37 MASON ST - BUILDING INSPECTION (2) 1
The Commonwealth of Massachusetts
(.,`-7 i. Department of Public Safety
{47•• Nlassach I set is Ste lc Building Cndc(7,40 CNIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Scrlion For Official Use Onh.)
Building Permit Nwuber __ Date Applied: ____ Building Official:
SECTION 1: LOCATION(Please indicate Block N and Lot#for locations for which a street address is not available)
No. ,nun Street Cily /"ro+vn Zip Code Name of Building(if applicably)
SECTION 2:PROPOSED WORK
Fdilion tit NIA Stale Code used It New Construction dteck here❑or check all that apph in the Iwo r %%s hcluw
Fxistinf; ISuilJ ing Rcpai Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of OCCupanCV ❑ Other ❑ Specify:_
Arc building plans and/or construction dowunJnnts 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:__
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION, ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here tf an Existing Building Investigation and Evaluation is enclostst(See 780 CNiR 34) ❑
Existing Use Group(s): Proposed Use Group(s):_
SECTION 4:BUILDING HEIGHT AND AP,
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(C-heck as a licabiel _
A: Assembly A-I ❑ A-2❑ Nightclub ❑ A-3 ❑ A-i❑ A-5❑ B: Business Cl E: Educational ❑
F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ 1-1 2❑ 7 + ,7
1: Institutional 1-'1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑
S: Storage S-1 ❑ 5-2❑ U: Utility❑ Speci.
Special Use -
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ HA ❑ Iltl ❑ IIIA ❑ IIIB ❑ Iv ❑ V.\ ❑ vli ❑
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:
Public❑ Check if ou lside Floral Zone❑ Indfc.uc numiripal❑ A trench will nut be Licensed Disposal Site❑
Private❑ or indintiA Zone: or un site system ❑ .required ❑or trench or specify:--___--
permit is enclosed ❑
Railroad right-of-way: Ilazards to Air Navigation: V.l l l"I", , . ":I'.,�,. ,+ i" ,. -:
Not Applicable❑ Is Structure within airport approach area? Is Iheir rev ie+v completed?
or Consent to Build inclosed❑ Yes❑ or:No❑ lbs❑ No ❑
SECTION N:CONTENT OF CFRTIFICA'rE OF OCCUPANCY
Edition tit Code: Use Group(s): I\'pr ul CarLclrnCliUn: OCrup.mt Load per Hoor:
I loco Ih6 building contain an Sprink1vr Sestvm?:________Special St ipu lal ions:
SECTION9; PROPI:RI-Y OWNER AUIIIOR IZA'IION
N.urrc.ul I r\Jdi vvs of Properly l/l 1 r
Zip
Nu and Street City/Futs,n
Name (Prim)
Property Owner Con last Information: 517a 79q 9. 4 —
I elephone No.(business) Telephone No. (cell) c-mail address
It applicable, the properly owner hereby authorizes
_--- Name Street Address Ci[y/Town Slate Zip
load on the pro petty owner's behalf, in all matters relative to work authorized by [his building enmit a p lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed s pace and/or not under Construction Control then check here 13 and ski Sr•eliun 111.I
10.1 Registered Professional Responsible for Construction Control
5777 03 -7J /6/4?O.
Re ristration Number
Nantc(Ijegist�^t)Q TelSphon No e-mail address --� 6.F //
•7 �s.r /J /�/'J. ll�s /L
Street Address City/Town Stale Zip Discipline Expiration Date
10.2 General Contractor
XComparan,,AA rZ
\ Name of Person Responsible for Construction License No. and Type if Applicable
7- a. QJGry �i PM,t'
Street Addres City/Town State Zip
Tele phone No. business Telephone No. cell e-mail address
SECTION 11 to n f Itl__;.t droll r �;n Irn INPUT.\Nr.I'_M I n--_.VI I M.G.L.G.152. 25C 6
AV orkers'Compensation Insurance Affidavit from the h1A Deparhment of Industrial Accialents 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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6)=$
1. Building S Building Permit Fee-Total Construction Cost x_(hpsert here
2. Electrical S appropriate municipal factor)=$
1, Plumbing 5
Note: Minimurm fee=$ (contact municipality)
X 4. \lechanical (HVAC) $
3. plcchanical (Other) Enclose chock payable to —
6,Total Cost S �o`?.(/Q9 (contact municipality)and write check nun per ore
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering Illy name below, 1 herebv attest under the pains and penalties of perjun that ell of the information contained in this
application is lain and amrrate to the best of my knopcicdge dad understanding. /
15_-7f
-----. - _— .— Title— — -elepho c No. Date
Pleas•prju��TTvO'�h,y+n tam d sign e
J �7----
_------- _ — — —— -_----- tat•
Sheet :\ddress City/Town .n l
Municipal Inspector to fill out this section upon application approval:
N u• late
I I�
l 2
057
;� CITY OF SALEM
1t' )
PUBLIC I RUPRERTY
:�W DEPARTMENT
.nu'..NI I Y:,NIV ul l
\Is14 41
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1'r.l. v7S.713•93'$ OF,x v7N.71r•IyM
Workers' Compensation lnsurunce UOdavit: Oullders/ContractorsiEiectricians/Pto bens
'1 , 1licant Inrtmnatioll
C�
PI in
V:IITCIIIuunv.i OraanuariarvinJlvnluull: t a 'hl
�J(Irusv: 7
City,Slaw,zip._ arw
Phone I �'7K,1j-3PiF7
Is ry y ou an vuq,leyer:'Check the appropriate boa;
1. cml a vmptuyur with t/ 4. 0 1 mn a guncral conuactor and 1 I yM or project(required):
❑ empluyvcs(full and/ur part-time).a huvv hirvd the suit-cumrava,rs 6' ❑New construction
1,un a late jamprictur ar partner- listed on rho aeachcd.sheet 7• ❑Remodeling
ship and havo no vinpluyvus These subcontractors have
working lilt Ina in any capacity. workers'comp,insurance. tl• mmolirion
IKo workers'cutup. insurance 3. ❑ We are a corporation and its 9. ❑Building addition
1.Ej
required.) .""'cars have ewrvisud their 10.[]Electrical repairs or additions
1 a111 a holneuwnvr Jilin$all work right Ofv 011111 ion pur blOL 1 L❑Plumbing repairs or aJditione
mysclL IN*workers'comp. c. 132,§1(4),and we hnva no
nsurance rcyuited.) r .1111"layvuN. IKo workers' 12.0 Ruot'repairs
comp. insurancv ruyuiril I3.0 Other
''s O•,q,hcaN thm cAdo lW NI mum:Jw till",I,srCbun 41uw dwwuq Iheir wwhute'cVn,pIlIllWluN plies udurelwi,NL
'I I.INM.wNrre why,Iatnul title mail jil chW(indICAtine dlvy Ju Juie dl wort ails Ihvw AW uwaiM euarneren Inwr w1Yna a new mlll4va Indlurina Yp'e•
f,.nlri.uln rAd.Met Isis hoe Intrr Jrryhee•u1 aJdiltlNyl.shYe1 Allrine the IIaNN el rUb.o Nraclaw and their awkllr"I 1111 al jn INIbn l%w
/rue un vurplayrr that Ie pruvid/nr Ivarkers'rurnOenmtlon hLtarrmee jar fay emie/aJvr.4 Bdmv d the psr//sy env/m1 ails
arrnatlrrs
Insuranvu Company.Vmne:Q�'�n'�+Zan,e
I-G
policy a or Sclr•im. Lie.mil ~ lfrj h ,7�
y F.:lpirmwn Dare:
tub Site AWdress: .Y? �?9fg s%`• /
Cny;Slate/zip:.\nach n cagy of 1M werkan'eumpcnsatlua policy dvelarallun page(showing the policy nunlbur and expiration date).
Parluru w secure vaveraye as required uuJcr Svt;Iiu4_51%ul'JIOL c. 132 call lead to rite imposition oleriminal yenaltiea era
eti lip m S LSnO./ln y Istai sa III* i imprisnnmcnr, us I":"J.c civil perlall a in'hit Porto of a STOP IVORK ORDER and a fine
of up ro i'Jn.rN)N Jay Igainat qIe vLN:nnr. lie advLwd thut a copy urthu oinvinem may be IurwarJuJ W the Ullice 1,
:or tnrvan�Jnnn ul';6u UI,\ :or nlsurarcc.ovcruyv \critic JUun.
/Ju ha•rrAy r crtijy unJar Nye pnine,rod pros//!ee u/prr/nry/hut the in urrlrat/oe j provided abave is Nae and corrvrR
t7%/trio/roe an/y, po not Irrirr in thlr urt•u, to be ra,ny/cted Ay city ur tolrn n//lrruL
II I
(ilv ur 1'n lrn:
--' Pcnnif/l.Icvn.a a
Issuing .\ulhority (circle one):
I. 111..Ird „r lIV41111 I. Iluddul•� Ilcp.rrtmenl 1. Cit). orul Clerk 4. C••lectric.Il tnlpccrur i, (+lambing InspcNar
b. I11hrr
__ I'huue Y• i
informationand Instructions
r:tut m the service of mulher uuJer.illy coanct of hire.
>I,u;oehusens licnenl Laws chupter lit lrywres all employers to provide workers compenxauun tisr thci"Ii ogees.
IIthu.al 11011,1* Hatule, an fT0I40fe Ix Jc1111eJ Jl"...every rK
apress or ,nPIWJ-pral ,ir written." oroGun ur other Icgal entity,or Jny Iwo or titers
urtnership.asaeelJtlOn.core or the
�n rmpluyfr 1+Joined at"an mJividual, p Win vn, loy'ees, however the
t the foregoing 411094J in a joint entuer rIsC And
atweu ulo or other legal cncty,employing ya deceased
ee peJ employer,t of the
i CCCrVar or trustee ut .ul indIVIJ0a1. p
s Woos w Jo mainlenunce, cunsuuenon at repair work on wch dwelling haws
owner of a dwelling house having not more than Three apartments and who resides therein,or t •ace
Iwellmg hound of another who employ pe
or on the grounds or builJing appurtenant thereto shall not because of such employment be J withhold
to is as employer.
�IGL chapter 152, 425C(6) also states that "$very slut*or local llcensing agency shall withhold va lbfooat or
Compliance with the insurance coverage required.'
rrnewal of s Ile►ass or p*rmlt to operate•business or to construct buildings la tht commonwaultb or any
v + C 7►irate"Neither the conunanwealth not any of its political subdivisions+hall
applicant &license
has not prod acceptable evidence of comp
AJJicionully, `IGL chupter 15_, i-5
enter into any eumract for the perfomtanca of public work until acceptable guidance of cunlpliwlce w ith the ulsuronc
requirements of this chupter have been presented to the contracting authority."
Applicants to our situation and, if
compensation atllJavit calnpletely,by checking the boxes that apply Y
its and hors*number($)Along wick thou carti8cate(s)of
Please lilt out the workers' comps LLP)with no employees other than the
necessary,supply sub-eoneractor(r)nice(LL )at Limited
P
workers' compansation ilnuranct. If an LLC or LLP does have
insurance• Limited Liability Companies(LLC)or Limited Liability PartnenhiW
memb*rs or partners, are not
tt re it d to carry
�w this s'CO via$ring be submitted o the Deptlrtment of Industrial
l'idavit should
employees,u policy is require artment of
ta
heation for the permit a license is being requested,not the Dap
\ccidenta for conelrrnation of insuraneo coverage. Also be sun to slgr and Juts the uftldn;o obtain utwormen f
he rummeJ w rho city or town that
have any qucstioos regarding the low of if you ore required
Industrial,\cciJents. Should y uttalent at the nulnlser listed below. Self-insured camPanies should enter their
compensation policy.please call the Dee
%elf•insuranes license number on fit a ro riute lino.
City of'rows Officials provided u splice at the bottom
the applicant.
Please he.ore that the affidavit is complete :mJ printed legibly. The Department w
Of the affi lrvit for you to till out in the event the Office of Investigations has to contact you rcgardditi
given ear,need only submit one affidavit indicating current
Of 11 e f sure to till in the prrr act in the event
then which will be used as a reference number. InIst addition,an applicant
Mat must submit multiple ix nary) rid Under
"Job Site in any ti Y be provided to the
policy information of necessary) and under"Job Site Address"
amped or marrkedlbyi I*a y orsiowo lnay lueaiunP in.(city
tuwn►.",\copy of file ufflduvit that has been officially sump'
applicant as proof that a valid ufllduvit is on rile for tLture permits ar licenses. t now ato any usine t ss Or : be tilled out each
ic.r,�M�Yrc rose act permit tor citizen is burn leavee�e.) id prsining 3 lollesus NOTirequired o latecomp not releteth Cal'fldav tmltrercial venture
I he 1)il;cc cooperation and should you hJve•illy yuesuons,
of lovestigatiuns vsuuld Idle to thank you in aJvancc for your
please du nut hcsitale to give USA call.
fhc u.p:uunau'r aJrlre+s, telcphuna aThend CommOnwealth of Massachusetts
Deputtnent of Industrial Accidents
Olflea of Isvadgsdons
600 W&Wngton Street
Boston, MA 02111
'red. N 617-727.4900 ext 406 or 1•g77-MASSAFE
Fox N 517-727-7749
g.211.u5 www.mass.gov/din
CITY OF S.u.E.NI, j**YLxSSACHUSETTS
BCILDLNG DEPART\IEtiT
120 WASHNGTON STREET, Jma FLOOR
T1rL (978) 74S-959S
FAX(978) 740-9846
KI\tBEA EY DRISCOLL
MAYOR T Hows ST.Pmjtaa
DIRECTOR OF FLUX PROPERTY/111CILDLNG COMMISSIONER
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 I I L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al 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
l 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of faOffhty)
(address of facility)
signature of permit applicant
V
dace
VV SIONSPLUS Mm 3314400
Page No. of Pages
® 0
/ GIRARD CONSTRUCTION
A Company You Can.Count On!
DANVERS, MA 01923
(978) 423.3881 • Fax (978) 774.1520
'ROPOS SUBMITTE TO PHONE DATE
STRE2T JOB NAME
:ITV. TE antl ZIP CODE r JOB LOCATION
1RCHITECT _ DATE OF PLANS JOBPHONE
We hereby submit specifications and estimates for:
q 60/d be ZI
hbtncnlrd
/ki�r /� OA all �QmIZi;4�-
d ins�r��ce ,
We Propose hereby to furnish material and labor— complete in accordance with above specifications, for the sum of:
�lluia/—s- nof l�or�hss �?n,nb ' d / 8 o_a
lJ.��2 J2C dollars($
Payment to be made as follows. _ / , !
07
moo,All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
chores over and above the estimate. All agreements contingent upon strikes. accidents or
delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our Note:This prop0 al may be
workers are fully covered by Workman's Compensation Insurance, withdrawn by us H not aoce d within days.
Acceptance of Proposal —The above prices,specifications
and conditions are satisfactory and are hereby accepted.You are authorized to do the Signature-
work,as specified.Payment will be 7 e as 99ned above. g
Date of Acceptance: (/O 2 Signature
RightFax 142-1 8/26/2010 7: 05: 18 AM PAGE 2/003 Fax Server
/ ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 08/26/2010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE -
DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS
j CERTIFICATE OF
f( INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND
THE
CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the
terms and
conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder
in lieu of
such endorsement(s). ,
PRODUCER CONTACT -
.. NAME:
PHONE FAX
LAURANZANO INS AGENCY (A/C,No,EXt): FAX -
- (A/C,No):
107 DODGE STREET E-MAIL
ADDRESS:
PRODUCER
BEVERLY.MA 01915 CUSTOMER ID C:
7242D INSURER(S)AFFORDING COVERAGE NAICI
INSURED INSURER A: AMERICAN ZURICH INSURANCE COMPANY
INSURER B:
GIRARD SCOTT M DBA GIRARD CONSTRUCTION INSURER C: _
INSURER 0:
7 EDEN GLEN AVENUE - INSURER E:
DANVERS.MA 01923 INSURER F:
-COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED
BY
THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS YID CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAM.
INSR AODLSUBR POLICYEFFOATE POLICYEXPDATE
TYPE OF INSURANCE POLICY NUMBER (umomyYYY) (M YYYY) LIMITS -
LTR MR WVD
GENERAL LIABILITY - EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED $
CLAIMS MADE -OCCUR. PREMISES(Eaoccurrarm) .
MED EXP(Any one Person) $ ,
PERSONAL as ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER. - GENERAL AGGREGATE $
POLICY PROJECT LOC PRODUCTS-COMP/OP AGO $
AUTOMOBILE LIABILITY COMBINED SINGLE $
ANY AUTO LIMIT(Ea axMent)
ALL OWNED AUTOS BODILY INJURY $ -
SCHEDULE AUTOS (Per Person)
HIRED AUTOS BODILY INJURY $
(Per accident)
NON-OWNED AUTOS PROPERTY DAMAGE $
(Per accident)
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE - $
DEDUCTIBLE $ -
RETENTION $ $
WORKER'S COMPENSATION AND WC STATUTORY LIMITS OTHER
EMPOLYER'S LIABILITY YIN U69851 M628.10 07/30/2010 07/30/2011
YIN E.L.EACH ACCIDENT IS 100,000
ANY PROPERITOR/PARTNEWEXECUTIVE N -
CFFICERWEMBERERCLUDED? N . E.L.DISEASE EAEMPLOYEE $ 100.000
(MaMetary in NH) - - E.L.DISEASE POLICY LIMIT $ 500.000
II Y.I.desnibe Under
DESCRIPTION OF OPERATIONS blow
DESCRIPTION OF OPERATIONS40CATIONS/VEHICLES/RESTRICTIONS/$PECIAL ITEMS '
THIS REPLACES ANY PRIOR CERTIRCATG ISSUED TO THE CPRTInCATC HOLDER AFTCCTING WORKERS COMP COVERAGE
'ITIE WORKERS'COMPENSATION N1LICY DONS NOT PROVIDE COVERAGE FOR GIRARD SCOTT M.
CERTIFICATE HOLDER - CANCELLATION.
CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE
93 WASHINGTON STREET WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
SALEM,MA 01970 - W A Bolinder
etl
nq-1wichuccttc- pc!tartmcnt of Public Sitar
' ns'in
&card pt' Building Rcrul;Specialty License Standard*
Construction Supervisor Sp
,License: OS SL 107070 W_.-.. _�..,
Restricted to: RF ,
SCOTT GIRARD i
7 EDEN GLEN AVENUE
DANVERS, MA 01923 '
Expiration: 11/1 t2011
�-� T rit: 101070.
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