4 MARTIN LN - BUILDING INSPECTION � J
4,w
The Commonwealth of Massacl ` ' AR ,q. �
(� Department of Public Safety YXI +
Massachusetts State Budding Code(780 Cf
Building Permit Application for any Building other than a One-or k9 Ebye li g
\O (This Section For Official Use Only)
Budding Permit Number: Date Applied: Budding official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
Z/ /4+27/N li4laR a e r.-r Aof Q l q7U
1 No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK.
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition O (Please fill out and submit Appendix 1)
Change of Use Cl I Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or 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:
i
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) O
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.)
Total Area(sq. ft.)and Total Height(ft.) -
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional I-1 Cl I-2❑ 1-3❑ 14❑ 1 M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ ILIA ❑ RIB ❑ 1 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 Trench Permit: Debris Removal:LicensedDis Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \.1\I list i i,.,_Crnmnision Ijc.�� t.r xv":
Not Applicable❑ F
cture within airport approach area? Is their review completed?
or Consent to Budd enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
math b1 z� CK - w6 \
1 1
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name nd Addre of Property Owner "
✓�^ AwAff! l q,¢/ y / ta/LTinl �,�v � 6 u, Ol 97 a
Name(Print) - a' // No.and Street 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 owners behalf,in all matters relative to work authorized by this budding permit application.
SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix 2) -
f budding is less than 35,000 cu.R:of enclosed space and/or,not under Construction Control then check here O and skip Section 10.1
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
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:4V0WKERS'C0k1J1FNSA I'[ON INSUI:ANCE AFF'IUAVII' M.G.L.c.152.S 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents most 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 ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE.
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3. Plumbing $
4.Mechanical (FfVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ 3"Tp O (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 id penalties of perjury that all of the information contained in this
application is true and accurate to the best my,knowled and understanding.
4.i/r een / (� &/I _386- 32? TCOOG
Please print nd sig�n mar}}i T�itle Telephone No. Date
�! r7l Laox 4 /c rti fit# 01 rp'7o
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: -
Name Dat
1
.. QTY OF SALEM, MMSACME M
BUILDING DEPARTMENT
i 120 WASFIINGTON STREET,3'FLOOR
TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR MiOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date ;�3 SNn I
Job location
Home Owner Address
Present Mailing Address
The current exemption of"Homeowners"was extended to-include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one* or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner"shall submit to the Building Official,on a form acceptable
to the Building Official,that he/she be responsible for all such work performed under the Building
Per
mit.
mit.
The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he she will comp
ly ply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECT AR
The Commonwealth of Massachuset s Ryfr
4 Department of Public Safetg
Massachusetts State Building Code(7$ O NINN 20 A
Building Permit Application for any Building other than a One-or Two-Family D w elling
(This Section For Official Use Only) -.
`V Building Permit Number: Date Applied: Building Official:. .. . _
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1
60 Washington Street Salem 01970
—\ No.and Street City/Town Zip Code Name of Building(if applicable)
MSECTION 2:PROPOSED WORK -
Edition of MA State Code used If New Construction check here❑ or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or 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: Re.pl a rr .t trim boards f t r floor-
.. of building
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) ❑
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.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business E: Educational ❑
F: Factor F-1 ❑ F2[IH: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4 ElH-5❑
I: Institutional I-1❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
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;5 IIIB ❑ IV O 1 VA O VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
Water Supply: Flood Zone Information:- Sewage Disposal: Trench Permit: Licensed Disposal Site❑
Public 9 Check if outside Flood Zone El Indicate municipal ALA trench will not be P
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable A Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or Noll Yes❑ No 1W
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code-IBC 2009Jse Group(s): B Type of Construction: I I I Occupant Load per Floor: 50
Does the building contain an Sprinkler System?: Yes Special Stipulations:
Ci -A,A—ey-D C-eD"r
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
60 Washington St. LLC 7 Rantoul Street Beverly MA. 01915
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Owner 978.922 .0800 978 423 6344 sgoldberg@goldbergproperti sRE.com
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 permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
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
Goldberg Property Management Inc.
Company Name
Steven J. Goldberg CS 065097
Name of Person Responsible for Construction License No. and Type if Applicable
9 Old Planters Rd. Beverly MA 01915
Street Address City/Town State Zip
978- 922 0800 978-423-6344 sgo db rg@goldhergpronerttecRE.com
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMI ENSATION 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 O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ 2,500.00 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 2,500.00 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,f hereby ittelt under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the my kn e d understanding.
��.,.` 617V -" - G3yv
o —
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: � }0 '�^' 6 9
Name Date
The Common ivealth ofMassachusefts.
Department oflndustrialAccidents
®ffzce ofInvasWgations
600 Wash ingtonStreet
Boston,.r134 02111
www.mass.govldia
Workers' Compensat]an Insurance Affidavit, Bi faders/Contractors/Electricians/Plulribers
Applican$Inforination Please Print Le 'blv
Name(Bwine;s/Organi2ation/Indivi¢ual): Goldberg Properties Management Inc
Address: 7 Rantoul Street Suite , 100B
City/State/Zip: Beverly, MA. 01915 Phone#: 978. 922.0800 .
F
an employer? Check the appropriate box: Type COT project(required):
a employer with 4. I am a general contractor and I
loyees (full and/or part-time).* have hired the sub-contractors 6. O New construction
a sole proprietor orpartner- listed on the attached sheet. 7. ❑Remodeling
andhave no employees These sub-contractors have S, Demolition
_ employees and have workers'king for in any capacity. -
workers' comp.iusurance comp. insurance.# 9 ❑Building addition
red] 5. 0 We are a corporation and its 10.❑$lectdcal repairs or additions a homeowner doing ail work Officers have exercised their 11. Phmxbin rri t of exem h l', epars or additions .lf[No workers'comp. P p •on per MGL12.❑Roofrepairsanee required.]t c. 151, §1(4);and we have no
employees.[No workers' 13.0 Other
coin .insurance required.]
*Any applicant thatchocka box ill must also fill out the section below showing their woikeis'comyensation policy information.
t Homeowners who submitthis affidavtt indicating they arc doing all work mci then him outside coatractors must shbmita now affidavitiodicating such.
dConhaotors that check this box must attached an additional sheet showing the mane ofthe sub-comractorrand state whetheror not those entities have
employees. Ifthe subcontractors have employees,.they must provide their workers'comp.policy number.
I am do employer that is providing workers'compensation insgrartce for my employees. Below is thepolicy andjob ske
inforriagtion.
Insurance Company Name: A.I.M. Mutual Insurance COMPAny
Policy#orSelfins.Lic.#: policy # AWC-400-70 66 0-7016_ Expire4ionDate: ()5/01 /17 _
Job Site Address: . 66 Washington Street City/State/Zip: Salem, MA 019170
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 ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or the-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 maybe forwarded to the Office of
Investigations of the DL4 for insurance coverage.verifibation.
Ida hereby certify er the par s an penalties afpe&iy that the information prold ri above is trine and'verrect.
Si ' ature: Date:
Phone#• �L
Offzciai use only. Do not write in this area, to be completed by city or town affciaL
City or Town: Permit(License#
Issuing Authority{circle oae)r
1.Board of Health 2.BuilditigDepartment 3. Chy/Town CIerk 4,ElectricaI Inspector 5.Plumbing Inspector.
6.Other
Contact Person; Phone#:
The Commonwealth of MassachusettsjY
Board of Building Regulations and Standards ;t FE }AU I $ itSfI ;M
SALEM
Massachusetts State Building Code,780 CMR gevr d 2011
Building Permit Application To Construct,Repair,Renovate OJ hZLI 1A 8
One-or Tlvo-Family Dwelling
r� This S,eetion For OSIcial,Use
Building permit tditmtier: Date Applied.
Z
Iliaieting OtHcial(Print i lame) Sfgnature s
� ' SEC-TIOiV L•SITE INI�ORMATIOIV , .
1.1 Pr p Add r s: 1.2 Assessors Map&Parcel Numbers
X. Sfi
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ _
SECTION 2: PROl'I R3 Y O�VN&RSII,TjP—t / ) 7
4 Ow er'ooff Record: /�
l /� �1�N f//l2/
Name(Print) W City,State,ZIP
�. 97k Y04 /222 SI�o1S58 114, ,
No.and Street Telephone Email Addrds
SECTION 3:DESCRIPTION OF PROPOSEDRK=WO (eheck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repars(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Descri lion of proposedWorld:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)- - - -
1.Building $ 1- Building Permit Fee:$ Indicate how fee is determ'utew
❑standard Cityfrown Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees;
4.Mechanical (RVAC) $ List:
5.Mechanical (Fire $ Tottall Ali Fees:$
Suppression,
Check No, Cheek Amount: Cash Amount;
6.Total Project Cost: $ 15bo ❑Paid m Full ❑Outstanding Balance flue:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Su'pe visor License(CSL)
License Number Expiration Date
Name of CSL Holder ir '� i'(.1. t ,} List CSL Type(see below)
No.and Street T}yetioh''. .
U I Unrestricted(Buildings up to 35,000 cu.ft.
R I Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M I Masonry
RC Rooling Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State ZIP Tel hone
SECTION 6:WORKEW COMPENSAn4DN RgSURANCE AFFHIAVIT OLGj- C.152.§ 25C(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes ..........❑ No...........❑
E 7a3 O W1NER AUTHbRIZATION'tO BE C'OMPI,ETEO WHEN
OWNIER'S AGENT R CONTRACTOR APPI IES FQR J3 BNG PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
co ed' this a lication is true and accurate to the besstt+of my knowledge and understanding.
V1J
Print Owner's o^uthonzed Agent's Name(Electronic Signature) f Dare
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.s yLo Information on the Construction Supervisor License can be found at www.mass.aov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.it.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
m° QTYOF SALEM, MASSACHUSETTS
BLILDING DEPARTMENT
120 WASHINGTONSTREET 3" FLOOR
TEL. (978) 745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOROFPUBLICPROPERTY/BUILDING COMIviISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date
Job Location 3e tVClPr Sfi SO1041y, 0/97y
Home Owner Address �y ouo
Present Mailing Address_ saim-0
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner' shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR