33 PARK ST - BUILDING INSPECTION a� m
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a The Commonwealth of Massa
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Department of Public Saf*
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Massachusetts State Building Code(780 CMR) P �
�� Building Permit Application for any Building other than a &O"T%d-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 address is not available)
No.and Street City/Town. Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
u l Existing Building❑ Repair Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
I Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineerin Peer Revlie�w required? _Yes ❑ No G�
Brief Description of Proposed Work:tY-k tLC y11C,�1 � ^� WUWf CUT Q� 45 � Y�-,103
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) ❑
Existing Use Group(s): Proposed Use Group(s):
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 applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
R Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build.enclosed❑ Yes❑ or No❑ Yes❑ No ❑
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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
f Name and Address of Property Owner
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Name(Print) P U-lY,ut� No.and Street City/Town Zip
Proper Owner Contact Information:
LbsolaLUbwht EXe(-, 9 $4S1X�..� $4 ` ClYncr QrY11rm1 ra arQ
Title Telephone No. (business) Telephone No. (cell) marl addres�_
If applicable,the property owner hereby authorizes
Willa 1`-��_ R6kry_ St , -�cD MA (A9w
Name '1eJ—T Street Address CityCity/TPPC3 State Zip
to act on the property owner's behalf,ill matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Drom Mafia mok,h
Company Name
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Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Awn State Zip
g3t.5_u-acd +E -2o� -yo_6 0,., Uw i y Arrncurr r 4.ccw
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$�
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contactgunicipality)�
5.Mechanical Other $ Enclose check payable to � t/
6.Total Cost $5� .J"V3 (contact municipality)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
application is true and accur7 e t.74 y knowledge and understanding. te
se ring t and s; ame Title Telehonp elo.
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Street Address City/Town State Zip
13/_
Municipal Inspector to fill out this section upon application approval: 41.4 Jr
Name 41 Date
CITY OF SALEN4 2NLNSSACHUSETTS
• BL'ILDNG DEPART\iENT
p 120 WASHINGTON STREET, Y°FLOOR
TEL (978) 745-9595
FIlx(978) 740-9846
KINIBERI.EY DRISCOLL
MAYOR THomiAs ST.Pm m
DIRECTOR OF PULIC PROPERTY/ButLDLVG COSMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Ousiiwss,Organizatiorvindividual): 4.AA1111
Address: }fir .5 ",
City/State/Zip: _ (�I�I (00 Phone #:1 q �) ,J3o� g(oI �L-
A,r_e,(you an employer?Check the appropriate box: Type of project(required):
L tvl I am a employer with�O 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).* have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7. Oemodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers' comp. insurance. g. ❑ Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised[hair
10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. (No workers' comp. C. 152,§1(4),and we have no 12.❑ Roof rc airs
insurance required.)t employees. [No workers' 13ZOther ll�'
comp. insurance required.)
•Any applic;ml that checks box BI must also Gll uut the s tim below showing their workers'compensation policy information.
'I lomeowm"who submit this affidavit indicating they are doing all work and then hire outside contmcrom most submit a new affidavit indicating such.
$]mtra:tun that check this box most anachci un additional shxet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compeasatlon insurance for my employees. Below Is the policy and job site
iujormarion.
Insurance Company Name: f���fY➢(IPC� Frndt APYS �Vl�C1Yl�t°
Policy#or Self-ins. Lic.#:_V1A Q 005D Ue�a,%/ Expiration Date: �0 _
Job Site Address:�l�J_ q4 I S(o �IY 7IY � City/State/Zip: ` ,, �AA ONOK)
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 of MOL 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 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
Investigation:of the DIA for insurance coverage verification.
I do hereby cert under t e ad penalties of perjury that the information provided above is true and correct
Si mat ue:
Date:
Poe,Y:
Official use only. Do not write in this area,to be completed by city or town g1ttriaL
City or Town: Permit/I.Icense
Issuing Authority(circle one):
1. board of Health 2.Building Department 3.City/fawn Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other._�
Contact Person:_.--- _ Phone#:
!
DANCO-2 OP ID: EL
f ,4CORo° CERTIFICATE OF LIABILITY INSURANCE DATEoa106/2016
os/2o15
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 INSURER(S), 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 TACT
McLaughlin Insurance Agency PHONE F
828 Lynn Fells Parkway aC No E,a:781.665-2775 ac No;781-6650295
Melrose,MA 02176 aooliEss:
John E.McLaughlin Jr.
INSURER(S)AFFORDING COVERAGE NAIC9
INSURER A:Commerce Insurance Company 34754
INSURED Danco Management Inc. INSURERB:AmTrust International Underwr.
67 Foster Street,91
Peabody,MA 01960 INSURER C:Associated Employers Insur.Co
INSURERD:Associated International Insur 27189
INSURE
INSURERF:RE:
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.
ILTR TYPE OF IN RDOL SURANCE POLICY EFF POLICY EXP
POLICY NUMBER MWDO MID LIMBS
B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
CLAIMS-MADEFx]OCCUR AES1021335-00 0910412014 09104/2015 PREMISES(Ea occurrence) It 200,00
MED EXP(Arty orle person) $ 5,00
PERSONAL&ADV INJURY $ 1,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00
Ok
POLICY a PET LOC PRODUCTS-COMPIOPAGG $ 2,000,00
OTHER: $
AUTOMOBILE LIABILITY C MBINED IN LE LIMIT $ 1,000,00
Ea accidem
A ANY AUTO 15MMBGL792 04/03/2015 04/03/2016 BODILY INJURY(Per person) $
ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
X X NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
X I UMBRELLA LWB OCCUR EACH OCCURRENCE $ 2,000,00
X
D ExcEssuAe CLAIMS-MADE CUBW5218414 09/04/2014 0910412015 AGGREGATE It 2,000,00
DED RETENTION$ $
WORKERS COMPENSATION X PER TH-
AND EMPLOYERS'LIABILITY STATUTE ER
C ANY PROPRIETORIPARTNERIEXECUTIVE Y/N WCCSOOSO13822 09/0212014 0910212015 E.L.EACH ACCIDENT $ 500,00
OFFICE WMEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,00
N yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 50Or00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addhlonal Remarks Schedule,may be attached It more space Is required)
Evidence of insurance
CERTIFICATE HOLDER CANCELLATION
SALEM-7
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
120 Washington St 3rd Floor ACCORDANCE WITH THE POLICY PROVISIONS.
Salem,MA 01970
AUTHORIZED REPRESENTATIVE
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