2 PIONEER TER - BUILDING INSPECTION t �
The Commonwealth of Massajphgt4gts
Department of Pubhe sfy`ft #6r�1 iiYfC
Massachusetts State Building Code(780 CMR)
hh,� Building Permit Application for a St$ gMe�,Buikli 5
60 (This Section For Official Use Only)(u�U I1Y�UU I� 44 KK
Building Permit Number: DateA hed:
PP State Bldg Insp:
_ SECTION 1:LOCATION
l No.and Street 2 Pioneer Terrace
Salem 01970-
�_ Assessors Map# Block# City/Town Zip Code Name of Bldg/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❑ I Alteration ❑ I Addition
❑ Demolition ❑ (Please fill out and submit Appendix 2)
Change of Use ❑ Change of Occupancy ❑ I 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: New Fire Alarm System
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 Grou 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❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ IH: High Hazard H-1❑ 14-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 El 1-2❑I-3 El 1-4❑ M: Mercamile❑ R Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U. Utility❑ I Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ HIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 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
Private❑ or identify Zone: or on site system❑ required❑or trench Site? ❑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❑ No❑ Yes❑ No El ❑
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?:Yes❑ No❑ Special Stipulations:
Design occupant load peer floor area and assembly space:
SECTION 9: STATE AGENCY AUTHORIZATION
Name and Address of State Agency with Property Jurisdiction and/or Ownership:
Name(print) No.and Street City/Town Zip Code
State Agency Contact Information:
Name(print) r Title Telephone Number e-mail address
This Agency Contact as the representative of the State Agency with property jurisdiction and/or ownership hereby authorizes
Name Street Address City/Town State Zip Code
to apply for and act on the Agency's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
ff a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and slop Section 10.1)
Otherwise provide construction control forms see section 107 in the code as required by the state' ector.
10.1 Registered Professional Responsible for Construction Control (professional coordinating document submittal)
- - x
Name(Registrant) Telephone Number e-mail address Registration Number
Street Address City/Town State Discipline Expiration Date
10.2 General Contractor
Company Name Jupiter Electric,Inc.
A9679
Name of Person Responsible for Construction James E Marshall License No.and Type if Applicable
01952-
Street Address 142 Lafayette Rd City/Town Salisbury State X4A Zip Code
-978-499-7776 x - - jupiterelectric@comcast.net
Business Phone Cell Phone 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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: CAMIS value of the Building $
(Labor and Materials) If not known provide request to DCAM via form at
1.Building $ hft://www.mass.gov/cam/CANflS/canlisUser.html
2.Electrical $
Total Contract Amount(see note 1)=$
3.Plumbing $
Building Permit Fee(see note 2)_$
4.Mechanical (HVAC) $ Note:Minimum fee=$25.00
5.Mechanical Other $ Enclose check payable to The Commonwealth of MA and write check
6.Total Cost $ 33 490.00 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
applicati and accurate to the best of my knowledge and understanding. Further,I am authorized to submit this
a cation on b of the state agency with jurisdiction and/or ownership of the subject property.
James us
jmjupiterelectric@comcast.net 978-499-7776 x Nov.8,2016
lectroin tune e) Email
Telephone Date
Treasurer 142 Lafayette Rd Salisbury MA 01951-
Title Street Address City/Town State Zi Code
State Ins or to fill out this section upon application approval:
Name Date
\ The Commonwealth of Massachusetts
kviDepartment of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):Jupiter Electric, Inc.
Address: 142 B Lafayette Road
City/State/Zip:Salisbury, MA 01952 Phone #:978-499-7776
Are you an employer?Check the appropriate box: Type of project(required):
I.O I am a employer with 36 employees(full and/or part-timet- 7. New construction
2.M I am a sole proprietor or partnership and have no employees working for me in
8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
3.O I am a homeowner doing all work myself.[No workers'comp.insurance required./ 9. ❑Demolition
4.E]1 am a homeowner and will be hiring contractors to conduct all work on my property, 1 will 10❑Building addition
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 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]g,❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.*
6. We are a corporation and its officers have exercised their right of exemption per MGL c.
14.QOther Fire Alarm Upgrades
152,§](4),and we have no employees.1No workers'comp.insurance required.]
Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
+Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name:DeSantis Insurane Agency
Policy#or Self-ins.Lie.4:4087276461 Expiration Date: 12/23/2016
Job Site Address: 2. Pioneer Terrace City/State/zip:Salem, MA 01970
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cer fy under ains a hies ofperjury that the information provided above is true and correct.
Si nature: Date: l� -
Phone# 78-49 -
Of tcial use only. Do rite in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
,m,� COMMONWEALTH OF MASffiHIJSETT$. .
BQARV OF
ELECTRICIANS
ISSUES THE FOLLOWING LICENSE AS A
REGISTERED MASTER ELECTRICIAN- a
it
JAMES-EMARSHALi
'JUPITER ELECTRIC INC
1 RANDAIL kiD'
MIDDLETON,MA 01949-1464
i
0679 07,131/2019 74257
CONTROL # J 6 3131.7
IMPORTANT
If your license is lost,damaged or destroyed;is inaccurate;or
needs to be corrected,visit our web site at mass.gov/dpl for
instructions to ensure the proper mailing of your Renewal
Application and any other correspondence.
This license is subject to Mast,,-,,chusetts General Laws and
regulations.Your license is a privilege, and cannot be lent or
assigned to any person or entity L- -er penalty of law. Keep this
license on your person or posted required by law and/or
regulations.
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