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12 OAK ST - BUILDING INSPECTION The Commonwealth of Massachusetts Department of Public Safety Q{ J . \faesachusctls Stale Building Code(780 CMR)Seventh Edition Cit y of Salem Building Permit Application for any, Building other than a 1- or 2-Family Dwj�j, (This Section For Official Use Only) Building Permit Number: Date Applied: Building Inspector: SECTION 1: LOCATION (Please indicate Block 0 and Lot aY for locations for which a street address is not available) No. and Street CitY /Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 'El ' Is an Independent Structural Engineer in.Peer Review required? Yes ❑ No P1 _. Brief Description of Proposed Work: VC1C S i 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 app licable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑ 1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4 S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a Ilcable) ❑ IIA [JIB VB ❑IA ❑ IB ❑ IIA ❑ 118 SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Fluid Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑ required ❑or trench ur,pccifv: I'rivate❑ or indentifY Zone: or on site sa:stern ❑ ),remit d enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: VA I lktorir c„nnna i„i,m Itev i,„ Pr, \ut Apphcable❑ I,StruClure anlhua airport approach area.' Is their re%ie%% completed.' -r C,,n,ent to Budd cnclo,ed ❑ N'e,❑ or.No❑ Yes ❑ \n ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY I[dilton of Code: L,e Cruupl,i: rape,.(Gna,iruChIm: OCCupant Load per Rnor: Doe, Iha•build//i Ig cuntain.an Sprinkler S\ tem.' Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION r Name and Address yNj Properly Owner 8[�s I�' �' ��r1 C1sn � L ('l�lll �! I� 1 Name(Print) No.and Street City/Town Zip Property 0%%ner Conlact`Information: 1 0- t/ �� � Tit �f hone No. (business) Telephone No. (cell) e-mail address ft C7(\ + i ca ble', (Ne propert% owner he eh t horizes Name Street Address City/Town State Zip to act on the pro pert%owner's behalf, trial] matters relative to work authorized by this building permit a p plication. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If buildin•is less than 350)(1 cu.ft.of endowd s ace and/or not under Construction Control then check here O and skip Section 10 1) 10. a istered Professional Responsible for Construction Control C'�`'(� <(e rwO�l-) y ok kN 10660.3 N m ( e No. e-mail addressRegistration Numbe Rtin(.S2 7& Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor C(f CottarENaTet,, Nam o/Pe n Responsible for C structiun (� � License (No. and Type if Applicable creel dress City/Town State Zip ( b � :2f.LG — � �l ULC37t " Telephone No. (business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION 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 O No 0 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 $ 4. Mechanical (HVAC) $ Note: Minimum fee=$ �(contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6. Total Cost is /s� (contact municipalit )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 applies o is true and accurate to the best ofC( 41, owledge and understanding. C clap r Pleas /r— , p - Van ign name Title Telephone No. Date i ce, �� � .Gi- . N�, a7cn s Street Address Citt'/Town Z p Municipal Inspector to fill out this section upon application approval: " s� o +c o Name D.ue AP'R/30/2010/FRI 11 :52 AM P, 001/001 ''��® CERTIFICATE OF LIABILITY INSURANCE 4/30/203.0 PRODUCER (603)432-6414 FAX: (603)432-3852 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Financial Insurance Services Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 950 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Derry NH 03038 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A.Peerless Insurance Co A d Wood Construction Inc INSURER B: PO BOX 1769 INSURER INSURER D_ Salem NH 03079 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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS. INSR NDUL POLICY DUMBER POLICY EFFECTIVE POLICY EXPIRATIONNSBO TYPE OF INSURANCE DATE fMMIPQP� DATE fMM1DPffl1YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES JE.occsvrenEU ce $ 50,000 A I C MS MADE ❑X OCCUR CBP8706685 8/16/2009 8/16/2010 MED EXP(Any or,e person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER: —PRODUCTS-COMPIOPAGG $ 2,000,000 X POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ee awd t) $ 1,000,000 A ALL OV.NED AUTOS 5A8693505 7/8/2009 7/8/2010 BODILY INJURY X SCHEDULED AUTOS (Per person) IF X HIRED AUTOS BODILY INJURY E X NON-ONNEDAUTOS (Per acvdden0 PROPERTY DAMAGE $ (Per awdent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ MY AUTO OTHERTHAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE E OCCUR El MS MAIJE AGGREGATE E E DECUCTIBLE E RETENTION $ $ WORKERS COMPENSATION I NC STATH- IT"- AND EMPLOYERS'LIABILITY Y I N CRY ANY PROPRIETORAPARTNERIEXECUTIVE❑ E L.EACH ACCIDENT L OFFICER/MEMBER EXCLUDED! (Mandatoryln NH) EL DISEASE-EA EMPLOYE $' If yes.desenbe uMer SPECIAL PROVISIONS be[. EL_DISEASE-POLICYLMIT $ OTHER DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENOORSEMENTI SPECIAL PROVISIONS n CERTIFICATE HOLDER CANCELLATION (978)740-0404 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Ann Richardson DATE THEREOF,THE ISSUING INSURER HALL ENDEAVORTO MAIL 10 DAYS w RITTEN 12 Oak Street NOMCETO THE CERTIFICATE HOLDER NAMED TOTHE LEFT,BUT FAILURE TO DO SO SHALL _A Salem, MA 01970 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Sam Fragala/DEBRA . ,. _ _� - . - ,'?'<'-<:::-y;_.,_<!1'•-. ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200e01) The ACORD name and logo are registered marks of ACORD ) RpP 30 10 03: 08p P. 1 A 03110/2CORDTN CERTIFICATE OF LIABILITY INSURANCE DATE a2o10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Matthews Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 162 Parker St HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lawrence, MA 01843 978-681-1112 `INSURERS AFFORDING COVERAGE NAIC N INSURED A.J.Wood Construction,Inc. INSURERA: Liberty mutual Ins. P.O.BOX INSURER B' Salem, NH 03D79 INSURERC: INSURER D. 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 ADO' POUCYEFFECTNE POLICY EXPIRATION POLICY NUMBER p LIMITS GENERAL LIABILITY EACHOCCURRENCE S COMMERCIAL GENERAL LIABIUtt [ DAMAGE-7-0 PREMISESS(ENY) S CLAIMS MADE OCCUR MED EXP(Anyone MMM) S _ PERSONAL B ADV INJURY E i GENERA-AGGREGATE E GENT AGGRE UNI T MIT APPLIES PER j PRODUCTS-COMPIOP AGG S POLICY PRO- iIFCT LOC AUTOMOBILE LIABILITY COMBINED_ ANY AUTO Fa a"itlam)SINGLE LIMIT AU-OWNED OWNED AUTOS BODILY INJURY SCHEDULED AUTOS LPefJ ..) E I NRED AL'OS BODILY INJURY E ' NONOWNED AUTOS (Per ec6tlMrc) PROPERTY DAMAGE S ' (Per 2aitlenl) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT E ANY AUTO EA ACC S OTHER THAN AUTO ONLY: AGO 3 EXCESSNMBRELLALWBILITY W ;EACH OCCURRENCE S OCCUR CLAIMSMADE AGGREGATE S E DEDUCTIBLE S RETENTION S S WORKERS COMPENSATION AND WC231S353819029 02/13/2010 02/13/2011 wcr TAN- OTH- ER EMPLOYERS UAB1UTY ANY CE"EM6ER EXCLUD IEXECUTIV E E.L.EACHACCIDENT E 500.000 OFFICERRdEMBER EXCLUDED) E.L.DISEASE-EA EMPLOYEE E 500 OOO S yas,AL PRO Vr IO SPECIAL PROVISIONS Mav EL DISEASE-Poucr LIMIT E 500000- OTHER i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Ann Richardson GATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN 12 Oak Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO 00 30 SHALL Salem, MA 01970 IMPOSE NO OBUGATION OR UASIUTY OF ANY KBND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORURD REPRESENTATIVE/i ACORD 25(2001108) I/ ©ACORD CORPORATION 1988 s CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT .rids pit) ,I""I \I .n�M I.0�1.,+111\L.,lV S1III: #�•\II\I, �t.Ni.\, 11141,•:1', _ Trt:1)ry.745-199S •f ts:N7t•7+s,aJr, Construction Debris Disposal Affidavit (required lur all demolition mtd 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 N _ 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 l 1. S 150A. The debris will be transported by: Ina=of hauler) The debris will be disposed of in (nameul as rty T taddrm+ul tacday) +ISnature of Ikrnu date