2 NEW LIBERTY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
I Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Famiy D ell'
(This Section For Official Use Only)
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)
o2 uwb waySl S�( Q6Yl� �(� 1/
NoNo.and Street City/Town Zip Code Name of Building(if applicable O tym�
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❑ I Alteratiori")q Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes X No ❑
Is an Independent Structural Engineering Peer R view required? 1 Yes No
Brief Description of Proposeo Work:
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.) VA
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: Facto F-1❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 0 H-5❑
1: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2 Cl R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONS,TRUCTION TYPE(Check as applicable)
IA 17 IB 0 IIA ❑ IIB ❑ IIIA)C( IIIB ❑ IV ❑ 1 VA 0 VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
Water Supply: Flood Zone[reformation: Sewage Disposal: Trench Permit: Licensed Disposal Site❑
Public,X Check if outside Flood Zone❑ Indicate municipaIX A trench will not be P
Private❑ or indentify Zone: or on site system❑ required 0 or trench or specify: _
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes 0 or No X, Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code:Lte se Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
TEL. (978)694-4111 matt@sassoconstruction.com
FAX(978)694-9226
CELL(508)265-0036
j It� AI��tcw�
"
CONSTRUCTION CO., INC.
GENERAL CONTRACTORS
231 ANDOVER STREET
MATT PIMENTEL WILMINGTON,MA 01887
4
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
�rc
Name(Print)(`(U5, eV fY) No.and Street City/Town Zip
Property Owner Contact Information:
�M oi�IJ �5 1 Cd 3-5 +a- o3C� s 111- 1c l�® 2(yLf
Title CF'1 v R 4 Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the roperty owner hereby authorizes A
a
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 O and skip Section 10.1
10.1 Registered Professional 1Reesponsible for Construction Control
2 �L`YoJehC0i�75� J 1�?LI� CaGC�CornerS�r�ar�uF
Na
Cre�gistra5 h�t)_ f fGfsz ele ho 0. e-mail address gis atjp(N r
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
ja]5Name�5-o e7o' ;Jruc� )'oti Cn_, lcQ
Company
ll'"I I ( �1a`C 1J o Cs 1 RC3
Name of Person Responsible for Constr ction License No. and Type if Applicabl
'd3 I �lJdC�.-m s� . )1)Tn) .�Thcty' 1 � DI D
Street Address �.1 City/Town State Zip
C Llll l M3To-)'e���z�s�eou,}�( e})a�.0
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATTON 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}' suance of the building permit.
Is a signed Affidavit submitted with this application? Yes J$ No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)
1.Building $ �(® 5 •(OCR Building Permit Fee=Total Construction Cost x Insert here
2.Electrical $ appropriate municipal factor)=S��la I•O O
3.Plumbing $ -
4.Mechanical (HVAC) $ c- Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $
�Q Enclose check payable to
6.Total Cost $ y'S'sl(Q�'� (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 ue and accurate to bes my ow edge and understandin .
0`3/ rp tint and sign m�e} f 1 'j��jN 7 Title./7 Telephone—0 Date
15�
Street Address W City/ own rfSttate --S-Zip
f�L
Municipal Inspector to fill out this section upon application approval:
Name Date
f 1
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. I Item Submitted Incomplete Not Required
1 I Architectural
2 Foundation )C
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
S Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investi ation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation }�
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original perntit
fee.
Registered Professional Contact Information
C'�rp1eR�-iave �t-'hi #�1s 4��99�yz�v (����i
Name(Registrant) Telephone No. e-mail address Re tration Number
�CaliSfaTefroerz Ward /
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State Zi
�. CITY OF S.UEik 1. TN'LkSSACHUSETTS
BL'MBNG DEPAR-r%MNT
6
u 130 WASHNGTON STREET, 3"0 FLOOR
Ta- (978) 745-9595
FA-X(978) 740-9M
Kj-,f$FRLEY DRISCOLL
T
MAYOR �Ioat.+s Sr.PtFYRR
DIRECTOR OF PUBLIC PROPERTY/BUHMNI G COND USSIONER
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 111.5
Debris, and the provisions of MGL c 40, S 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:
KQ01)2;6f C�]0 )-�J
(name of hauler)
The debris will be disposed of in :
—T VZ
(name of facility)
c�10 Ill , Lur� h
(address of facility)
i
stgna lire of permit applicant
date 1'a.
dcbriutT�ia;
CITY OF S.U.E.N1, , xsSACHUSETTS
BuI DLNIG DEPAATS&.NIT
t a• 120 WASHLNGTON STREET,3w FLOOR -
°f TEL (978)745-9595
FAX(978) 740-9846
KI,,tBFRi EY DRISCOLL
MAYOR Ttioeus ST.PfEItRE
DIRECTOR OF PUBLIC PROPERTY/BCILMNIG CONL%MIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AllfiliCilint information �Plleaase Print Legibly
Name(Busitns Orrganizationiiindiv�id�uaap C.: C1�� j
Address: (�">� / � ,L: -IrP k ' �}
City/State/Zip:Ik)7 �Lrd Phone N:___
,A�rje¶you an employer?Check g appropriate box: Type of project(required):
14 1 am a employer with / 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: Z ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs oradditions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§I(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.) 13.❑Other,
*Any applirum that checks box 91 most abw fill out the action bctow showing their wakes'wmprnsalian policy information.
t I Inmeuwnrn who submit this affidavit indicating they uv doing all work and then hire outside contmcton must submit a now affidavit indicating such.
:Comractors that check this Sax must attached an additional short showing the name of tee sub.comnctm and their workers'camp.policy information.
I am an employer that is providing workers'compensatlon Insurance for my employees. Below Is the porky and Jab site
information. r
Insurance Company Name: �/�C}p,
Policy 4 or Self-ins.
nLihe. N:-/I II ''a 0—51� /—e�'� l l% l / Expiration Dated
Job Site Address: C?!\�C,W v�!/�1 l N JJ City/State/Zip:
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 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 S250.00 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 under the pains and penaties a perjury that the information provided above/is true and carrect.
Swnaite[e: Date: J /
Phone N:
Official use only. Do not write in this urea to be completed by city or town orichd
City or'rown: Permit/License N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone N:
OMMERCE AND INDUSTRY INSURANCE COMPANY 0076366-00 WC-----051 -75-7699- -
-------------------- ------------ - -----
5172 013-82-1011 -00
a NEW YORK
ASSO CONSTRUCTION CO, INC. C H A RT I S
31 ANDOVER ST
'ILMINGTON, MA 01887-1001 A Chartis company
EXECUTIVE OFFICES:
EE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 175 Water Street
New York, NY 10038
D9 00002o61
BOSTON INSURANCE BROKERAGE INC.
WORKERS COMPENSATION AND EMPLOYERS 24 FEDERAL STREET
LIABILITY POLICY INFORMATION PAGE 4TH FLOOR
BOSTON MA 02110-0000
NSURED IS PREVIOUS POLICY NUMBER
;ORPORATION I NEW
DTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610
ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the insured's
mailing address FROM 10/01 /11 TO 10101 /12
EM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states l
IT isted
here:
CT MA NH RI -
B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed In item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 1 000,000 each accident
Bodily Injury by Disease $ 1 .000 000 policy limit
Bodily Injury by Disease $ 1 ,000,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
AK AL AR AZ CA CO DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NJ NM
NV NY OK OR PA SC SO TN TX UT VA VT WI WV
D. This policy includes these endorsements and schedules:
SEE EXTENSION OF ITEM 30. OF THE INFORMATION PAGE - WC990612
ITEM 6 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Premium Basis Rate Per Estimated
Classifications Code Number Total Remuneration $100 OF Re. Premium
❑X Annual ❑3 Year muneration Annual ❑3 Year
SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754
TAXES/ASSESSMENTS/SURCHARGES $971
EXPENSE CON STANT(EXCEPT WHERE APPLICABLE 6Y STATE) $338 MA
MINIMUM PREMIUM $750 NH TOTAL ESTIMATED ANNUAL PREMIUM $17 336
If indicated below, interim adjustments of premium shall be made:
Semi-Annually Quarterly Monthly DEPOSIT PREMIUM
09/28/11 PARSIPPANY 82
Issue Dale Issuing Office Authorized Representative WC 00 00 01A
39967(Rav'd 04108)
11ua1iI nl I inldln ]fill It nlrl nJ.
Cons..uc,:cn aipervisor Licen3e
plc-n:u: Ci 92345
I
MATT PIMENTEL
16 SPENCERS CT
ANDOVER, MA 01810
F r,
c%�-- may fj� ��pr iUor. 5/4/2013
Owo))Wi 14900
CONSTRUCTION CONTROL—ARCHITECT
SALEM, MASS.
Project Number 1230 Project Title PEABODY ESSEX MUSEUM
Project Location 2 NEW LIBERTY ST Name of Building SALEM VISITOR CENTER
Nature of Proj ect Interior renovations for new office space on the first& second floors
In accordance with Section 107.6 of the Massachusetts State Building Code Amendments Eight Edition,
I, CHARLES COCHRAN Registration No. 6559
Being a registered professional architect, I have prepared or directly supervised the preparation of all
design plans, computations and specifications for the above named project and that such plans,
computations and specifications meet the applicable provisions of the 2009 IEBC, 2009 IBC AND 780
Massachusetts State Building Code Amendments Eight Edition, all acceptable engineering practices, and
applicable laws and ordinances for the proposed and occupancy.
I will do the following: Architectural:
1. Review for conformance to design concept: shop drawings, samples and other submittals
2. Review and approve the quality control procedures for all code-required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become, generally familiar with the
progress and quality of the work and to determine, in general, if the work is being performed in a
manner consistent with the construction documents.
I will be on the construction site and/or I will send other appropriately qualified design professionals,to
determine that the work is proceeding in accordance with the documents submitted with the building
permit application, and the applicable provisions of the 780 Massachusetts State Building Code
Amendments Eight Edition as specified in Section 107.6.
I will provide the Inspector of Buildings with an original, stamped report for site visits, scheduled or
otherwise. I understand that no Certificate of Occupancy will be issued until all reports and a Statement
of Project Completion have been filed with and approved by the Inspec r of Buildings.
Signed
Date
af 0 AgCyl.i
i
V CHARIES d` v
�4 A. n� v
COCHRAN -
No.6559
s
WESMTFAORD S' w
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