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17 PATRIOT LN - BUILDING INSPECTION 1 ;► The Commonwealth of Massachusetts Department of Public Safety •e NfassaCIIUSCB?State Building Code(780 CMR)Seventh Edition City of Salem Building Permit Application for any Building other than a I- or 2-Family Dwellin (This Section For Official Use Only) Building Permit Number: Date Applied: Building Inspector: SECTION 1: LOCATION (Please indicate Block N and Lot N for locations for which a street address is not available) '1, QrUR� \ t .\ `^ o.and Street City /Town Zip Code Name of Building(if applicable) `!, \ SECTION 2: PROPOSED WORK If New Co structiun check here ❑ur check all that apply in the two rows below (V\ Existing Building ❑ Repair Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No / IS an Independent Structural Engineerin• eer Re Wur r� equii-reeq.VI` �0M Yes ❑ No 8 Brief Description of Proposed k: CP�uo�12 NaE CLk—? ( taro r.'ts 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): jA2LKtrAPAA �r\ Proposed Use Group(s): r Existing Hazard Index 780 MR 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.) 'Z Total Area (sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑ I: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4 ❑ S: Storage S-1 ❑ S-2 O - U: Utility ❑ Special Use ❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE (Check as applicable) n103I IIA ❑ 11B ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION (referto780CMR 111.0 for details on each item) Flood Zone Information: Sewage Disposal: Tren=Pemit: Debris Removal: heck if Outside Flo,,d Zone❑ Indicate municipal ❑ � trenLicensed Diaposal ',ite❑ r indentik Zone:_ Or on site sv<tem ❑ requireur,pecihpermit Railroad right-of-way: Hazards to Air Navigation: \I:\ li>n Sri;l .nnin >*i •n K,cir„ f'n \,d \ppicab .' ❑ I.tit niClurc ,rrthin airpnrt opprOadt •ire.t' b !heir rrcirw cumplc0.•d' nr C nt,unt to Build endn.ed ❑ Ye,❑ or.\n❑ 't ❑ \o ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY I[dwm ..ICaic: C,e(Iroupl>i: Ic peal COnslniRium OCcupant load per PlOOr I)oc.the building contain an Sprinkler tit aem': Special Stipulations: r SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Ipe �OwnerAr � � *A A e Nu.and Street City/Town I"6 F" Zip :Name (I ring , Property 0%%ner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner herebv authorizes Name Street Address City/Town State Zip to act on the +ro perty owner's behalf, in all matters relative to work authorized by this buildin6 permit application SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (It buildin•is less than 35,000 cu. ft.of enclosed s pace and/or not under Construction Conlrul then check here O and skip Section 10 0 10.1 Registered Professional Res /o�nsiblle for Construction Control 1. VViV C�) V�a `3C> � 9aCvq�OUf?�Sa+ �,,y x°"^'�It 4r (Regi tra4p Trleph ne Nu. a-mail address Re istry atiun Number 1� _ III I Zon at Street Address City/Town State Zip Discipline xpuanun Date 10.2 General Contractor &P(kLJ �Ms6d) fn 1� � Cj Q4 Q `fC�n I�Sat,�of Person Re,+'�unslbke-for Con�+tF'uc�yn � ��n cense No. and Type if AP licable�2��� 1 M -'YCJ'r` 1`1 M�P�(FX:�ICA 60 0 ARPY Street Address City/Town State Zip b I F -�- Sol 61 Telephone No.(business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c.152.§ 2506)) 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 Estimated Costs: (Labor L) ��rU 0 Item and Materials) Total Construction Cost(from Item 6) _$ — 1. Building $ 3 zoo . 00 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ S00 . oo appropriate municipal factor)=$ 3. Plumbing $ 00© O Note: Minimum fee=$ (contact municipality) 4. Mechanical (HVAC) $ 5. Mechanical (Other) $ Enclose check payable to 6. Total Cost $ -?-00 . 00 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest tinder the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and rmderstanding. I I,on �e-A c,)n o� 61�-'?--�2- 9ojcl Please print in, ign n,une Title Telephone Noy Dale 1ti � a � CX ' ,street Address City/T,n%n S to Zip Municipal Inspector to fill out this section upon application approval: N, e )ate I CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT >i 110 WA,iI IING ION S rlt I:LT • SA I'M. ti1 Aii.\t III 'I I'iivl`I Tcl:978•,'4 9i9511':\X:978J4C,9846 Construction Debris Disposal Affidavit (required fur 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 tt __ 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 I11. S 150A. The debris will be transported by: l �1 2 6 (flame of hauler) The debris will be disposed of in lk lame of face fly) NOD. 3Z8: 111 r, (address of facility) signatu f(molt applicant date e.•hI I;,11 d,w 074--Y- _Q Boas ureon��,°am taod`; I .# Crds onshucryon Supervisor License Lice'4'` CS, 91068= 010 Trt 22693 Rdn TIMUR DEYCH 14 BERKELEY COUP BROOKLINE, .w CITY OF SM EM. NLkSSACHUSETTS SU DLYG DEPARTNM'%T 120 WASHINGTON STREET. 360 FLOOR TEL (978) 745-959S F.ILx(978) 740-9846 (V.,lBEpJEY DRISCOL �AYOIt "IltobtAs ST.P�itit8 DIRECTOR OF PLSLIC PROPERTY/SUMDLNG CMMITSSIONER Workers' Compensation Insurance Altidavit: Builders/ContractorsElectriciansIPt m ben A11011cant Information Please Print Legibly Nainc iousi�ortanizaiiominJrvidu.J): u w- Address: N \r-0 Q`f J ' City/Statazip:JcDC,)LGMa /)0'%qLT phoneo: 61? -9-3D -,301 1 Are on as employer?Cheek the appropriate boa: Type of project(required): �� 1. I am a employer with 1 4. 0 1 am a general contractor and 1 employees(full and/or part-time)." have hired the suctractors 6. ❑New construction bon 2.Idl am a sole proprietor or Partner- listed an the attached sheet : 7. 0 Remodeling :hip and have no employed Then sub-contractors have a. 0 Demolition working for me in any capacity, workers'comp,inaunnee. 9. 0 Building addition _ INo workers'comp. insurance S. 0 We are a corporation and its I0.❑ Electrical repairs or additions oRicen have exercised their 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 12.0 Roof repairs insurance required.) t employees. LNo workers' a 3.❑Other— Any comp, insurance requited.] 'Any applicant thrl checks boa el mull ater till out the section brim showing tbrit worker'conspersedw policy Irdo"noolmL 'I I.vtxmnes who submit this affidavit indicating they an doing all work ants does him ounide eunowans nwui ndemil a now alttdrrii indkaiftll wok. ['.mtm;son thin clack Ohio box mud anached an slditi,wl dot showing the none of the sull ' Inhere and their workers'comp.policy istarmotion. l one an employer that Is providing workers'compenaradon Jnaarranea for my employees, Bdaw/s the pepry and Job alb informwion. /� In,urance Company Name: y �,kCLA( L ��Su>f LM CA— Policy N or Self-ins. Lic.N:- PT3 \J C11 © Expiration Data: (( 11 9 1 ZD C Job Sire Address: 1� 07f11��I 0.�1Q, City/Statezip: lPAvl r ,tivack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage a required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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. Ile advised that a copy of this statement maybe forwarded to the Office of Invcaugadions oldie DIA for insurance coverage verification. Id*Jrerrhy certify under the pains and penalties of perjury that the informatlorr provided above is true and correK nr true: / Dutc 9/2$ )g iOfcial use arty. Do not write in obis area,robe runnpleted by city or town ofJk•i fi City or ruwn: __ __ Pcrmltll.lccme M Lsuing.\whurily (circle one): j I. Itoard of lieuUh 2. Building Department J. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other lunlact Person: _ -_. _.. Phone g: 26ie ffamret Condominium Trust September 29, 2009 VIA FAX: 978-740-9846 City of Salem. Building Department To Whom. It May Concern: Plcase be advised that the Board of Trustees at Hamlet Condominium has approved of the renovations requested by.Mr. Gaft at 17 Patriot Lane. The contractor conducting the work is Gregory Cbakhov. Should you need any additional information, please contact this office at 978-532-4800, Skfaerely' ll' Sherman CR S INSi�iELD MANAGEMENT CORP., As Managing Agent for Hamlet Condominium `Hfanagedoy('rouwmt siefdManagement Corp, 18 Crormw1itierdS'treet, Rabody, -WA 07960 O.one(978)532-4800. Tax,(978)5.32-6023. E-mai[OK JW J4.321