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126 NORTH ST - BUILDING INSPECTION The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Twu;prmal,4q��,-, (This Section For Official Use Only) Date Applied.'_-"_T-'�:,i*W' �Bcildm'g_Officiakl���, � Building Permit Number; SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a ovedaddress is not avhfa�1�111­ iu Nq_1 0 No.and Street City/Town Zip Code Name of Building(if applicable) WORK W 6,A, SECtION2:PROPOSED Edition of MA State Code used— If New Construction check here 0 or check all that apply in the two rows below Existing Builclingt3, Repair 0 � Alteration 0 Addition 0 1 Demolition 0 (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy 0 1 Other 1aSpecify: f'QQ+ Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No IL Is an Independent Structural Engineering Peer Review r quired? I t lq� Yes 0 No Brief Des -zht 4_, C Proposed Re vqole 4 E'A A& %0� � all ANU 0,4 9�, �A 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) 13 Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING'HEIGHT ANDAREA"' 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) %W�tgag�g i u --­9V A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A4 0 A-507— B: Business 0 E: Educational 0 F: Factory F-1 0 F2 0 11. HighIlazard H-1 13 H-2 0 H-3 13 H4 0 H-5 11 I: Institutional 1-10 1-2 11 1-3 0 1-4 0 M. z Residential cantile4& R: Residenal R-10 R-2 0 R-3 0 R-4 0 .. S: Storage S-1 0 S-20 Uutility 0 Special Use 0 and please describe below: Special Use: -r "tSECTION 6:CONSTRUCTIONTYPE(Check as applicable) IA 0 IB [3 IIA 13 IIB 13 IIIA [I IIIB 0 IVO IVAD VB [3 ......SECTION 7-.SITE INFORMATION(refer to 780 CMR 111.0 1 etails n or d on each item)z.I Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit., Debris Removal: Public 0 Check if outside Flood Zone[I Indicate municipal 0 A trench will not be Licensed Disposal Site 0 Private 0 or indentify Zone:— or on site system 13 required 0 or trench or specify: permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable D Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0 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: SECTION 9: PROPERTY OWNER AUTHORIZATION,!'; Name and Address of Property Owner Hca�. � aV 1110 IVO r`�St ��rr 1 Z� Name(Print) No.and Street City/Town Zip Property Owner Contact Information: °nVZlI- IDS 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. „�. ; .w:SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If buildin .less than 35,000 cu.ft.of enclose space � � �d s ace and/or not underLonstruction Control then check here O and ski Section 101 t'^ .10.1 Registered Professional Responsible for Construction Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Qed.. P44,% l �C Company pNpamee...�} LL Name of Person Res onsible for Construction n License No. and Type if Applicable za( S 60VQ�\�.1 m� nXq Street Addrebts �-'�7 Ci Town /n Stat Telephone No.(business) Telephone No. cell e-mail address Msp: .�<: I SECTION 11:WORKERS`COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C6 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 O SECTION 12:CONSTRUCTION.COSTS AND:PERMIT FEE r Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ �U� 1.Building $ 3 k I(W 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 $ ` k O d (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT T -> 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 t e best of my knowledge and understanding. G ��� u��1�� ou9rer Rn -Ti _�� 3I Please print and sign name Title Telephone No Date LB1 OgQ St Qryee R \+� _ \Qt� Street Address Cfty/Town State Zip Municipal Inspectorto fill out this section upon application approval #`"— =' '1�`--��- =`'' -_- „^--z^�+- �^� ��� s .r;r;; '.� . ....�:_ .___� :_ .� ';`. .. ..Name.�-. H..,. .. .:: t.,.,. .,w<' Date `. .•.n 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. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may re wire repeaters) 6 HVAC 7 Electrical 8 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 Budding Survey/Investi ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR Workers Compensation Insurance E222 Hazardous Material Miti ation Documentation Other(Specify) Other S eciOther(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 pe»nit fee. Registered Professional Contact Information 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 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 Zip i Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block# and Lot#for locations for which a street address is not available) No. and Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) CITY OF Sm.E.NI, NLkSSACHusms • Bunn ING DEPART\IEINT 120 WASHINGTON STREET, 3'°FLOOR TEL (978) 745-9595 FAX(978) 740-9846 IQJfBERIEY DRISCOLL MAYOR THoatas ST.PmRRz DIRECTOR OF PUBLIC PROPERTY/BUILDING COND IISSIO,FR 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: (name of hauler) The debris will be disposed of in Tr-() ' ar' (na a of faci .ty) 2l F0t-'d St �V0ck-t�r'� ,m� G'L!0v (address of facility) QA1 t nature of permit applicant Y13fI � date dcbrivlr.dm i CITY OF S�UX,,\I, N'L iSSACHUSEM • BUILDING DEPARTMENT - 120 WASHINGTON STREET,3"FLOOR TEL (978) 745-9595 FAX(978)740-9846 KIMBERI.EY DRISCOLL MAYOR THOMAs ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\MSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anplicant Information Please Print Legibly Name(BusinesslOrganizatioNlndividwl):f 1 lSMl u Address: PQ &Y` qu City/State/Zip: f a o4t�eop IR Is Phone R1-7 RWo Are you an employer?Check the appropriate box: Ty pe of project(require: 11-94 am a employer with 1 4. 0 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have s. ❑ Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp. insurance 5. 0 We are a corporation and its !0.❑Electrical repairs or additions officers have exercised thew 3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. C. 152,§1(4),and we have no 12.M Roof repairs insurance required.]t employees.[No workers' 13.0 Other, comp. insurance required.] •Any upplicom that chocks box g 1 most also fill out the secnioo below showing their workers'eompene scion policy infornatiom ,I bnu:uwner;who submit this affidavit indicating they are doing all work and then hire outside contractors into,submit a over Mdavit indicating such 'Contractors that check this box must attached an additional sleet showing the name of the wb cromntcton and their workem'comp,put icy infennswes. I am an employer that Is providing workers'compensation Insurance for my employees. Below Is the policy and Jab site information. 1 Insurance Company Name:—� Q(S TM\earkn,&� V Policy#or Self-ins.Lic. #: Expiration Date: (v // Job Site Address: ['�� Fitt ctl� St City/State/Zip: Q1 o ri, /MRT1vf_-l(l 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 e. 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 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. l do hereby Wilry under thepains sad penal, ojperJury that the hrjarmation provided above is true and correca 1.61 Date: l I Phone#: crm qZ� dq Ojftcial use only. Do not write in this area,to be completed by city or town official City or Town: _ PermitILIcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: GLENN 13ATTISTELLI CO. ' PAINTING-ROOFING-SIDING-CARPENTRY P.O. BOX 496 BEVERLY, MASSACHUSETTS 01915 Office: 978-927-8956 Office: 978-922-6338 Cell: 617-962-1235 Fax: 978-921-9202 Re: Job estimate I/we the representative/owner(s)of the premises mentioned below,hereby contract with and authorize you as contractor,to furnish all necessary materials and labor and to install the improvements on said premises according to the following specifications: Owner's Name: Arge Hiou Ter. (978)777-1158 (978)335-6425 Job Address: 126 North St. city: Salem state: MA zip: 01970 Contractor Obligations: 1) If necessary secure Building Permit with tine E f�af 2) All work will be done to code. 3) A clean job site will be reasonably maintained at all times. 4) Contractor has all necessary Public Liability and Workmen's Compensation. Proposed Work Roofing-EDPM(Rubber) 1. Remove existing roof down to roof deck. 2. Furnish and install 6" rigid insulation. 3. Furnish and install cover board. (tapered—4"to 1") 4. Furnish and install.060 EPDM membrane fully adhered rubber roof. 5. Furnish and install aluminum edge metal at perimeter. 6. Flash all penetrations and curbs. 7. Flash parapet coping using.024 aluminum. 8. Flash and apply termination bar at wall. 77 9. Remove all debris from job site. Total Price $ , Notes: r s Any rotted sheathing will be replace for$4.00/112 Pricing assumes one layer of EPDM and one layer of tar and gravel roofing. Warranty: 20 year materials and 5 years labor. Applicable Conditions: Payment to be made in 1/3— 1/3— 1/6 and balance at completion unless other arrangements are agreed upon. ?'2 The parties have agreed to the specifications of the contract this day of 201 Contractor. I Owner: I The Commonwealth of Massachusetts `1 Department of Public Safety Massachusetts State Building Code (780 CMR) Building Permit Application to Construct,Repair,Renovate or Demolish any Building other than aOne-or Two-Family Dwelling Code and Other Requirements for Building Permits The Department of Public Safety has issued these building permit application forms so that municipalities across the state can move toward use of a single permit form and consistent permit application process. The MA State Building Code specifies the requirements of building permits and the applicant is advised to review and be familiar with these requirements in order to avoid some of the common permit application problems. Likewise the applicant should be aware that some municipalities require that the owner confirm, even prior to acceptance of the building permit application, that no outstanding property taxes,water fees, etc.exist. Filing Instructions 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be reviewed if construction documents, specifications, fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a check for the Building Permit fee. The fee may be calculated using the information to be supplied in section 12 of the Building Permit Application. The check is to be made payable to the local city or town where the work will be done.