103-105 LORING AVE - BUILDING INSPECTION ;► ' The Commonwealth of Massachusetts
. l Department of Public Safety
,..,,.j \I.uachusetls State Budding Code(780 C\IR)Seventh Edition
City of Salem
v BuildingPermit A lication for any Building other than a I- or 2-Family Dwellin
(This Section For Official U..e Only)
�. Building Permit Number: Date Applied: Building Inspector:
SECTION l:LOCATION(Please indicate Block N and Lot 0 for locations for which a street address is not available)
No.and Street City /Toavn Zip Cade Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here Cl or check.ill that apply in the two rows below
Existing Building❑ Repair Alteration ❑ lition ClPlease fill out and submit Appendix 1)
Addition O Demo
Change of Use ❑ j Change of Occupancy IOther ❑ Specify: t o
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 13
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 63
Brief Description of Proposed Work: -
1A���
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 Croup(s): Proposed Use Group(s): t
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.)
SECT70N 5.USE GROUP(Check as app livable)
A: Assembly A-I ❑ A-2r ❑ A-2nc0 A-3 O A40 A-5O B. Business ❑ E: Educational ❑
F: Facto F-1 O F2❑ H: High Hazard H-1 ❑ H-2 O H-3 ❑ H-4 O H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 14❑ M: Mercantile O R: Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage S-1 Cl S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIAO fill Cl [III C37 IV O 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:
PP Y .
Public ❑ Check if outside Flood Zone❑ Indicate municipal ❑ ATrench will not be Ltcen.ed Dispowtl Site❑
required❑or trench or.pccif\:
I mete❑ or indcnti(c Zone: 1, on ate>vdem O permit is enclosed❑
Railroad right-of-way: Hazards to Air.Navigation: \I,\ I luh,m Connoi-w,Rea i,•,,
\'It Applicable❑ I.Strucnne tcuhm airport approach area.+ I.their review completed? .
a llnt�cnt to Budd citdo,ed ❑ 1'e.❑ or No❑ Ye.❑ \o ❑
SECTION B:CONTENT OF CERTIFICATE OF OCCUPANCY
I:'d tton of (-, .lac U,v(.roupid: . rapeof Con.trucuun: 1
. l caipant Load per Plour:
I)—le, The•buddutg t nttam.In Sprinkler Sc.lem' Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address❑t Property Owner
Name(Print) Nu.and Street City/rown Zip
1'ruperty lhy ner Contact Information:
p w•,�...c,— CA's N23 - a 160 — —
Title Telephone No. (business) Telephone No. (cell) a-mad address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relate e w work authorized by this building permit a >,lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
tll buildin•is liNs than.ti,WU cu. It.of enclusavl s.ace and/or not under Construction Control then check here O and slup Station IU.I)
10.1 Registered Professional Responsible for Construction Control -
Name(Registrant) Telephone Nu. e-mail address; Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
'
Ca`�I SfCK �JJ �1 C}i.-� P-( '1C-C.in..oc�G��.. � �r✓�C
Cump-l_n,y,Name:
Name Perwn [ipmsiblr fur Cunstruction License No. and Type if Applicable
O , \��Y l3 r Sa fie., , AA o l 4 t o
$t t Address City/Town State Zip
yd�_ (�1cu 472- ffl - -1-11 a
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COWENSATION INSURANCE AFFIDAVIT(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 application? Yes 0 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
1. Building $ 6c-' Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing E
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ —' Enclose check payable to
6.Total Cost $ ap6 (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 contained in this
application is true.md accurate ki the best of my knowledge and understanding. -
`�i�c
Please urt and n name Title Telephone No. Dale
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: � �� _ ��� XD
Name Date
cx �t 5i�y �179
,A CITY OF SALEM
PUBLIC PROPRERTY
�.
DEPARTMENT
I'.11: MI I1 '•Mlr 1'•I1 '
\I .1"N I_'C�•.\.111.\L:+!V)1'Mtl'f�5.11 I fl,ti1.1».N I11 N I,•IF I:171.70")P6 •1'.\9:778'740.11846
Construction Debris Disposal Aftldavit
(required lur ail demolition and renovation work)
In accurdancti with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40,S 54;
Dui Wing Permit p is issued with the condition that the debris resulting from
this work shall he disposed of in a properly liccnud waste disposal facility as defined by MGL c
I l L S 150A.
The debris will be transported by:
Ilame of hauler)
The debris will be disposed of in
✓ C
4 '
(natrla ut 7]�ny
UVI 1/a
t;Iddres,\Ir t�.dllyl
l� 4
+Isnature OFlxrmit applicant
"4- -)`7 - l y
due
Ichn•dl L,r
t
CITY OF S.U.E.`I9 UX5SACHL;SETTS.
EILMDLNG DEPARTMENT
1_2o W.1 mmarON STMET. r FLOOR
TEL (978)745•9595
FAX(978) 7449611111
KINIBEA"Y ORMOIl
NAYOI< THohW ST.PIaRRR
DlliAMR OP pL eLIC PtOPERTY/K RDLVG CONMOSSION ER
Workers' Compenaatlon Insurance Affidavit: Guilders/Contractors/ElectrlclansiPlumbers
anallcant Infarmallon Plea
se Print Letibly
Natneltlurtne+.Orynuanevlr.bvArall: bin ISK\<
Address: x :>,
City/Stare/Zrp: se-1 (v ✓A Phone N �, 1 0 —1 t t l7 ct
\re oe n empteyer!Cheek the appropriate beat Typo orproist(regrlre'
1.�1 am a rrnployor with 4. ❑ 1 am a SMOW eoaaaeW Mad I b Q Now construction
employes(fWl and/or part-time).• have hkad the m►eomiticaow
2.Q 1 am a ate proprias of parmer- listed an the anschad abed: y ❑Remodeling
.hip and have no employes Then sub-ctammaters have a. Q Demolition
worbin ror ma in as cat workers'comp.imuenea
{ y capacity. 9. Q DuiWin{addition
INo workers'comp insurance S. Q We sro a corporadars and is
' rcquiraLl
otlleers haw exercised the* I0.❑Electrical repairs or additiom
).Q 1 am a homeowner doing ad work rigW of esanprion per mail. I I.Q Plumbing repairs or additions
myself.(Ne worbaa'comp. C. 1 S2,#1(d),oral we haw no 12.0 Roof rapsiea
insurance required.)r employetw.LNe waters'
comp insurance ttnpireii 13.❑Otbar
Any appnm/filer dWO as et near Asia In WA tM arena stew Aawino thdr ealaw'�r pa"indrnYles,
'❑.sum, ., i the suhwe Ole atedva indletltq that'an"M all waA ad thin hire wibawosra nsnr a.laaa a nw allldmvb MinriA.nA.
lhd hW11 till Ua nor aeavh.e ere 3466WW it%"r..+ty dw news attr wr..rnn...r ds.lt wwa.a'mn7•p.ttay hanws.da.
/utw ew rwplrys�tAae d pnv//Iw,*trrrerrs'roaprwradra/rararswp/es a4 ray/oyaea QeArw b tAe pNlej rw//e1 alit
!n/orwrwlsw
Insurance Company Nomr.
Policy a or Self•ins.Lie.As: ON F_i< Expiration Dow:
Job Site Address I c� ( u 1� - C City/StatNZip: Sin(c v,-A A
.%track a copy of the workers'compensation pollen deelaralles pop(Ameing the palky i amboe and aplrWoa date
Pailun to stun coverage as required under 3ation 25A of MGL a 152 can Ind to the imposition arcriminal penalties Ora
fine up to S 000.00 and/or one-year imprisonment.as well an civil peneltis is the farm of a STOP WORK ORDER and a ifotl
of up to 5250.001 day jtlainst the violator. Ile advi.*W that a copy of this statement maybe rurwurded to the Odder of
Mccauymiun.ut'the DIA far insurance coremtla svitkatwa.
/J@ herby errs!y u thr iwa a ytnr w o/per/ury PAN tAr in/arnedow provided abow is�tlnta rn/a wrtd
,;.! t
OJJfiir!we md/t Or nor writ/iw%hie crew rr d/.rrwp/i/d by riry w taxw a//k 4A i
city orruwn: Yrrmit/Llcensel__, __ __ I
Isawnt.%whenty ltirc4 nnq:
1. Iluard of Iltallb 1. Auddlnahepartnsval ). City/fown Clerk 4. flectriaal Nipecior 5. Plumbing Inspector
&.Other
i /,•mast Person: _ _ .. Phone a•