86 NORTH ST - BUILDING INSPECTION (2) may/ c�
t ��✓ - 2� - 03`73
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The Commonwealth of Massachusetts
�¢ t`a# �j 9v Department of Public Safety
Staes,rchuseus Watr Bwlaiing Cardr t780 C\aR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a I-or 2-FamilyDwelli
(This Sectkm F(w Official UseL)nly)
Building Permit Numbrc Date Applied: Buildin"Inaprctuc
SECTION I:LOCATION(Please indicate Block d and Lot C for locations for which a street address is not avails
No.and Street V4 Cite° tTo,rn Zip cmir Name of Buildi g(if applicable)
SECTION 2:PROPOSED WORK
It New Construction check here Our check all that apply in the twu rows below
Existing Building Repair 0 Attrr:rtiun ❑ Addition 0 Demolition 0 (Please fill out and submit Appendix t)
�h,e
nge of Occupancy D Other Specify:-e.. „.. _ . building plans and/or cunstruction ducuments being supplied as part of this permit application? Yes rr No ❑
Is an Independent Structural Enginevrirt• Review recIuired? -/ _ Yes CI Nol Q
Brief Descripteu u ruposi Wurk: -1/I�J7d'r�2� J -� 1,51�/�ei C'O �E O.G'�C.e�- 7c
��'7�ilLJ
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 7aO CMR 3402A) Cl
Existing Use Group(s): Proposed Use Group(s): f
Existing Hazard index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of FFuars/Stories(include basement levels)&Area Per Floor(scF ft.) I1� /
Total Area(sq.ftJ and Total Height(ft.) 00 17,04
SECTION 5:USE GROUP(Check u aF ficable)
A. Assembly A-1 0 A-2r 0 A-2nc 13 A-3 0 A-4 0 A-5 E7 I B: Business E: Educational 0
F: Facto F-I 0 F2 0 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-S Cl
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-1 0 M: Mercantile 0 R: Residential R-113 R-2❑ R-313 R-4 0
S: Storage SI 0 S-2 ❑ U: Utility 0 Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicablel
IA 0 !B 0 ItA 0 FIR 0 IIfA 0 FHB 0 IV 0 VA 0 VB 0
l SECTION 7:SITE INFORMATION(refer to 7W CMR 111.a far detaits on each itemt
1 Trench Permit: Debris Removal:i )`cater Supply: Flood Zone fn Formation: Sewage Disposal-
f'ubl�i C hviV. rt oul>�.ie Pl. ,,.{ Lime 0 lnd�calr muninpal
:t trench ra.r!t n.,t he Lriemet# Oi t.>«.,I Site*
Prrvate0 ITtnefe•ntde Zune•: err ern-etc.e-tem0 ra•.(ttlra¢fnortrrnctr ur.I+ei1fr.
� prrmrt r.rn,-t<e.eef 0 _
{ Railroad right-uf-way: ppj Hazards to Ai, Navigation: MA I f„1.•,u c ..,,,n,........R........ Pn•....:
Vi \ h.e(dr0 I (.�tru.'nnu ..nh�n.ur n.t rnaih.u'r.t' l+thcu' rc.ic.c:•nn(dclod' f
.:Crt�oRt tBu rf.t c•nd.,.ect❑ ( }e-0 ,.r.\',r0 Yr- 0 No0
E SECTION&CONTENT OF CERTIFICA FE OF OCCUPANCY 4
f.#rtrt rzd t.ntc- __ C-r t:r.u1.t-t_ _. __ F`rir.rtE v,.troaet. n: ___ tl.arh.,nt L"Ol rfFo- r
•- l l••o,for hut6l„+y;o-.nt.Itn.nl�,rm.(er Sc..rm': �+.•aai VtpuF.ru.:r"- i
a A SECTION 4 PROPERTY OWNER AUTHORIZATION
Name td Add +oh 11 erty Ownr
la�o � ssri�,,1rQ66
Name(Print) No-and5t rl Cily/Town Lip
s•)honer omao Informatiun.�j� q,JO
41—o- S/✓�e2 %��d„us® tsS_ corn
Title Telephone No.(busme v) Telephone No. (cell) e-mad address
I(.it,+plicla�blr,the p/nrprrh•owner herebvauthorizes
/ 0/ Cxe �
n/.SyTi
Name Street Address Cily/Town State Lip
to act on the tro etc owner behalf,m all matters relative to work authrmzed by this building +ermit a t licatiun.
SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2)
tit buildi •is leers than 35,W0 cu.R.of trclosed r and/or not tuider CaxtsYruclhun Contnl then check here O and ski iectim 1031
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
102 Geneemi Contracttoor
Company
GGu1� e ,5P
Name of P ptmstb fur C ch License No. and Type if Applicable
Z ;%�. Vv t .�/ C'1r.cad o�s�a
Street Address G City/T to Zip
dg- 17 s�.Z� - �'rb � j����v L-2: Cet lY�m+.�if<rl ¢dS Gym
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WO ER5 hiPFNSATtON OVSURANCE AFF[DAVIT(M.G.L.c 152.§2506))
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 appfication7 Yee No 17
SECTION 12.CONSTRUCTION COSTS AND PERMIT
6 E
Item Estimated Costs:(Labor
)=$
Total Construction Cost(from Item 6 ���Tl�• '�
and Materials)
1.Building $ Building Permit Fee-Total Construction Cost x T(Insert here
2.Electr'cat _ S appropriate municipal factor)_$
3. Plumbing $ dam,
1.Mechanical (HVAC) fi Note:Minimum fee=9j (contactumcipaht )
5.Mechanical ((?thee) $ Enthuse check payable to
b.Totai Cost S G, OD (contact munici lity)and write c k number here
SECTION 13:SIGNATURE OF BUILDING PERT 17'APPLICANT
By entering my Paine be€mv.I hereby attest under the patns and penalties ref per{ury that ant of the inhsrmauisrn cr.ntaine t in this
,epphcauarn is trruue and accurate to the 1x t of my knowled eand rnderstandmg.
I Ytea.r ftrent an r ^.t P.u/n�'�/ � ��r Ea'icfth. nr\u. {Ache
'beet .Wdre,. Cstt:'rot%n ate e'ep
i
i Municipal Inspector to fill out this section upon application approval.
Name Rate
`� ��M1t t. cftusctt. Depaatrncnt of-Public Satety
Board of $urkLn ReLul lions and St'a'"dar ds
.. Construction Supervisor License.
License: CS 40225 - -
Restricted to: ad '
:z x
DAVID J SCANLO_ N '
56 SAWMILL`RD fs�r g
DUDLEY, MA 01571 µ.,z
czprralion: 6/9/2010
( .nun. Tr=: 26007
CITY OF SAI.EM� 2UNSSAMUSETTS
• BLMDWG DEPARTM&NT
130 WASH NGTON STREET,3w FLOOR
T L (978) 745-959S
FAX(978)740-9946
KIMBERI.EY DRISCOLL
MAYOR THOMAS ST.P¢RRs
DIRECTOR OF Pl:BLIC PROPERTY/Bt:ADLNG CO3,CMSIOJiER
Workers' Compensation Insurance Affidavit: BuildersiCentractors/Electricians/Plumbera
Anplicant information J / /Please Print I edbly
Name Iausirtesv:Organimtiontt�ndividduaq:
Address- 57
City/State/Zip: Phone#:
Are you an employer?Cheek the appropriate bos
YJ pI yer with .J d 4. ❑ 1 am a 6. � Newof con (required)'
1. I am a tan o general contractor and 1
employees(fidt and/or part-time)-` have hired the stub otmnaaols 6- []New coaruucritm
2.❑ 1 am a sole proprietor or partner. listed on the attached sheet: 7. Remodeling
ship and have no employcerc These sub-conttarxors have It. ❑Demolition
working for me in any capacity. workers'comp,insurance. 9- ❑Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised thew
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LE]Plumbing repairs or additions
myscIE[no workers'camp. c. 15Z§1(4).and we have no 12.0 Roof repairs //��
insurance required.]t employees.[No wenitess' 13.[�Otha/1��.� C077(Z !�2
comp.insurance requited.)
'Any appliaet that etas*s box Of must alas fdl out the section bedow showing their wd='�upeasadan WKy fafum Uoa
*Ibsmeowttns who subaut this anidava indkiang they are doing.11 work and thm hie matraam must subitit a new affidavit iodie dng sack
:Contrsxon that chi k this box oust amxhod an a Wuoaal chit showiog Ne nmtte of gn sub-comatctwa and thek warhen'm P,policy infamtau".
I um as employer that is provfding workers'compensation lasuratreejar my employeM Below is thepo//cy and job she
fnsuntner Company Name:_ n 7/,P�firaGG>_ ftgt-.•fir•<L
G
Policy#or Self-iris.Lic.M a/ar/1,2- Expiration Date: /
Job Site Address:— �d �7� <�77 City/State(Lip:� vLvn� /�e
Artach a copy of the workers'compensation policy declaration page(showing the poft 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains as a!� perfary that theinfarmation propided above is true sad correcL
�_ Darr S d
Phu #- STJ — 87 SG3a�
Official use only. Do rat write in this are%to be completed by city or town of feria[
City or Town: PermidUcense#
Issuing Aulhority(circle one):
1.Board of health L Building Q,-partment 3.Chylfown Clerk 4.Electrical inspector 5. Plumbing Inspector
b.Other
Contact Person: Phone#.
t
05/07/2010 07: 31 5089875517 OXFORD INSURANCE PAGE 02/02
AvORD CERTIFICATE OF LIABILITY INSURANCE DATE{MN1/os/o7/ olo2010 Y)
TM.
PRODU 117�
OXFORD
ER Phase; NC 3aAGE Fec 508-9B1-0083 THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION
OXFORD INSURANC E AGENCY INC MA ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P O BOX HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
OXFORD MA 01540 ALTER THE COVERAGE AFFORDED BY THE POLICIES B OW.
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Endurance American Specialty ins Co. _
LAMOUNTAIN BROTHERS INC. INSURER B: Commerce Insurance Co, _
37 FEDERAL HILL RC PAD
OXFORD,MA 01540 INSURER C: Endurance American Specialty ins.Co. _
INSURER D; Commerce A Industry Insurance CO. _
INSURER E:
COVERAGES
THE POLICIES OF INSUPW ICE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED, NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY SE ISSUED OR
MAY PERTAIN, THE INSURWCE AFFORDED BY THE POLICIES PF.SCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIM TEL SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN$R nDP TYPE OF INSUI LANCE POUCYNUMBER POLICrEFFEciNE POUCY EEPIBIITIDN
LTR IN^ DATPID D LIMITS
GENERAL LULBIU rY ECC101003700 11/01109 11/01/10 EACH OCquRRFNCE $ 2,050,000
X CO, MERCl/L GENERAL LIABILITY DAMAGB TO RENTED $ $O,OOD
PREMIBEB IEg O Wronva)_
X CLAIM'. MAOE�X OCCUR MED,EXP(Any me perwn) 1 51G00
A X XOU INCLU[ED _ PERSONAL&ADV INJURY 3 2,000,0_00
X BLANI¢TACDmONALINS GENERAI,AGGREGATE $ _. 3.000.000
GEHL AGGREGA7 ELIMITAPPLIES PER: PRODUCTS-COMP/OP AGO. 8 3,0OD,000
POLICY X P cO`- Loc "
AUTOMOBILE LUI 3ILITY XT4527 11/01/09 11/D1/10 COMBINED SINGLE LIMIT
X ANY AUTO (Ea eeeltleAl) $ 1,o0D,000
ALL OWNED AUTOS BODILY INJURY
B X SCHEDULE(AUTOS (Perpweon) S
X HIRWAUT(S
X NON-OWNS)AUTOS BODILY INJURY $
(Peraw np
X MCB90 END INCLUOED
PROPEP (DAMAGE 5.. . .
Par RCehlanl
cARAce L3aBaIr r
AUTO ONLY-FA AC_C_IDENr $
ANY AUTO OTHER THAN FA ACC $AUTO ONLY AGG S
IXCESS I UMBRELLA LIABILITY EX3101003701 11/01/09 11/01110 EACH OCCURRENCE S 2,000,000
X OCCUR - ICLAIMS E AGGREGATE S w 2,000,OOD
C S _
DEDUCTIBLE -"- -
S
RETENTION F
WORKERS COMPENSATION AND WC kI Drr�
WPLOYERs-LIAMLITY WC5316512 09/3D/09 09130l10 X TOBYLiHDM _
D Axv NtOPwEToamaaTweREXeeuTIVE 111.EACH ACCIDENT 3 1,0001000
OFFlCaafNl[MBER E%CLUPE]9
E.L.DISEASE-EA EMPLOYEE s 1,000,000
6PaelAL PROVIBIPNa aglow E L OISEASF.POLICYLIMIT S 1,000,000
OTHER:POLLUTION I.IAMUTY POUCY ECC101003700 11/01/09 11101/10 1$2,000,000 per Occurrence
A $3,000,000 Aggregate
DESCRIPTION OF OPEiRAT10NS/LOCATI0N3/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDEI I CANCELLATION
City Of Salem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TFIF
Building Department EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS
130 Washington Street,3rd Floor 'WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE
Bt TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABIUtYOF ANY RIND UPON THE INSURER,
Salem,MA 01970 ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE • e
Attention: Brian M, Ravenelle
ACORD 25(2001108) Certificate# 47333
0ACORD CORPORATION 1988
a ,
CITY OF S'UH.. I, jNLkss kaiL'SETTS
BuI DLNGDEPjLmm%'T
130 WASHLYGTON STREET,320 FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
K[atgFRr RY DRISCOLL
MAYOR T HOMAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUMDIIVG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 790 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 wi 11 be transported by:
(name of hauler)
The debris will be disposed of
in :
(name of facility) 7
(address of facility)
signature 'omit applicant
S/7 la
date
htuiaitLdce