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11 PIONEER TER - BUILDING INSPECTION The ColnmOnVela of Massachusetts`�WEWE- 1 Department of Public Safety %APFIC`TMNA ` i rl Massachusetts State Building Code(780 CMR) Building Permit Application for a State Owned W4ft 14 A 9: 58 ('This Section For Official Use Only) {� Building Permit Number: Date Applied: State Bldg Insp: k SECTION 1:LOCATION 1 No.and Street 11 Pioneer Terrace Salem 01970- City/Town ZipCode Name of Bldg d'applicable) Assessors Map# Block# $(� pp ' ) Kq j—N.D CG 0 SECTION 2:PROPOSED WORK t� Edition of MA State Code used: If New Construction check here❑or check all that apply in the two rows below \\\ Existing Building❑ Repair❑ Alteration ❑ Addition Demolition❑ ❑ (Please fill out and submit Appendix 2) 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 required? Yes ❑ No ❑ Brief Description of Proposed Work: New Fire Alarm System SECTION 3:COMPLETE THIS SECTION IF EMSTING 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❑ B: Business ❑ E: Educational ❑ R. Facto F-1❑ F2❑ H: HI Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-S❑ I: Institutional I-1❑I-2❑I-3❑I 4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R 4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ HA ❑ HB ❑ IIIA ❑ IIIB ❑ IV El VA El 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 ors ec ify permit is enclosed El ? ❑ P ' 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❑ NA❑ 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: jA fanl 0 P l.t�v rS 00- gS50 J e SECTION 9: STATE AGENCY AUTHORIZATION Name and Address of State Agency with Property Jurisdiction and/or Ownership: �C�-,M tlol�avNC� �3bti. 2�1 C44r4Zat 2. ST' �of�Ll�� 1 Name(print) No.and Street City/Town Zip Code State Agency Contact Information: i � Name(print) 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) If a building is less than 35,000 ot.ft of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1) Otherwise provide construction control forms see section 107 in the code as requireCt by the state ins tor. 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 %1A Zip Code -978499-7776 x jupiterelectric@comcastnet Business Phone Cell Phone a-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.In§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 $ ft://www.mass-yov/cam/CAMISZcamisUseT.htinj 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 a and accurate to the best of my knowledge and understanding. Further,I am authorized to submit this r ation on be of the state agency with jurisdiction and/or ownership of the subject property. es arshal jmjupiterelectric@comcast.net 978-499-7776 x Nov.8,2016 in tore e) Email Telephone Date Treasurer 142 Lafayette Rd Salisbury MA 01951- Title Street Address City/Town State Zio Code State Ins or to fill out this section upon application approval: Date Name - I The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia R'orkers'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): 1.E]I am a employer with_36 employees(full and/or part-time).* T ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for Inc in $. ❑ Remodeling any capacity.[No workers'comp.insurance required_] 3.F]I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions Arl]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[hair right of exemption per MGL c. 14.QOther Fire Alarm Upgrades 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box 41 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 insurancefor my employees. Below is the policy and job site information. Insurance Company Name:DeSantis Insurane Agency Policy#or Self-ins.Lic.#:4087276461 Expiration Date: 12/23/2016 Job Site Address:_ 1 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 a 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 fJ'under ains a !ties ofperjury that the information provided above is true and correct. Si nature: Date: aPhone# 78-49 - Of rcial 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#: L COMMONWEALTH OF M,4SSACFiIlSETTS • • • • BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A REGISTERED MASTER ELECTRICIAN , JAMES E MARSHALL. j© JUPITER ELECTRIC INC M 1 RANDALLRO - 1z MIDDLETON, MA 09949.1454 J 9679 07,13112019 74257 CONTROL # J 6 3 1 317 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 your person orrposted L required by law and/or of law.Keep this regulations.