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12 MAY ST - BUILDING INSPECTION
r r The Commonwealth of Massachusetts Department of Public Safety I ��.-,..✓ .%lassachusMS State Building Code(780 OMR)Seventh Edition City of Salem BuildingPermit Application for an Building other than a 1- or 2-Fami1 Dwellin (This Section For Official Use Only) l\ Building Permit Number: Date Applied: r Building Inspector: SECTION 1: LOCATION (Please indicate Block N and Lot N for locations for which a street address is not available) I MIRY S i 3 SR zc No.and Street City /Town Zip Code Name of Building(it applicable) (� SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ 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 p u a lication? Yes ❑ No ❑ Is an Indepe uctural Engineer.nj��Peer Review required? ,,nn ,/ Yes ❑ No ❑ Brief Descri u Proposed Work: �'='rl�o zt T► -p /./ V- J'P O1, tN t e hL F W e rQ ai N ET [3t1/_�_/YVS r91L14-1-10fV Qk- 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 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.) SECTION 5:USE GROUP(Check as applicable) RFacto!j y A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ al 1-1 ❑ 1-2 ❑ 1-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4 ❑ -1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV VA VB ❑ SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) rl'rlc'Ite ater Supply: Flood Zone Information: Sewage Disposal: Trench Permit: =DebrisRemoval:PP Y�Public❑ Check if ouhidr Flood Zone❑ Indicate municipalA trench will not be required Our trench ❑ or indentily Zonr: ur on ate scatem ❑ ),remit is enclosed ❑Railroad right-of-way: Hazards to Air:Navigation: %I:\ I lirloric C,nnmi>sLin Itotir.r Prtnl1ppllca ble ❑ I,Strn:ature rcuhin airportapproacharea' Is Iheir re%irty omipleted' r C nnx•nl to Budd enclox'd ❑ Yea❑ ur.Nn❑ 1'c•a ❑ \'n ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Ld Won of Code, Use Group(>): T\c pe ut Construction: Occupant Load per 1:1uur: Doe, [lie building contain an Sprinkler S%,tem': Special Stipulations: ,�L s 7J - 11"e 7 - 6 6 &3 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner - G( Name(Print) No.ane�el Citv/Town Lip Property Oecner Contact Information: Title Telephone:No. (business) Telephone No. (cel e-mail address If applicable, the prupertY owner hereby authorizes Name Street Address Citv/Town State Zip to act on the +ro pert% owner's behalf, in all matters relative to work authorized by this building Lermit a plication. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If building is less than 350k)cu. ft.of enclosed s pace and/or not under Construction Control then check here Oand.,kip Section I0.0 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. General Contractor U�- ' \ ompany Name: Gt S �s��Z/ Nyl(,n Ew tspsp�Sle fyf C}tnstructiun License No. and Type tf A plicable I S ree dr ss ,f� City/Town Stat Zip _ 5,9 AL1e-I Y�iZtk COW! I c�3 -- Sys N Telephone No. cell Telephone No.(business) No_(cell) e-mail address SECTION 11:WORKERS'CONTENSATION 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 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 $ Enclose check payable to �T'1Q 4. Mechanical (H VAC) $ Note: Minimum fee=$ _ OF ��7 (contact municipality) 5. Mechanical (Other) $ Vii 5 Lti V 6.Total Cost $ (contact municipality)and write chec 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 In the best of my knowledge and understanding. Please print and sign name Title Telephone No. Date titreet :\ddress City/Town _t. e Zi l 2JrU Municipal Inspector to fill out this section upon application approval: a e Date . CITY OF SALEM PUBLIC PROPRERTY a % DEPARTMENT nxt .?N 51'n ELT 4 5.0 I`N4 MA,i.0 �u ;1 �;,:I�•. 1'rf:978.74 9595 • 1C,s:978-7449846 Construction Debris Disposal At'tidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section t 1 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit tt - _ is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c l 11. S 150A. The debris will be transported by: 1-lpMf o� �� bS�L4�G5 1)ur%1P6 ./ 60. (name of hauler) R� ;Cak 1. The debris will be disposed of in -- ".__ (name ut aci ity) (oddrexs of facility) r ,igna(u of permit applicant ,late CITY OF S.II.ENI, iNYLAiSSACHUSETTS Bu DLYG DEPARTMENT 120 WASHIINGTON STREET, 3aa FLOOR TE1_ (978) 745-9595 F.%X(978) 74048M KI�tBERLEY DRISCO[S MAYOR THoMAs ST.PIERRS DIRECTOR OF PLOLIC PROPERTY/11LIMLNG CO%L%IISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlc(ans/Plumbers alralleant Information Please Print Legibly Natnelausincv OrtattiratiomIndhvidual): _.E-BE-1VE-Z---eig Address: 2S lJ�. �A1�l� r'jq 1 City/Statc/Zip �J Cie Z . lv/r} Df91SPhone q: 978. 3 d Z/ 3702 ,ire you to employer'Cheek the appropriate box: Type of project(required): 1.❑ 1 am a=player with 4. ❑ I an a general contractor and 1 employees(full and/or part-time).• have hired the sub contraetors 6. ❑New construction 2J�5-1 am a sole pmprietor or partner- listed on the attached sheeL : y- Memodeling ship and have no employe= Then sub-contractor:have H. ❑Demolition workingfor me in an ca aci svorkm'comp.insurance Y P tY• 9. Building addition required.) workers'comp. insurance S. ❑ We are a corhave orationexercised and it 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.(No workers'comp. C. 152.§1(4),and we have no 12,0 Roof repairs insurance required.] t employees. [No workers' 13.Q Other COMP. insurance required.] J I 'Any uppkcarn thud checks boa el mull Sea fill use the saetto below showisg their wosda'comp",gim policy infumutloa. 'I6vswuwtwa who submit this affidavit indicaina they am doing all work and then him ouoide centraa:rem mtat suhmit a new af0dava indiodins suck T„mmetors dud check this Iws mud a"whod an additwtwl ahem showing dw name of tlw au►.renuaeba and their workers,comp.policy infartnauen. i am an employer that ls providing'workers'compensation Insaromee for my employees, seiow is the policy atrdlob lit= information Q n� Insurance Company.Nome: Policy N or Self-ins. Lic. N: G S 022 3?1VAPi q Z-1 f2 9 Expiralion Date: 0 -3 - 20/00 Job Sire Address: /!0t Migs J / ?� City/StaWzip._5,*z r9M SOW 0 t /j(o ,mach a copy of the workers'compensation policy declaration page(showing the policy number and expiration daft). Failure to secure coverage as required under Section 25A of.•MGL c. 152 can lead to the imposition of criminal penalties of■ fine up to S 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 S230.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of Inacaugatiuna ul'the DIA for insurance coverage verification. 1110 hereby certify s nd P,naldes of perjury that the information provided ubove is true and caeca Phone�: 9�8 . 36� 3 Offt'rial uae only. Do not write in this area, to be camplered by city or town o/liciaL city or PermitA.Icense \tahurity (circle one I ): 1. Iluard u(lleulih 2. Ruilding Department I C'ityrrown Clerk J. Electrical hupector 5. Plumbing Impeetor 6. Other U,olacl Person. _ ._. Phone N: '4"40RH CERTIFICATE OF LIABILITY INSURANCE DADDYY 10/28o/2a/zo0s PRODUCER (978)532-5445 FAX: (978)532-2217 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION B.K. McCarthy Ansurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 10 CentenAi;a1„ Drive t ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. West Entrance Peabody MA 01960 INSURERS AFFORDING COVERAGE NAIC p INSURED; INSURER,Travelers .Casualty & Surety 31191 Ebenezer Carpenter & More, DBA: Raquel daSilva INSURERB: 25 W. Dane Street - INSURER C: INSURER D: Beverly MA 01915 INSURER E: COVERAGES 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 AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION T POLICY NUMBER 0 DATE M/DDIYYYY LIMITS GENERAL LIABILITY _EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence). $ 300,000 A CLAIMSMADE X OCCUR I6809039N275ACJ09 8/13/2009 8/13/2010 MED EXP(Anyone person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 L GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _PRO_DUCTS-COMP/OP AGO $ 2,000,000 X POLICY PRO- LOC AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOSi BODILY INJURY NON-OWNED AUTOS {Per accident) $ _ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY - AUTOONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGO $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $IJ OCCUR CLAIMS MADE AGGREGATE _$ __.. $.. _. _ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- 'ANDEMPLOYERS'LIABILITY ^ _—TORY.LIMITS:_ ER IYIN ANY PROPRIETOR/PARTNER/EXECUTIVE LJ ! Y.L.EACH ACCIDENT $ 't OFFICERIMEMBER.EXCLUDED? t ,xvK iA+++ ♦.A"' (Mandatory in NH) .E.L.DISEASE EA EMPLOYEE $ Y _ If yes,describe under S -� SPECIAL PROVISIONS be. E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Refer to policy for exclusionary endorsements and special provisions. CERTIFICATE HOLDER CANCELLATION (97 8)531—022 0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City Of Salem DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Kelly NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 12 May Street Salem, MA 01970 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. 9e' AUTHORIZED REPRESENTATIVE �j John McCarthy/LG4 O "w r"��C•�2f'2"'"'! " " ACORD 25(2009/01) ©1988.2009 ACORD CORPORATION. All rights reserved. INS025(200901) The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2009/01) INS025(200901)