn OWNER AU 1110RIZA'I[ON
F�it
of I'rapvrly Chenrr .
� fc_ owe ---
No.and Street Cih'/Town — - Zip ntact Infonnalion1 itle Telephone No. (business) Telephone No. (cell) e-mail address
It applicable, the property owner hereby authorizes
���i�� P IOtcXf�w7u�seeY�SG�aU_S� Critx+r l _4 ?r
Name Street Address City/Town Stale Zip
Ill act on the property ocv ner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildin.is Icss tlian 35,000 cu.ft.of enclosed space and or not under Construction Control then check here 0 and ski Suction 10.I
e 10.1 R istered Professional Responsible for Construction Control
Name Registrant) _ a-mail address Registration Number
lawr- W.Agt1 fib*Al 5`t ( I = VI Dk3> � 5/i i
Street Address City/Town Slate Zip Discipline Es) ra ion Date
10.2 General Contractor � ,�,y�
_ ( 4KC(f'� l--4WCf-
&f `O f+ CONJ'tD—
Company Name
6LlZec-��-
Name of Person Responsible for Construction License No. and Type if Applicable
IOfo`f fZ WSGff.C�Ze�t3 S1 Esttiu[t'SfE£L WA 014'io
Street Address City/Town State - Zip
Telephone No. business Telephone No. cell a-mail address
SECTION 11:tcu na,hl ti'c ON W]_\Sn_tu a.N 1:V61q:A.NC V Atiijw v'I M.G.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 a lication? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE -
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=S7t17
1. Budding $ Building Permit Fee=Total Construction Cost x (Insert here
? Electrical S appropriate municipal factor)=5
3. Plumbing S
a. Mechanical (HVAC) S Note: Minimum fee=S (contact loon icipalily)
3. ,Mechanical Other S Enclose check payable to
h. Total Cost $ 3CV's7 Ilicontact numicipality)and write check number here
SECTION 13:SIGNATURE F BUILDING PERMIT APPLICANT
Ny entering my name below, I hereby altcst,under u• ails as d penalties of perjory that all of the information contained in this
application is true and accurate to the best oftiny td understanding. i
Please print andpps�yll�mo�p�e .Title T lcphonpe: . Dale
Sheet Address City/Town Stte Zi
Municipal Inspector to fill out this section upon application approval: �C6 W
Name — Dale
i
; 11 CITY OF SALEM
(PUBLIC PROPRERTY
1 Y ,n I DEPARTMENT
wq n f N.•11
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I!:\1tA%td.\%it,r,\318CYT ).%l l•N, At.1 U.11.1It a1'11��177.'.
Yorkers' Cumpensotlon Insuruner :1111duvir. 8ullders/Contractors/Ele<trlclyns/Plumbers
J tllcan In tirfnutio
VillnelllUVlla%YI)/aylVLlltNlnJlrulYYl p•t-��]��I •T �.Ap� lrl h1
1 W"1C
ltltlresv: C7 .v
City,State,lip-
I'huned 7J�3' r6'f_l-,3Z
I .1ry y uu an eugrloyar'!Chuuk the:glprnyrlwq boa;
I ❑ 1 .0 a employer witA J. ❑ 1 :ua a gunural cauuaelor and I 1 yPe urprn/act(regalrvd);
nlpluyeuY(lull anlYur purt•linu).• have hired the.vuh•uumracrors h' ❑New cullntructiun
-s 1 um a solo pmpriunw fir partner• listed on the atraehed.cheat t vhip and have no uln lu cvr �• ❑Ranodelin�
%corking Air no in any opacity. nits
ro'goelp iny�ce.•
g. ❑fyemalirion
I I'm wurlturs'cutup. insurance 3. ❑ We are a corporation and its 9• ❑ Outfitting addiliun
ruyuircd.J 'Wrcers have evervinud their 7.(] 1 11114 hotnv u%vnur Juing all work right of e.�eln lion 10.[]Electrical repairs or additions
myself. jKla %vorkcrs'cool D per bl(1L I L❑Plumbing repairs or additiary
invuraca r D• C. !32,¢1(J),and wa Maw fin
rc4uired.J clnployeer. (P'o%varkeq' 12.�uul'npuia
fir.•,giber%,6s1 ahvcYs comp, insuranav rnuit d.J 13.L10 O#I, Q� C
Y,u rl mace aIm fill lM w- klur Jwlrm I
I I„m.nrr,pn vM%,Jlna/this 4irchivlt indk+tina Illlty ur,IW'Iry all work a,y l nwY%ri vunl
e•nWt111I11 Rlaicy Inhunlw'(„ntrlvnry lh11 akvY'h,s boa mum atuhvd•n
iIu/urn iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliillI
Ydl,wt Mlla hMsr fluid
cafr f/ldsal rMlllmeibyae wran ar ds rOm nmd YtsYle vv"Ailing
A,wn enlp/ayrrthud lrPruvidlnX n nr"'vCamp.
,Phil
in JIlan*minail•,wavr►seurnprnmflawunul4rw Y p/1 re:R Br/utr/r rAr pa/8p and/ul.rih Insurance Conlpally.Vmnc-._
I'nlicy id,w Sulr•ins. Lic.it: -
---._ EApiratwn Date:��
lob Situ \dJrc�s; ��
\RuA it cu C'Jy,Slatelzip.
Dy of file workers'amnpenlattww pulley Juclarallon page(showing the polky numbu►and esplratlua dote),
P,ll luau u). aura eucernye it required ulIdiprim Suaiun'Sf\ul'.\IGL a. 132 eau lead to file imposition o(eritninal penalties era
Foe up nl 1'I Sn0.fN)an,Yur uua•year 6n ris,imnunr, as wall ar cicd
drllll to i 230.04.1 Juy IdJ11Uf Ill*ri.)l.1f it IIe ad r- that a al pa°ulflu in the Iurtn ut'a STOP 1VORK ORDER and a tine
la%,,.u�aa'nu ul';hu IJh\ for io.uru�c „ r�. a % • RY of the clufamwn may be Aun. Iurw arJaJ W ]he Ulliaa uf'
}• •l site
/Ju hcvrAy r:nijy teal/,•r r r I d u/tits ujyrr/wry abut the in unnuNow
\I,: • j prvrided bur it bur and errree6
J �� l
I0j/14 iul mr d4y. DoDnl nJI'trio in this drew. fu At ruury/rad Ay city ur to Iva a//lase[ '
(ity ur
I%%uing .\uthurit � P�'rtnivl.Iermal
y (circle nnu);
I. IL,.utJ Ir IIvalrla 1. Iluddnl� lhp.lrtlta''lt I. t;ill.'fonn C'Ierk J. Lleclria.11 lul lee lur i,
6. Ihhvr
I l Aunpiny In%yccrar
t•."44 Act 1'vwu:
.. �_ I'Aunr P
i
information and instructions
tkl( their
I ae U.UItusatta
Ucneral Laws chapter I i2 requues all euyrla)a ion m the scry Je of another under
^ny �untnct of hire +
I`unu.art ro sus.uwta, an rnrpfurN is JctineJ a+"...every In
:.preys ur unPI j, oral or written." oranun ur other legal cnhry, ,.any two or more
�n c,�ployet is JetincJ as"am tnJividual. Purtnenhip,assoetanoa.eery
umt enterynso, and including the legal represautarives of a deceased CCO. How.orpluycr,of hhe
a J ,n a )o in '"' ,oy t of the
,,t the G,revuld engat.' Wmanhtp- sssoetatWo ar other legal cnesi amp Y {
ccerver of truateg of.u1 indivtJual, p
owner of a dwelling house having not more than three apartmanu and who reside+therein,or rho n
Of wch employment be JeemeJ to be as employe."
,Iwellrng house of another who employ"persons to Jo maintenunca,cunatruction or repair work on so b Jw employer."
ome
,,r otr the grounds ar building appurtanant thereto shall not because
�SC(ty) also store+that"very slate air legal lagenalo{agaaey hall
withheld the Issuance or
,, it. chapter 132. 4- required
rtnow+l of+license or pornslt to operate•bualaass or to construct w� ih,+lnau Is ran+�coverage
any
VP +, '23C(7i states"Neither the commoce wl h nor any of its politic( subdivisions+hall
r llcunt wile
not produced aeeapta ,t svideace uteump
1JJitiunully, �IGL chuptat 1 S- i ubliu work until aece vable gviJena ui cuntyliastee with the insunnca
cnsr into any contract tot the Perform.rice of D
1
re tof int cnts ul'thi+dwpt+r have been presented to the contractin{authority,"
>yyUcent{ checking the boxes that aDPIY to your situation and it
litaiv s(e+)and phone number($)along with their c employees
of
plc:rw Till out the workarf' compensation )-'Id re completely.by paruterslups(LLP)with no employe++other than the
necessary-supply sub-contractor(p nies(L. have
workers' compensation aubtnired to the Depatbriont o�Industrial insurance' Limited Liability companies(LLC)or Limited Liability ryinsurance. if an LLC of LLP
members or partner. un requite
8 adviseot required to d hat this alfldavk'nay be
employees u policy is Also be sure ro alp cad duo the not the Ckportmgnt the
>ucidenu for contlrtnation of insurance covcaroison for the permit ar h0gree is being requested,to obtain+workers'
or town that the upp uestI Ins regarding the law ar if you are required
ho rctrtmeJ to the eiry you have MY 4 tee should error their
Industrial Accidanu. Should y ant+t the number listed below. Self-insured companies
compensation policy. plea"call the Deoroppr
self insurance license number on the a ro riaro lino.
City or rows omelets Department has provided u space at the butwnl
tinted legibly. The Depa the applicant..
Plcase he aura that the affidavit is cumplcto ;tad phad leant
of the Air or you to IiII nut in the evget the Ol hie of Investigations
l be used'"s need only cub nu aria �tTldsv{it indicating current
nce
lieutian,in any given y r; ur
I'I:ases ba sure ro till in iha pr;rniUlicanso number which will be used;'ha.ante+houlJtwrite'ullllocutiirunrtnin n ap (' Y
tlr:rt moat submit tnultipi+yannit"licaalt under-Job 2pP'lob cito AJdress' the apP '" be provided to the
pulicy.iotormatitsn I if necessary)' ed or marked by ds city or town tray Peach
Policy"��copy of the unlJuvit that has been officially sump'
Applicant as proof that l valid t -nduvit is on rile for tLtun permit+or licenses. t now a urines must m Illled nut ntu
annit not related to any business or commercial venture
arrun is VOT required to complete this affidavit.
y ear. VVItcre a hurries owner or citixcn is obtaining a license of
t i.e. a Jag Ucenm or permit to burn leaves etc.) laid P you have.sly yuesuons,
ttg vu us a all a
kase to in drank you aJvancc for your cooparalion anJ shoul
Ju nut hesitate to d
nc� l).Paruncnt's addrars. tolephune aTh Commonwealth of Masuehum"411
Deparuaent of Industrial Accidents .
Offlea of jilivestigsdons
Street
Epp W&Shingtan
Boston, MA 02111
'rel. q 617.727E 00 ext 6l7 702 of I-sj7.MASSAFE
w w.mass.gov/die
CITY OF S.U_E.Nfg AUASSACHUSETTS
BI:ILDLNG DEPARTMENT
120 WAiHLNGTON STREET, 340 FLoolt
I M (978) 74S-959S
FAX(978).7404846
Kl\tBERIJcY D&WOLL
, THomu ST.ftza 3
DIRECTOL OF PLSUC PROPERIY/HCII.DLNG CONNISSIONER
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 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit tl is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
ff:52( �_
(name of hauler)
The debriss will bedisposed of in
(name of facility)
k-C%?U061;:LO 4(iddress
of fac'lity) ermit applicant
Jam
:.hn..rl( Lw
` Massachusetts- Department of,Public Saret�- .
Surd hr Building Re-4ulatiuns and Standards
Construction Supervisor License
License: CS 79511 _
MICHAELJ MCKEARNEY
1064 R WASHINGTON ST
GLOUCESTER, MA 01930 ,+
r
Expiration: 5/1/2013
('on missimwr T Tr#: 16021