Loading...
16 LYNCH ST - BPA-16-1394 SASS K lie )�4o f The Commonweafth" cif-, w; Department of Public Safety Massachusetts State Bu,'W "V"One- Ro-Family Dwelling Building Permit Application for any Building other than a or (This Section For Official Use Only) Building Permit Number':` +'k Date Applied. Building Official. —t 9 Of SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)-- ---- 4wa 1.4 9121970 AC4­110r'=aq No.and dire-et 4 City/Town Zip Code Name of Building(if/appli 11e) hjz: '7 SECTION 2:PROPOSED WORK Edition of MA State Code used- If New Construction check here LI-61check all that apply in the two rows below Existing Building 0 Repair 0 Alteration 0 1 Addition 0 1 Demolition 0 (Please fill out and submit Appendix 1) Change of Use 0 Change of Occupancy 0 1 Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 66 No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No 0 Brief Descriz on go Prop ed Work: z 44 �u -1 - - -4qv" .,jq;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) IJ 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.) v Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GRQUP,(Check as applicable);, A: Assembly A-I 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0 F: Factory F-1 0 F2 11 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0 I: Institutional 1-10 1-2 0 1-31:1 1-4 0 M: Mercantile 0 R: Residential R-10 R-2 0 R-3 EI R-4 0 S: Storage S-10 S-20 U: utility[j Special Use 0 and please describe below: Special Use: SECTION 6:CONSTRUCTION,TYPE(Check as applicable)- IA 0 IB 13 IIA 0 IIB 0 IIIA 0 IIIB 0 IVO IVAD VB 0 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: Public2f Check if outside Flood Zone 0 Indicate municipal/ A trench will not be Licensed Disposal Site 0 Private 0 or indentify Zone: or on site system 11 required 0 or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 11 Yes 0 or No[] Yes 0 No 0 IF ........ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY ,,r,., s�1 Edition of Code: Use Group(s):— Type of Construction:— Occupant Load per Floor: Does the building contain an Sprinkler System?:—Special Stipulations: The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code (780 CMR) yrv ?i Building Permit Application to Construct, Repair, Renovate or Demolish any Building other than a One- or Two-Family Dwelling Code and Other Requirements for Building Permits The Department of Public Safety has issued these building permit application forms so that municipalities across the state can move toward use of a single permit form and consistent permit application process. The MA State Building Code specifies the requirements of building permits and the applicant is advised to review and be familiar with these requirements in order to avoid some of the common permit application problems. Likewise the applicant should be aware that some municipalities require that the owner confirm, even prior to acceptance of the building permit application, that no outstanding property taxes, water fees, etc. exist. Filing Instructions 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be reviewed if construction documents, specifications, fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a check for the Building Permit fee. The fee may be calculated using the information to be supplied in section 12 of the Building Permit Application. The check is to be made payable to the local city or town where the work will be done. l tii• SECTION 4. PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Sueet City/Town Zip Property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail 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 relative to work authorized by this building ernut application. t�,E ,. _ )a'E SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) =t If buildin is less than,35,000 cu.R.of enclosed space and or not under Construction Control then check here O and _ .., t`h( / nd ski Section 101 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 = G . mpany P&Ihe Name of Person esponsible for Construction License No. and Type if Applicable Street Addr - City/Town State Zip XIZZ Telephone No. business Telephone No. cell e-mail address r SECTION 11:WORKERS'COMPENSATION 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❑ No ❑ ' SECTION I2:'CONSTRUCTION COSTS AND PERMIT FEE J .. ,... Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6) _$ 1.Building $ ©0 0 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ .0 i7.0 appropriate municipal factor) _$ 3.Plumbing $ lDG?� 9p 4.Mechanical (HVAC) $ Ll , Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ y 45 i (contact municipality)and write check number here `SECTION 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 knowledge and understanding. Ple se print an gn name Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval. i x Name, .. ' Date r_.... Fri: .....__... " Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot # for locations for which a street address is not available) No. and Street City /Town Zip Name of Building (if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) i CITY OF SALEM ROUTING SLIP New Construction Certificate of Occupancy LOCATION 16 5 r DATE ASSESSORS DATE 1 1Z6 1, 93 Washington CITY CLERK CLERK DATE for Engineer: On behalf of �93 Washington St. I avid H. K �nowlton, P.E. City En meter l PUBLIC SERVICES DATE t4I28� Lb ,i er. On b ^ Liar Engineer. On behalf of 120 Washin St. lryid H. Knoywllt/ton, P.E. City Engineer k.WATER DATE (1/L,9))( a�Eng veer: On behalf of 120 Washington St, oawd`H. Knowl on; RE. City Enginew CROSS CONNECTION"JljATE �) Z� , �f 5 Jefferson Av ��IQ lvitw i,Matew�w��.h'.� r,r XPLANNING l/"ti� DATE h1l51LC1kP 1104(s ov% plan rvA4Fk24 120 Washington St. V�� 11,K.1Q0k%a— CONSERVATION ' ATE p O 120 Washington St. ELECTRICAL "ATE 48 Lafayette . FIRE PREVENTIOI�or� ,&.Q ATE 912 ) 29 Fort Avenue HEALTH DATE 120 Washington St. BUILDING INSPECTOR DATE 120 Washington St. d - w Requirements New or Re-use Construction August 24,2012 Page 3 Baca ow Prevention Device Design Data Sheet (one form for each device) J 1.Facility: A. Name: <k,4i N U 1� �je c o� Sc (e yvi - vn v ss r ti 1 F / J B. Address: /6 (e� , v^1* C. Phone Number: 9-7 r-- 7v v- 4360 D. Contact Person: wuLx, B. Contact Phone Number: S o�- q S&- /f 3`1 F. New or Existing Facility?: Nrnt,..) G. Description of the type of business and functions which are carried out at this facility: i {1 I i 2. Owner: A. Name: SV�e_-F i s r J T rvs t- B. Address: a'1 s4.e f 5<Izo:ij w1g n4f-)() C. Phone Number; - o - o 3. Device Data: A. Device Type: D C y A B. Model Number: 3 5 o y)s T C. Size: 4" D. Hot or Cold water device?: c o i 0 E. By-pass arrangement?: Yes C_) No F. Type of valves: (Devices and valves installed on fire protection systems must be UL listed or FM approved): G. From what type of contamination is the water supply protected?: f Requirements New or Re-use Construction August 24,2012 Page 4 4.Plan Submittal Requirements: A. A minimum 8'/2 X 11-inch detailed schematic or blueprint,with a completed title block, d stamped/signed by Licensed Plumber and/or Fire Protection Engineer,showing: a. the potable and non-potable water immediately surrounding the backflow prevention device. b. Type of chemical(s)used(if any)and the type of equipment downstream and upstream of the device, c. Alignment of the device. d. Device height above the floor. e. Device distance from wall(s). { f. Location of upstream and downstream shut-off valves. 5. Device Testing(refer to 310 CMR 22.22; 9) A. As required by 310 CMR 22.22 and the City of Salem Cross Connection Control Program, a. Reduced pressure principle backflow devices (RPZ's)shall be inspected and tested at least semi-annually by the City,but not sooner than within 5 months after the first inspection. b. Double check valve assembly (DCVA's) and pressure vacuum breaker(PV's) devices shall be inspected and tested annually. c. In cases where the City feels that due to the degree of hazard involved,additional testing s�wartan ed Backflow preven `on devices will e tested more frequently.Costs of the annual test and additional tests will be borne by the Groner. Submitted by: j2pL� s-, Company: ALA- Cs )- Phone Number: 9 7,f- 7 t.4 Date: /U IN/(a Owner/Agent: Signature: Date: /o a g c2 6 O For City use only: Design Approved by Cross Control Program Coordinator?: Yes U No( )Date: Device Inspected: Date: Approved?: Yes U No U Approval Letter Sent to Owner: Yes U No Date: IkplaGe %Jdewalk witA CUNWA40- . ,�, ?.�1S�tb Ac�o► Co�rurllr CRossw a1� f :eu V C.kkAM Haar ✓ w y I f ^''— ! -, r N If J � NEJY GYMNASIUM BUILDING c " / b • !� 'i; p r F007FiRI4'f ARE(J.= 11`390 f S.F._. o/r/ ,T .Y,.1 f w ! L / T. r J7 s44 m�4°s�� 1 r'"�_�xdp�� f �•/�P;.{�` .. (r.!/ �%jjj(f i ! wnim e.vm' nz . v ��.._. �-®�.._•.��e._— _.v _ v..,...�,._...� ��!�a! SITE PLAN a>7w"r_ amamo eBU..i Cy7YOFSM IA MASSAa"E7T BULUMDBrARnEn 120 WAMC7ONSMeT,30FLM IkL 745-9393. $I�BRTLrjrrflFI XL FAX 740-9M MAYOR 71io�ruST.P Construction Debris Disposa/Affidavit (required forall demolition andrenovation work) In accordance with the sba edition of the State Building Code, 780 CMR. Section 111.S ftft; and the provisions of MGL c00,S 54; Buti ft Permit it is issued with the condition that the debris resuf ft from this work shag be disposed of in a properly lk:ensed waste deposit facility as defined by MGL c 111,S iSQA. The debris will be transported by. PAg utc ( jac IP (name of hauler) The debris will be disposed of in: (name of fadlity) —� (address of facility) nature of applicant Date The Commonwealth of Massachusetts Department oflndustrialAccidents x 1 Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name/j/.t� )UZ Address: Ci /State/Zi n n' P' "nD Phone#: ft :w- !A ?,J Are you an employer?Check the appropriate box: Business Type(required): 1. I am a employer with '7e'57 employees(full and/ 5. ❑Retail or part-time).* 6. ❑RestaurantBar/EatingEstablishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers' comp.insurance required]** 11.❑Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance jar my a loyees. Below is the policy information. Insurance Company Name: 414g Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# AWd--kp,6 /297—,2" eA Expiration Date: /19411 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,,trndev:(tre pai p alties of perjury that the information provided above is true and correct. SiQnaturdt,. �'T Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.imss.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply your insurance company's name,address and phone number along with a certificate of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'workers'compensation insurance. If an LLC or LLP does have employees, a policy is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 www.mass.gov/dia Fonn Revised 02-23-15 l Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-001247 _ construction Supervisor MICHAEL J WELCH J=' . 21 BRADKEE/RD MARBLEHEAD MA 01945 ,,. Expiration: Commissioner 01/01/2018