25 PEABODY ST - BUILDING INSPECTION �j The Commonwealth of Massachusetts
Department of Public Safety
\ Oyu Massachusetts State Building Code(780 CMR)
` � Building Permit Application for any Building other than a One-or Two-Family Dwelling
V� ([his 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)
25 Peabody Street Salem 01970 National Wd
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
Existing Building® Repair® 1 Alteration ❑ 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 ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
U
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.R.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable) `
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ® E: Educational ❑
F. FaM F-1❑ F2❑ H:—High Hazard H-1❑ H-2❑ H3 ❑ H4❑ H-5❑
I: Institutional I-1❑ 1-2❑ 1-3❑ 14❑ M. Mercantile❑ R. Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S1❑ S-2❑ U. Utility 13 Special Use❑and please describe below: _
_Special Use: —-
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 1110 IIA ❑ HB ❑ IIIA ❑ IIIB ❑ 1 IV 1 VA ❑ VB ❑
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 Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad rightof-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:
SECTION$ PROPERTY OWNER AUTHORIZATION.
Name and Address of Property Owner
Naaonal Grid Smite Co. 40 Sylan Road Waltham W451
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
shame a nnham 781 _ 907- _ 3685
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 property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL.(Please fill out Appendix 2)
(11building is less than 35,000 cu.ft of enclosed s e and/or not underComtruction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control "
Dan Champagne 866 _ 713 _2824 Dan@mofwiNqu ftymm 105557
Name(Registrant) Telephone No. e-mail address Registration Number
371ndusaail Peck Awess Road Middlefield CT 06455 V11=14
Street Address City/Town State Zip Discipline Expiration Date
102 General Contractor '
Quality Impmvamems,LLC,
Company Name
Christopher T.Vogt MCQ.09W842
Name of Person Resp y License No. and Type if Applicable
371 ndusaail Park Awasa Road Middlefield CT 06455
Street Address City/Town State Zip
866 - 713 - 2824 475 - 238 - 9204 Chns®moNriNquality.wm
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 O
SECTION 1Z CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $141500.DD Building Permit Fee=Total Construction Cost x (Insert here
-2.Electrical $ON appropriate municipal factor)_$
3.Plumbing $om
4.Mechanical (HVAC) $0.m Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $0.00 Enclose check payable to
6.Total Cost $144 50g 00 (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 accurate to the best of my knowledge and understanding.
Chita Vogt Owner 866 - 713 - 2824 1/1 2 12
Please print and sign name Title Telephone No. Date
371ndustrail Park Awess Roatl Middlefield CT 06455
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
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William Francis Galvin
Secretary of the
Commonwealth
May 13, 2011
TO WHOM IT MAY CONCERN:
I hereby certify that a certificate of registration of a Foreign Limited Liability Company
was filed in this office by
QUALITY IMPROVEMENTS, LLC
in accordance with the provisions of Massachusetts General Laws Chapter 156C
on April 8,2009.
I further certify that said Limited Liability Company has filed all annual reports due
and paid all fees with respect to such reports; that said Limited Liability Company has not filed a
certificate of cancellation or withdrawal; and that, said Limited Liability Company is in good
standing with this office.
I also certify that the names of all managers listed in the most recent filing are: NONE
I further certify that the name of persons authorized to act with respect to real property
instruments listed in the most recent filings are: CHRISTOPHER T. VOGT
In testimony of which,
I have hereunto affixed the
Great Seal of the Commonwealth
on the date first above written.
Secretary of the Commonwealth
Processed By:nem
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THE GARLAND COMPANY INC.
56' Salem #1
25 Peabody Street
Salem, MA
DATE: 06-29-10 ROOF AREA:
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