36 PERKINS ST - BUILDING INSPECTION 110 . IC1:-1- -r A- Lt
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hh� The Commonwealth o0miga se�€ts
Department of Public Safety
Massachusetts State Budding C9��(7 E$ 01
Building Permit Application for any Building other FHAh ne-or Two-Family Dwelling
` (Fhis.Section For Official Use Only)
l v Building Permit Number: Date.Applied: -Buildirig Official:
f� SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for whicti a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
6 Al SECPION2-PROPOSED WORK '.
Edition of MA State Ca used If New Construction check here❑or check all that apply in the two rows below
1 \J Existing Building Repair 91Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out mid submit Appendix 1)
Change of Use ❑ 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 jequired? Yes ❑ No
Brief Description of Proposed Work: Th e 7� �C�� /p 2 ry ,�L op/Z I
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): I 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 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑
R Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 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 plicable)
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)-
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❑ _
required❑or trench or specify:� t C�/
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \i,\.1 t„tr,i t.�n....ksi n a vw,v_Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 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 Systcm?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION r
Name and Address of Property Owner D _r
�6 I ,e S7 �o 'e yr. Wla,
Name(Print) No.and Street City/Town Zip
Property Owner Cdnfact4korinatiom r..
-
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) -
If building is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check-here O 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
. I
10.2 General Contractor -
CI 6 r `114
Cprupapy Name
1( 4-�j /0-1-v -1) 6Z-1 V 97 7.S`-CSr
IName of Person ponsible for Construction License No. and Type if Applicable
CK w ) t .L/(/,s Yw�)r/L den mod. a i y�
Street Address City/Town State Zip
—}+/ )�/�
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'CONIPENSA'I'ION INSURANCE AFF'IUAVIF 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 O
SECTION 12:.CONSTRUCTION COSTS.AND PERMIT FEE-
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ O o U , o-0
Building Permit Fee=Total Construction Cos[z_(Insert here
2.Electrical $ appropriate municipal factor)_$
�- 3. Plumbing $ C7
d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ p G D f c'r 0
(contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERblrr 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 edge and understanding.
d"'i L) sow l,-XJ. 7-d
P itle Telephone No.gn � � 0
.147
Street Address City/Town State Zip
of
Municipal Inspector to fill out this section upon application approval:
/ r Name _ Date _
2-7 Z'7
The Commonwealth of Massachusetts
Department of Industrial Accidents
Wrkers'
1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant information Please Print Lesribly
Name (Business/a,Orgarilzation/Individual): \J b o
Address: [ j,,l tit LW✓1 `i J
City/State/Zip: ✓ L-104A D/C Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑1 am a oyer with employees(full and/or part-time).- 7. ❑New construction
2. am a sole proprietor or partnership and have no employees working for me in $, modeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.= 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. C
Insurance Company Name: J J
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
s Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ida hereby ify u r ams and pe ..ties a perjury that the information provided abo a is true and correct.
Si .lure: . Date: d
Phone#: j
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
P�vC,7INs . �� r- � �c
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
I has not produced acceptable evidence of compliance with the insurance coverage required."
applicant who B 9
PP P P P
bi ions shall
2 2 C 7 states"Neither the commonwealth nor an of its political subdivisions Additionally,MGL chapter 15 , § 5 O Y
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been 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 number(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 at the 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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemtit/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 a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
RECEIVED
March 31, 2015 INSPECTIONAL SERVICES
Z015 MAR 31 A b: 41
RE: 36-38 Perkins Street, Unit 1-A
Salem, MA 01970
The undersigned hereby certifies that the 36-38 Condominium Association Trust
has authorized the continuation for the alterations and improvements of Unit 1A.
The owner covenants and promises to hold the Association harmless against any
and all claims arising out of, or as a result of, the construction, maintenance, or
repair.
Franklin Baez Date
Title: ��,G�a� �_
" QTY OF SALEM) MASSACHUSEM
BLULDING DEPARTMENT
ram_ 120 WASHINGTON STREET,3'FLOOR
TEL(978)745-9595
KHaERLEYDRISODLL FAX(978)740.9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUB"CPROPERTY/BUIIAING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work j
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
k U l/-T-4 T-k e"rC
(name of hauler)
The debris will be disposed of in:
(name of facility)
Al, S'L t,rz k, p ,G G�
(address of facility)
Xignature of applicant
Date
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( Massachusetts-Department of Public Safety
Board of Building Regulations and Standards j
Construction Supen isor
License CS-077565
I IS
JOHN J MULDOO P.
2 WALNUT ST
MARBLEHEAD1 A
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k Commissioner 08/01/2076
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CITY OF SALEM NWSACHUSEM
<„ x' BLIILDINGDEPARTMENT
\��,.� ; � `•! �7 120 WASHINGTON STREET,3RD FLOOR
TEL:978-745-9595
FAX:978-740-9846
KIMBERLEY DRISCOLL
MAYOR
THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER
REQUIRED INSPECTION NOTICE
36 PERKINS STREET — UNIT #1
January 22,2014
36 Perkins Street U I-A Realty Trust
Ramon Frometa—Trustee
P.O. Box 3
Swampscott,Massachusetts 01907
Mr. Frometa,
Our office received a complaint regarding possible egress issues and construction without a Building
Permit at your property located at 36 Perkins Street—Unit 1.The complaints were investigated on
Tuesday,January 14,2014; Said property appears to be in violation of Massachusetts State Building Code
requirements.
Under the provisions of 780 CMR, Section 104.6—Right of Entry, of the State Building Code,access to this property
must be granted for the purposes of this inspection. Please call this office upon receipt ofthis letter to schedule this
required inspection. If this property has rental units, these tenants must be notified in advance of this inspection,so
that access to these spaces may also be accomplished.
This Required Inspection shall be conducted by this office on Wednesday,January 29, 2014 at 10.00 a.m.; failure to
respond to this notification will be construed as non-compliance,and as such an Administrative Search Warrant will be
sought;-so as to allow the lawful inspection of this property.
If you have any further questions regarding this letter,please call this r*T^e^ 10'74'6/o_ef.A4
Respectfully,
Michael E,Lutrzykowski G `
Assistant Building Inspector AlbaC.Corona.perez,ESy,
407 62.8870
/cc: file, �� P.O.Box 3
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8r�np ,MA 0190'R �
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