50 PALMER ST - BUILDING INSPECTION (2) + No)�/- � City c:,,Salem Ward
a4c` '"
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete all Items in sections:1, It, ill, N, and IX.
I. AT(LOCATION) JrD /�A t_m E rt ST o STRICT
LOCATION NOj (STREET)
OF BETWEEN Cc>% eSS ST. AND � rc-t"CE -r.
BUILDING c sm�n (CROSS STRUT)
SUBDIVISION LOT BLOCK SIZE
II. TYPE AND COST OF BUILDING -All applicants complete Parts A -D
A. TYPE OF IMPROVEMENT D. PROPOSED USE•FOR"DEMOLITION"USE MOST RECENT USE
1 ® New building Residential Nonresidential
2 ❑ Addition(ff residential,enter number of new 12 ❑ One family 18 ❑ Amusement,recreational
housing units added,ff any,in part D. 13) 19 ❑ Chruch,other religious
13 ® Two or more tamil -Enter number
3 ❑ Alteration(See 2 above! of units ............./ .............................. 20 ❑ Industrial
21 ❑ Parking garage
4 ❑ Repair replacement 14 ❑ Transient hotel,motel,or dormitory-
Enter number of units ...........................
22 ❑ Service station,repair garage
5 ❑ Wrecking(X mu/tilamily residential,enter number 23 ❑ Hospital,institutional
of units in building in Part D, 13) 15 ❑ Garage 24 ❑ Office,bank,professional
6 ❑ Moving(relocation) 16 ❑ Carport 25 ❑ Public utility
7 ❑ Foundation only _ 26 E] School,library,other educational
.17 Other-Specify 27 ❑ Stores,mercantile
B.OWNERSHIP 28 ❑ Tanks,towers
8 ® Private(individual,corporation,nonprofit -
* 29 ❑ Other-Specify
i
institution,etc.)
9 ❑ Public(Federal,State,or local government
C.COST (Omit cents) Nonresidential-Describe in detail proposed use of buildings,e.g.,food processing plant,
I� machine shop,laundry building at hospital,elementary school,secondary school,college,
1 O. Cost of improvement ......................................................... $ 2 5 3 D parochial school,narking garage for department store,rental office building,office building
. at indust(ial plant.H use of existing building is being changed,enter proposed use.
To be installed but not included 11/i I I
in the above cost V('1r
aElectrical ........................................................................... 000
b. Plumbing .......................................................................... COO
c. Heating,air conditioning........................._............._... 0 00 i>
d. Other(elevator.etc.) ......................._...........................
11. TOTAL COST OF IMPROVEMENT $3,oco
111. SELECTED CHARACTERISTICS OF BUILDING - For new buildings and additions, complete Parts E.-L;demolition,
complete only Parts J& M, all others skip to IV
E. PRINCIPAL TYPE OF FRAME F. PRINCIPAL TYPE OF HEATING FUEL G. TYPE OF SEWAGE DISPOSAL- L TYPE OF MECHANICAL
30.❑ Masonry(wall bearing) 35 ®.Gas . - 4Q ® Public or private company will there be central air
31 ® Wood frame - 36 ❑ Oil 41 ❑ Private(septic tank.etc.) conditioning?
32 ❑ Structural steel 37 ❑ Electricity 44 ❑ yes 45 ❑ No
33 ❑ Reinforced concrete 38 ❑ Coal H. TYPE OF WATER SUPPLY Will there by an elevator?
34 ❑ Other-Specify 39 ❑ Other-Specify 42 ® Public or prorate company 46 ❑ yes 47 ❑ No
43 ❑ Private(well,cistem)
1 - _
r'
J.DIMENSIONS I -
ae. Number of stories ....................................3...................... M. DEMOLITION OF STRUCTURES:
49. Tow square feet of floor area Has Approval from Historical Commission been received
all floors,based on exterior 20 3 6$
dimensions ..............................................t........_._........... for any structure over fifty(50)years? Yes_ Now
50. Total land area sq.ft. 302..........- Dig Safe Number 060(n
K.NUMBER OF OFF-STREET PARKING SPACES `
Pest Control:
.......52. Outdoors- ..... 5 HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
. e
............ . ...................................
Yes No
L RESIDENTIAL BUILDINGS ONLY Water:
5a Eiclosed ............................................................................. Electric:
Gas: yes
Fun Sewer.
54. Number of
bathrooms DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
Partial...................................... - BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING:
Historic District? Yes_ No (If yes,please enclose documentation from Hist Com.)
Conservation Area? Yes_ No_ (If yes, please enclose Order of Conditions)
Has Fire Prevention approved and stamped plans or applications? Yes_ No
Is property located in the S.R.A./district? Yes_ No
Comply with Zoning? Yes✓ No (If no,enclose Board of Appeal decision)
Is lot grandfathered? Yes_ No-�L (If yes,submit documentationfif no,submit Board of Appeal decision)
If new construction, has the proper Routing Slip been enclosed? Yes✓ No_
Is Architectural Access Board approval required? Yes_ No ✓ (If yes, submit documentation)
Massachusetts State Contractor License # CS 0173834 Salem License #
Home Improvement Contractor# Homeowners Exempt form (if applicable) Yes_ No_
CONSTRUCTION TO BE COMMENCED WITHIN SIX (6) MONTHS OF ISSUANCE OF BUILDING PERMIT
CONSTRUCTION IS TO BE COMPLETED BY: Z rrWNTt-t S Slu¢n an extension is necessary, please submit
n writing to the Inspector of Buildings.
V. IDENTIFICATION . To be completed by all applicants
Name Mailing address-Number;stmel,cM,and state LP Code TeL No.
Owner or AI EM 9o/L ��Z G 91$ s'Lf�/At
'-� ��� � SAlcn rLlrt � o/gld
2. N , ��Eo MAirra Sr. STonrc-r�<vn AO sa oziso /'yW31
Contractor Builders
gees UoenseNO. Sam38'
3. es SvS S'r L�uraoiiu !-1y�
Architect or11n 111,)
Engineer NNt'1 G�d M,A C 01/p
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application
as his authorized agent and we agree to conform to all a licable laws of this jurisdiction.
Signature of applicant Address Application date
o �� . S46eZW W ousa
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building Use Group
Permit issued 19 Fire Grading
Building
Permit Fee $ Live Loading
Certificate of Occupancy $ Occupancy Load
Approved by:
Drain Tile $
Plan Review Fee $
TITLE
NOTES AND Data• (For department use)
z , q {I
I
AJ
So-
fl�L N
CU r S
PERMIT TO BE MAILED TO:
DATE MAILED:
Construction to be started by: Completed by.
VI ZONING PLAN EXAMINERS NOTES
DISTRICT
i
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
SITE OR PLOT PLAN •For Applicant Use
O N
i'hap 3 y to id 2
CITY OF SALEM
ROUTING SLIP
NEW CONSTRUCTION X
CERTIFICATE OF�OCCUPANCY
LOCATION: _ICCD ,44fo617- DATE
APPLICANT: 1j9wn AeK -r'7RUaUaG3 CORP.
ASSESSORS /
FRANK KULIK /�"E2 "/'�\ DATE: 2 Jl? �4i
(93 Washington Street) `
CITY CLERK
CHERYL LAPOINTE Ci11 u-o- f' DATE:
(93 Washington Street)
PUBLICE SERVICES
BRUCE THIBODEAU < DATE:
(120 Washington Street)4'Floor
WATER --
DOTTIE THIBODEAU
(120 Washington Street)4th Flo
CROSS CONNECT SUPERVISOR
BRIAN THIBODEAU DATE:
(5 Jefferson Avenue)
PLANNING
(120 Washington Street) 3'd Floor
CONSERVATION A Ca,. ApO ,4 :.
A�c���DATE: 8 '3 oL 1
(120 Washington Street) 3rd Floor
ELECTRICAL
JOHN GIARDI_—DATE:_ f
(48 Lafayette Str
FIRE PREVENTIOI ry'Z
ERIN GRIFFIN ��CC// Qx_ DATE: —eZ—
(29 Fort Avenue)
HEALTH JO \ff
JOANNE SCOTT DATE:
(120 Washington StreW41b Floor
BUILDING - /
THOMAS ST. P[ERRE XDATE: D �(120 Washington Street) 3`d Floor
P
CONST'RUCTiON CONTROL AFFIDAVIT
Project Number. Q)( Proiec.+ tt o 3oa Lib Date: 8 a 1 o to
Project Title: 50 ?alrAe2 s+rect >4 i Rdn�le { jous na
Project Location: 0 almeR S+rcet (former b 'eeefe- ''5 �es�4uaa^t
Name of Building: NIA
Scope of Project: won slruc f is of 1 s ur`(- amendable hoes 'n�
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
305eph L-- Lur%& AZ-r4 . MASS. REGISTRATION NO. 70/o BEING A REGISTERED
PROFESSIONAL ENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY
SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND
SPECIFICATIONS CONCERNING:__ _ - -- -- ._ ._._.. _ ......
Civil Architectural ✓ Structural ✓ Mechanical ✓
ConsuHant. o�eR o e +vHSsoc. CPnsml ^-r ross ed
Electrical �_ Fire Protection ✓ Other(specify) ainee2in�
CanSu.Hant: Crtoss-hela COASWIVnT- C2oss 'eia 6rvo�neeKi�1-
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES
AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO
DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS
APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING
AS SPECIFIED IN SECTION 116.2.2.
1. Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for building permit, and approval for conformance to the design concept.
2. Review and approval of the quality control procedures for all code required control materials.
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specked in the accepted engineering practice standards listed in
Appendix I.
PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALL A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE BUILDI IN PE OR. UPON COMPLETION
OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATI FACTORY COMPLETION
AND READINESS OF THE PROJECT FOR OCCUPANCY.
Signaturd
SUBSCRIBED
'AND
�SWORN TO BEFORE ME THIS 6) / DAY OF IqU u.st 200W1e
My commission Expires: l0 7
o ry Public
DIANE GIANOCOSTAS
Notary Public
My commission Expinss
June 7,2007
CITY OF SALEM
` PUBLIC PROPERTY
DEPARTMENT
KIMBERLEY DRISCOU
MAYOR 120 WASHINGTON Sr RE.Er •SAIEM,,MA:SACHUSE1lS 01970
TE—L 978-745-9595 4 FAX:978-740-9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ! Please Print Legibly
Name(liusitusslOreanization Individual): ^�^t�m R 21G ST9,LA LTUP_Cr 5 t Co R-P
Address: AND rnPvtN
City/State/Zip: JTZ>Ni✓WAnnn A OZISOPhoneg: 751 -4139—V700
Are von an employer!Check the appropriate box: Type orproject(required):
1.10 1 am a employer with h�0 4- [1 1 am a general contractor and 1 6 ❑New,construction
y ).
to em ees( p full and,or art-time ' have hired the sub-contractors
P listed on the attached sheet.; 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or parmer-
ship and have no employees These sub-contractors have 8. ® Demolition
workers' comp. insurance. 9, Building addition
working for me in any capacity.
No workers'cum 5. . We are a corporation and its
P insurance ❑
- officers have exercised their 10.El Electrical repairs or additions
required.] n repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing P
Myself. (No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.LNo workers' 13.❑ Other
comp: insurance required.]
-Airy. plicant that checks box#1 most also fill out the section Glow showing their workers'compehsmion policy inf nirmaion.
r I I.meowners who submit this affidavit indicating they are doing all work and then hire ou,sido eonrnraon most submit a new affidavit indicating such.
=Contractors.that check this box must attached un additional sheet showing the nante of the sub-contractors and their workers'comp.polity information.
mui ail employer that is providing workers'compensation insurance foraty employees. Below is die policy and job site
irrfonrrutio». M n
Insurance Company Name: ki 13�-Tx:..-'!
l'olicv#or Self-ins. Lic`#:- W C2-~312 3_ 5750 -C) O - Expiration Date: -z -b 7
Job Site Address: 50 2ALm E2 ST - City/State/Zip:,A�-rt't. . t•IQ UI pTD -
Aitach 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.`vLGL c. 152 can lead to the imposition of criminal penalties of a
tine 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$250.00 a day against the violator. fie advised that a copy of this statement may be forwarded to the Office of
lovcsiigations of the DIA for insurance coverage verification. -
do hereby certijy tder Cite pain•and mollies of perjury that the injorinullon provided above is trite and correct.
\J \ Slz Vim. Date: 7 �I 3/O(�
Phonez- 781- 13S--q?00 eeU 4 1:47 F003-229!r
Official use only. 'Do not write its this area,to be completed by city or town official
.City or Town: - Permit/1.1cense
Issuing Authority(circle one):
I. Board of health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other —
Contact Person: __ .__ Phone#:
r
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have bean presented to the contracting authority." -
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s),address(es)and phone nunmber(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. .The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department arthe number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials - -
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space.at the bottom
of the affidavit for you to till our in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the number which will be used as a reference number. In addition, an applicant.'
that must submit multiple pennit/license applications in any given year,need only:submit one affidavit indicating current,
policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the .
-applicant as proof that valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
year. Where home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. -
fhc Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
Please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727.4900 ext 406 or I-877-MASSAFE
Revised 5-26-05
Fax# 617-727-7749
www.inass.gov/dia
v%viru',' CER T IFICATE' CF`LIABILITY INSURANCE OP ID DATE(MIAMAYM
PRODICER LANDM-1 D2/08106
Eastern States Insurance THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Agency, Inc. ONLY AND CONFERS NO HOLDER.THIS CERTIFICATE AN CERTIFICATEUPON THE
TE DOES NOT AMEND EXTEND OR
50 Prospect. Street Waltham MA 02453 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
'Phone: 781-642-9000 Fax:781-.647-3670
NMR20 INSURERS AFFORDING COVERAGE NAIC#
DCRERA. St. Paul Travelers
WSURERR Americas Wholesalers
440 Maim Street
Landmark Structures Corp. - NSURERC Liberty Mutual/AR
Stoneham MA 02180 NsuTExO '
COVERAGES - ��E'
RE POLICIES OF NSURN•NCE LISTED BELOW KAyE BEEN ISSUED TORE NSIRED NAAEIT ABOVE FOR 71,E POLICY PERIOD PDICfOED.NOIWO/ISTAIDRTG
ANY REQUIREMENT,TERM W COMITION OF MY CONTRACT OR OTTER DOCUMENT WTIH RESPECT TO Mica MS CERTIFICATE MAY BE ISSUED OR
NAY PERTAIN,TIE UISUW LE AFFORDED BY TIE POLICES DESCRIBED H REIN IS SUB.ECTTO ALL 7 ETERM.D(CLUSIOb AI:O CONDTIIONS OF SUCH .
POLICES.AGC, GATE U M5 9fOWN MAY IMVE BEEN REDUCED BY PAID CLANG. -
LTR S - TYPEOFNSURANCE POLICY NUMBER DATE wM30m7 DATE MWODMNI LIMOS
GENERAL LIABILOY
A X ca EACFI OCCURRENCE $1,000,000
MNErTcw1 GELERµ LIABILITY CO 463D944-4 01/09/06 01/01/07 PREMISES Eeoc .. i-300,000
CI,UMS WDE X❑ XaR
. . - MEDORIA�v nelysml $5,000
PERSMAL A ADV"BY $1,000,000
-GENL AGGREGATE LIIM APPLIES PER: GEERM AGGREGATE s2,000,D00
POLICY X � LOC PRODUCTS•CO YCP AEG f2,DOD,---
. AVTUMOBILE LIABILITY,- - Emp Ben. .1,000,000 -
A X ANYAUTO - 810 4631)945-6 01109106. 01/01/07 IEe exkMiI ITJGfELaBT f1,000,000
ALL DV*ED AUTOS. ..
SCHEDULED A,rr_, - BODILY NARY - S
P�.PROfII
- MiED AUTO
NONFOWWD AUTOS- BODILY NLRY -
X Comp Ded:. $1,000 (PXxkEeNl s
X Collis Ded:$Sy0o0 PROPERTY°AVINGE
GARAGE LIABILITY - ..
"AM - AUFOONLY-EAACCIDEWr. . f
0FER iWVN 6AACC i.
NRO MY: AGG f
F]RCESSNMBRET,LA LNL NBILTTY ... . � ..
B
EA OCCIFdtENCE 12,00 0 1000
.OCCUR �.anlM•,MADE TBD 01/09/06 01/01/07 AGGREGATE
$2,000;000
DEDICTBLE
RETENTION
WORKERS COWENSATUNAND -
ENPLOYERsLIABNLR,,
C AINV PRCPRIETORIPARREJAETECDTNE WC2-31S-357507-010 01/21/0.6 01/21/07 E.L.EAONACCIOENT i500,000
OWICER61EWEi E%CLLOED]
I6IP�ECW�I OVISI LMvn EL DISEASE.P.EN9LOYFE iSDO,DUD _ .
OTHER ELDISEASE.POLICY LIMIT $500,000
PESMPOON OF OPERATIONS I LOCATIONS I VEMCLES l EKCLUSIONS AWED B ENDORSENEMI SPECLAL PROMSIONS
Evidence of insurance coverage.
q ERTIFlCATE HOLDER CANCELLATION
LAI1DZdFSR SHOULD ANY OFTME ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE G,IRXTION
. - DATE THEREOF.TIE ISSUmG NSLIRER WILL E EAVCR TO NAIL � DAYS WIOREN .
L(2001/09)
Structures Corp. NOTICE TO7NE CERTIROATE HOLDER NAAffD TO TTM LEFT,BUT FAILURE TO 0090 SWLLL
Street SPOSE NO OBLIGATION OR LIABLRY OF ANY KM UPON TTE NSURER TfB AGENTS OR
MA 02180 REPRESENTATIML
AUIHOROEp REPRESENTATIVE
r
0 ACORD CORPORATION 19RR
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KIMBERLBY DRISCOLL
MAYOR 120 WA.SHINGTON STREET SALEM,MA,SSACHUSETIS 01970
TE�978-745-9595 ♦ FAX:978-740-9846
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
-- (name of facility)
�L/WN w,4,V ,C4t/ , �a
Mess of f- •iat, lity)
signature of permit applicant
date
Ar6ri.a!'Ldoc