Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
35-41 NORTHEY ST - BUILDING INSPECTION
� / ono b ' The Commonwealth of Massachusetts ` Department of Public Safety t Massachusetts State Building Code(780 CMR) building Permit Application for any Building other than a One-or Two-Family Dwelling (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 addmss is n available) -ea + (3 A LL No.and Street City/'town Zip Code Name of Building(if applicable) SECTION 2 PROPOSED WORK Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ :\ddition❑ Demolition ❑ (Please fill out and submit Ap end IN 1) Change of Use ❑ j Changeof Occupancy Cl Other ❑ Specify: Ff7()V G Are building plats and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Descriptioq of Proposed Work: n 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 780CMR 34) ❑ Existing UseGroup(s): I Proposed UseGroup(s): SECTION 4:BUILDING MIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Fluor(sq.ft.) Total Area(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as ap licable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-I❑ A-5❑ B: Business ❑ E. Educational ❑ F: Facto F-1 ❑ F2❑ I H: High Hazard FI-1 ❑ H-2-❑ H-3 ❑ H-4❑ H-5❑ I: Institutional M ❑ I-2❑ 1-3❑ 1-4❑ NE Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ 11U: Utility❑ Special Use❑and please describe below: Special Use: , SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA Cl IB Cl IIA ❑ IIB ❑ IIIA ❑ II113 ❑,' IV.-❑ VA ❑ VB CI 4 SECTION 7:SITE INFORMATION(refer to 780 CDiR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: "Trench Permit: Debris Removal: r. Public❑ Check if outside Flood Zone❑ Indicate nttmicipal❑ A trench will nut be Licensed Disposal Site❑ Private❑ '. or indentify Zone: _ or on site system❑ required ❑or trench or specify: permit is enclosed❑ - Railroad right-of-way: hazards to Air Navigation: \L\.I Ii,.Ir�ric C'nnunisi��n Rcvw, Prone Not:\pplic ale❑ Is Structure ivithin airport approach area? Is their review cot npleted? o B or Consent ft)lit, enclosed ❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CON"FENT OF CERTIFICATE OF OCCUPANCY -� Edition of Cade Use Gruup(s): 'Type of Constnuction: Occupant Load per Floor: Does the building contain an Spri n kler Sys tem?: Special Stipulations: _ J SECTION 9: PROPERTY OWNER AUTHORIZATION Name and AdmI L�sS of Pr poly Owner AV b ��(�n e�'1�1 fZ✓� I !V l� D l j 0 �� e i �/ G A & �rL[l 0 0 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: / m rzl- Gl- 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 a cr.`bwtieds behalf,,in all matters relative fo work authorized b this buiid h ermit a licution. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If Wildio g is less than 951000 cu.ft.of enclosed space and or not under Construction Control then check here❑and siklp Section 10.1 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 Dale 10.2 General Contractor., . - Company Nat G ne c MI (— 1 1411 ) J 6 r7 Name of Persgn Responsible for Construction l 1 License,No, mild Type if Applicable &O Street Address City/Town State Zip ) Telephone No.jbuLi ness Telephone No. cell e-mail address SECTION II:IVOHKI'R9'CO\iPEN5A1'k.,N INSU LANCI:Al 1'llwff M.C.L.c.152. 25C6 A Workers'Compensation Insurance Affidavit from the vlA Department of Industrial Accidents must be completed:mild submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. ns Isla signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)='S I. Building 5 Building Permit Fee-Total Construction Cost x (Insert here 2. Electrical S -appropriate municipal factor)='S 1 Plumbing _ 5 contact nuunici lit Note: Minimum fee=$ ( P Y) I. Mechanical (FIVAC) $ S. Mechanical Other $ 'q Enclose check payable to V 6.Total Cost $ d Q (Contact mmticipality)and write check number here SECTION 17:SIGNATURE OF BUILDING PERMIT APPLICANT By entering illy 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 to the bAt of niy knowledge and uiulerstandiing. /ti/ / (nA C, e / I I ( 2 tO -7 CJ I /91 Please print a sign panne P 'Citle Telephone No. ntc A �h� fJn V STdrvt Slr C...�cct Address >'/ Cil Gown State Zip � Municipal Inspector to fill out this section upon application approval: Name Date CITY OF SM.Mvfs 1AL1SSACHUSEM BI:ILIMNG DEPARTMENT 3 120 WASHIINGTON STREET,3"FLOOR TEL (978)745-9595 FA.e(978) 740-9846 KIJIBER! RY DRISCOL T MAYOR �iOFtAS StP1ERR13 DIRECTOR OF PUBLIC PROPERTY/BUMDL`JG COSL\IiSSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers annlicant infirrmation Please Print Legibly Nalnc(Busitxy&organizatiutvindividual): �11��f Address: 35 �/11 �rl T?L- e L- 57'✓�G�- city/Stateyzip: cSQ/2YV) L4 C)/ / 6 Phone m: 78l 953 0) / C) Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These subcontractors have a. El Demolition working for me in any capacity. workers'camp.insurance. 9. Building addition (No workers'camp.insurance 5.'❑ We are a corporation pnd its. required) officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself.(No workers'camp. C. 152;§1(4),and we have no 12.0 Roof re airs insurance required.)t omployees.[No warkcrs' (3y Other. G t n comp.insurance required.J, -Any appllc:va that chucks her e I must also rill eat the section below showing their wadam'cumpensatua poficy infurmstfon. t I r,.vuwnen whd submit this adidnVit indicating they am Joing all work and than him"Illide"Mrataon must submit a new aindavit indicating such. :Gmtt son that check this box must attached an additional sheet showing the[lane of the suGconinctors and theirworksn'comp.policy Infsmeition. I ram an eutptayer that Is providing workers'compensatlon Lraurance for my empluye^ Below/i the policy and Job site information. insurance Company Name: >p y Policy 4 ur Self-ion.Lic. N:e,,( 1N.E hI r, ,J 7c0 ,,I 3 � ' �( , Expiration Date: g Jub site Address:3 5-to 1 kr`I ke / �� . �,{ KA f. kDl6 City/State/zip: :5 1�M ' Oa IM .lttacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to securo coverage as required under Section 23A of VIOL c. 152 can lead to the imposition of criminal penalties of a - fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a tine of up to S250.00 o day against the violator. lie advised that a copy of this statement may be furwardud to the Office of Investigations of the MA for insurance coverage verification I do hereby certify under the a nst and Pena l i of per/wry that the informutlon provided u6u a is true and correct cp tut • 13 Official use wdy. Do not write in this are,4 to be completed by city or rows o/J7clat - City or Town: _ PermiV7.1censeS Issuing,%inhority(circle one): ' 1. gourd of llcalth 2.Buildtn{;department 3.Cityffosrn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other - Contact Persona . ---- _------. PhaneB: CITY OF SM.E . 1NLAsSAC]HLSETI•S • BUILDLNG DEPARTMENT N 130 WASHINGTON STREET, 311D FLOOR TEL (978) 745-9595 F.ar(978) 7.10-9846 KIA{gFRT FF- D Y RTSCOLL MAYOR THO.NW ST.PIERRS DIRECTOR OF PUBLIC PROPERTY/BUILDING COSLMISSIONER 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 I50A. The debris will be transported by: ;y S12 • � (name of hauler) The debris will be disposed of in : -i Ye M -- (name of facility) (address of facility) - I . J lCA 4e, signature of permit applicant 1 13 date ddxisaff dux �., OP ID: MM CERTIFICATE OF LIABILITY INSURANCE D08116ATE /2013 ) OS/16/2013 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 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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). PRODUCER Phone:978-745-3300 NAMNT EACT John J Walsh Ins Agency,Inc Fax:978-745-9557 PHONE FAx P O Box 4407INC.No Ext: ac No: Salem,MA 01970.6407 E-MAIL ADDRESS: David C Bruett PRODUCER gHILL04 CUSTOMER IDp: INSURERS AFFORDING COVERAGE NAIC M INSURED Hill Properties,Inc. INSURERA:Guarcl Insurance Group Michael Hill INSURER B:Essex Insurance Company 6 Albion Avenue Stoneham, MA 02180 INSURER C INSURER D: INSURER E 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 AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE D POLICYNUMBER MM TR IDDNYYYI (MMIDDNYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 B X COMMERCIAL GENERAL LIABILITY 3DL1438 05/31/2013 05/31/2014 PREMISES Ea ocwrrence $ 50,000 CLAIMS-MADE aOCCUR MED EXP(Anyone person) $ EXC PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ EXC X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULEDAUTOS PROPERTY DAMAGE HIRED AUTOS (Peraccidenp $ NON-OWNEDAUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WCSTATU- OTH- AND EMPLOYERS'LIABILITY T Y LIM A ANY PROPRIETORIPARTNEWEXECUTIVE YIN HIWC322423 05/18/2013 05/18/2014 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? F1 NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,Hmore space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE THEREOF, City of Salem, MA ACCORDAINCEION WITH DATE THEPOLICY PROVISIONS.NOTICE WILL BE DELIVERED IN City Hall 93 Washington Street AUTHORIZED REPRESENTATIVE Salem, MA 01970 ©1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD '1 • __ i. � �. _ L.�! ... j? �~ ` ..r-. ..� _sue. _ — 1�... �. t � ' ate' 771 lo A _ _ Lu