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13 MARCH ST - BUILDING INSPECTION (3) � T The Commonwealth of Massachusetts `1 E; I, Department of Public Safety \la.,sachusetts Stale Buildin •Code 780 C.MR -,v n Edition A h 1 )4 r th Ed(hr n �In City of Salem WWW Building Permit Application for any Building other than a 1- or 2- 1 it Dwellin (This Section For Official Use Onlv) Building Permit Number: Date Applied: Building Inspector: SECTION 1: LOCATION (Please indicate Block 0 and Lot N for locations for which a street ad re s .;'n available) No. and Street City /Town Zip Code Name of Buildin v(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building drRepair❑ Alteration ❑ Addition ❑ molition ❑ (Please fill out a nd submit Appendix 1 ) Change of Use ❑ 1 Change of Occupancy ❑ 1 Orher ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural En nneerin Peer Review rri wired? Yes ❑ No ❑ Brief Description of Proposed Work: / [ glielz of 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) ❑ Existing Use Group(s): Proposed Use Group(s): r - ExistingHazard 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 5:USE GROUP(Check as app licable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B. Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: HiRb Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ 1-2 ❑ 1-3❑ f-4 ❑ M: Mercantile❑ R. Residential R-113 R-2❑ R-3 ❑ R-4 ❑ S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: ench Permit: Debris Removal: Public C heck if outside Flood Lune❑ Indicate municipal A trench will not be Licensed Disposal Site rcyuired ❑or trench ur s p I'r n'ah•❑ or uTdcnlily Zone: or on site scslem ❑ ucil\': permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: \I:\ I li>6 sic l �nnmir�ion H...n.. .Not Applicable❑ I.SIr:Cturc rvuhut airport apprnach area.' Is their re%icry completed.' or("m'cnt (o BUIld rndo.ed ❑ 1'es ❑ or No❑ Yes❑ \o ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY 1_.110:011 of C-I'la•: Lsr Grrn:p(sl: rr pr of Cunstrucuon: Ocai Pant Load per Flour D) w, the building;om(ain an Sprinkler Sc stem..' Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION t Name and Addr ss of P o arty Owner Name(Print) No.and Street City/Town Zip Pr rh'lhvner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address If tl� �plicable, the properly,m ner herpeby authorizes l Name Street Address City/Town ~late Zip to act on the +ru+erty owner's behalf, in all matters relative it,work authorized by this building permit a p Mica Gun. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If Intildin•is less than 350io cu. ft.of enclosed s pace and/or not under Construction Contrut then check here Oandskip Section IU.I) 10.1 Registered Professional Responsible for C o n st ruct ion Control ��d✓ CmgL��/�S'T� �.-�--`c'�` ��y,1 ,/�A/�!✓�!z'(ry/Ti�l✓/�� Name(Re ristmnt) Teleph ne No. a-marl address Registration Number Street Address tilty/Town Mate Zip Discipline Expiration Date 10.2 General Contractor u Cum ny Na Na a of a on es msible for Co +t tctiun I'r - 'tense No IO r licable Street Address City/Towryt J �t�e mod✓ �T Telephone No.(business) Telephone No. (cell) e-mail address 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 ' uance of the building permit. Is a signed Affidavit submitted with this application? Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor � eel and Materials) Total Construction Cost(from Item 6) _$ 0/ro� 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note: Minimum fee=$ (coot n nicip ) 5. Mechanical (Other) $ Enclose check payable to _y h 6. Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT - Bv entering my name below, I hereby attest tinder 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. lease prin and ,gK name ,}�/O Title Telephone No. Dale �trerl Address - City/Town tit Zip .Municipal Inspector to fill out this section upon application approval: 30 0 Name Date t t CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT .Mit: an I Y:)xlill rt 1. �Lir"g 12C WAiflt1(iIONS-txELT • SAL lixt, Msis.vcan if I IS )7� fr.l.: VS-743•9595 • I'sx. 978-74C-7Y46 Workers' Compensation Insurance Af ttlavit: Builders/Contractors/Electricians/Plumbers \nnlicant Information Please Print Leeibly �181T(:tducuxssiOr,+,anvatinrJindtvlduall:�(,� - /IJ�t r//J��//1 /A�// / :Address: 6!Y)r_ kD ��T le City S[a(ei7.ip: Phone /'•: :\n you an enytloyer? Check the appropriate be 'Type of project(required): I.❑ I and a employer with 4. I ant a general contractor and [ 6. ❑ New construction employees(full anLVur part-time).' have hired the sub-contractors .❑ 1 am a colt proprietor or partner- listed on the anachcd sheet. �• Remodeling ship oad have no empluyces These sub-contractors have S. ❑ Demolition ,working for me in any capacity. workers' comp. insurance. q. ❑ Building addition I No workers'coinp. insurance 5. ❑ We are a cotporution and its 10.❑ Electrical repairs or additions required.) oBiecrs have exercised their 3.❑ I am a homeowner doing all work right of exemption per NIGL I I.❑ [plumbing repairs or additions inyself. (No workers'cunip, c. 152. §1(4),and we have no 12. Roof repairs insurance required.) f onployees. [No workers' 13.0 Other ln cop. insurance required.] •any.yphcaul Alai checks box All must alas fill out the seclmt below slowing,heir workess'cumpens:aiuu policy inturnWllYn 'tiomcuwrwn who wlanaf this affidavit indiwling they are doing all work and then him outside contraction must.uhmil a new affidavit indiu,ring inch. -C'amrwoirs that check this box mtsl auached.m additional.,loan showing lM`nano of the tub<ontracion and their svurken'comp.ptdicy infannalon. /am an cagr/uyer,/rut it providing rvurkers'c•unrpen.cntinn insurance fur sty enlp/ogres. Below is the policy and job site fajwtnutiun. Insurance Company Name: Policy is or Sclf--ins. Lic. i}: ___.. .. . . ... .._ Expiration Date: Job Sitc Address: city/state/Zip: Altach 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`IGL c. 152 can lead to the imposition of criminal penalties of a line up to S1500.00 and/or one-year imprisoluncnt, ae well as civil penalties in the Lunn of a STOP WORK ORDER and a fine Of up to S250.00 if day agoinsl lite violator. Ilc advi3cd that a copy of fills statement may be Cur%arded to the Office uC Inr:saga eons ul'thu DIA for iniurance coverage terification. /do hereby certify under 1/0 filn•and p lnhfcr oj'perjary that the information provider/above is true and correct. tiirruure Mat , — — Official use only. Do not n•rfte in this area, tube completed by city or rotvn u/jichol City or'fovrn: ._ Pcrmit/I.icenste 0__ Iwsuing• tilhurily (circle one): I. Ill,ard of Ilvalilt 2. Iuilding Department 3. Cityi Town Clerk 4. Llectrical lnspector i. Plumbing Inspector I 6. Other Contact l'ervun: Information and Instructions Massachusetts General Laws chapter Lit requires all employers to provide workers' compensation for their employees. I'ur�uanl to this etatul C, an emPlnyee is defined as"...every person in the service of another under any contract of hire, %press or implied, oral or written." An employer is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more or the foregoing engaged in a joint 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." MG.L chapter t 52, v+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 nut any of its political subdivisions shall emer 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 sub-contractor(s)namc(s),.address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry 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 dote 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 he 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 penniu'licelse applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicmu should write"all locations in (city or town)."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. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he i)rlice or Investigations would like to thank you in advance fur your cooperation and should you have:my questions, please do nut hesitate to give us a call. The Dcparunent's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-727-7749 www.mass.gov/dia CITY OF SALEM ( PUBLIC PROPRERTY I DEPARTMENT M ul< 120WAS11M.;ONS❑t GrT • SAIIM. btAsiV I I t PII - 'f1:1: 978-745-9i95 • tSs X:978.740.9846 E Construction Debris Disposal Affidavit (required I'ur all demolition and renovatiun work) In accordance with the sixth edition of the State Building Code, 780 CIvIR section 1 1 1.5 Debris,_and-theprovisions_ofWLc40,_$54;_ : _ __._. . .. ---___.-_ Building Permit # _ _ is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111. S 150A. The debris will be transported by: name ofI iauler) p The debris will be disposed of in f (name u as y) �© Liar a2� AP' S—VO&I (add ss of facility) _0 a s' natur of permit applicant 1 — P date Jchri utl du< -