12 POPE ST - BUILDING INSPECTION (5) WRuiIAi..g
The Commonwealth of Massachusetts
Department of Public Safety
j. \1.ts.tahux•u.StateBuildingGKiel%SoC%IR)Sreenlh Editi on
City of Salem
Permit Application for any Building other than a 1-or 2-Family Dwelling
(this Section For Official U.set)tly)
Building Permit Number: Date Applied: I Budding Inspector:
SECTION 1: LOCATION(Please indicate Block 0 and Lot 0 for locations for which a street address is not available)
i)- s+e _ - Aawm 0100 Salome HvI4�
No.and Street City /Town Zip Qxle Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here Our check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration 't� Addition❑ Demolition O (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy O Other O Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes V No ❑ -...»+:.
Is an Independent Structural Engineering Peer Rev'i'ew�requird? Yes O No E1'
Brief Description of Proposed Work: � j-6(y.zl bVl (��hh�� L()t (I(.fA-t�'lA
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
N �_ CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Croup(s): Proposed Use Group(s): f
Existing Hazard Index 780 CMR 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.)
Total Area(sq.ft.)and Total Height(ft-)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 O A-2r O A-2nc❑ A-3 ❑ A4❑ A-5 O 1 B: Business ❑ E: Educational ❑
F: Facto F-I O F2❑ H: Hi Hazard H-1 O H-2❑ H-3 O H-4 O H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4 O M: Mercantile❑ R: Residential RA❑ R-2 Cl R-3 Cl R-4 O
S: Storage 5-1 O S-2❑ U: Utility O Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IBO IIAO IIBO MA IIIB ❑ IV VA VBO
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
N Debris Removal:
Water S pply: Flood Zone Information: Sewage Dispos Trench Permit:N p N
:\ trench will not l Li.- -d Di.la actI_ite
Pubhc❑ Check d nuL rda•Flnud Lnnr Indicate mumap•tl❑ rea wnxl ❑ur trench .a •-
fh-rcae❑ err indenUA Zuni:_ nr ern mite>rdrm❑ 1 )wtc:
promo t.a•ndo.rat ❑ _
I Railroad right-of-way: Hazards to Air Navigation: xt:\ i o.t,•n, t-,.rnou..u,n Itr Pit••
\„t \ h:able a,�
1,1, M h�trurture t�nhrn arrpurt�IJF'`•ru.tch area' I.then ret reu'crrmldrtrd.'
.a ll.n-rnt to Budd endo'ed 0 I lr.❑ err\u 1'a•.❑ \rr ❑
SECTION 8:CONTENT OF CERTIFICA rE OF( 'CUPANCY
l:ddn,n.,I I ,ode -..__Cv llrrru f.t.r rt)'c,rt l rrn.tru:mun: Occupant per liu.rr
I)r,.. th,•burldtnq cunlaut,tn tif.nnklrr}t.irm': >Pvcialjopul.unrn.
SECTION 9: PROPERTY OWNER AUTHORIZATION
.Nameand \ddressol Proper" Ovner
Sa kdA—kh, k0k. P- 'POPE Ca(orn _ 0J0
Name(PrAt) No.and Street Ci"'/Town Lip
I'ropvrty lhvner Contact Information: KtLJk(aJM OVV&U7
Prey rvausi( l(ox�trnl �JIG�aG1E✓ �lt�I- 231- )1 1 q _ _-
Title Telephone No. (business) Telephone No. (cell) a-mad address
If a +pliiablr, the proper",o.vner here v authonzrs 7�}
2 Vl((�Yl(1f K7 3YG( � V1 1 S((JI({ ()
Name Street Address City/Town State Zip
to act on the pro pert%owner's behalf,in all matters relative to work authunzed by this buildin •1,ermitapplication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(It Inaldin•is Items than 35,0tx1 cu.it of twit""< ace and/or not tinder Construction Control then check here O and skip Sectiun 10.11
10.1 Registered Professional Responsible for Construction Control
- ?40a mere-{tey,(4�i W rw_f �10313
Name(Registrant) TrlrpFnr Nu. email ad�ld�ress Registration Number
`�GI-F h/)U f &z I�rO�f)d'P/N-Q� Jul_ Q-2_q 0 Ul I 1�—
Street Address jCity/Town State Zip Discipline Expiration Date
10.2 General Contractor
t awgs4ko of W kA naPvnon 0�
Cum in Nam : N C ���3O
� � CS
Name t Person Res mstbl for onstruction License No. and Type if p licable
Street Address City/Town State Zip
lzw
Telephone No.(business) Telephone No.(cell) - e-mail address
SECTION 11:WORKERS'CObMSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2SC(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 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor ,f
and Materials) Total Construction Cost(from Item 6)=
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=S
3. Plumbing S
4.Mechanical (HVAC) S Note: Minimum fee=S (contact municipality)
5. Mechanical (Other) $ Enckne check payable to
6.Total Cost S <}- (contact munici lit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I herebv attest under the pains and)xnalties of perjury that all of the information contained in this
application is true and accurate to the best nt my knowledge and understanding.
ain V II ,ref lyw ksxmld ?�enf IDS 1CiP� 4gr4
Zr,,—pnm and sign name p ritlr rel,phone\u. Date
n • � �?� V�1P.S¢�y f � 01�
_1two N,Hrv— City;Tot,ri tat Zip
Municipal inspector to fill out this section upon application approval:
\am Pate to
The Commontreohh t f dlussuchuseas
Department n(lndustridl A cciden)s
Office Il ur 11 ijkgnin Street
6OI) I Lush ingtuu Street
/3osrmi. '!lass. 02111
Irrolv.mass.�ur/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumber~
Applicant Information Please Print Lc'ihh•_
V':DnC (Ousinc.�..'t tea utiratiolUlndividwd)1 Nane_gashemet Project Management, Inc.
Address: 32 Beverly Ave . - Suite 1-A
City/state/'/..ip: Marblehead, MA 019,15 I,1iiiiii0_ 781-727-6516
krc you an ouploser'.'Check the appropriate bov: "Type of project(required):
I. x I ale ut cmploeer with _ -L I am t general eonlrtcow and I 6. I New construction
unpfueees(full.moor part time) bade lured the sub cnntraclors 7. Renmdeline
'_ I am a sole proprietor or partner- listed on the.attached sheet.
ship and have no employees These sub-contraclur9 have >i. Demolitiaa
erorking lire ate in;my capacity. cngtlu)nes and have workers' +1. : 13uildine addition
[No workers'comp.insurance comp.inaumnce.I
required) i. We are a corporation and its 10. Electrical repairs or addition;
3. 1 am a homcow ner loin_all work officers have exercised their .
myscl l' INo scorkcrs'comp. right nt exemption peon MGl, 1 I. ` Plumbic_repots or additions
insurance requiiedl r c. 1 i2.§ It-1).and tec have no 12. Roof repairs
emplo%ccs. Ino aorker` 13. :-Odncr Wi re.l � �
camp. nimirancc required.) __ess au p.
`1 m applietu l that'herk,hue III mn<I ahu fin and the sre Linn helon>h...in;:their ttorYen•nunpen,aton pulirr inhtrtnntnn.
ttliunro..n en w hu'I omit thi,amdmit indirvtint;the are urine all wort.and then hire.nn.ide Gmlrartor,muw'ahmit a ne.. affidn'it imltratine tech.
rantu'tnt[that corm,this hoe nmat attach an addditand h"I.hm.in._the...... ttu<ul>-nmtnetun tars)note whether arnunlmvnnido ha.r engtmch if
the rule-cnntrmm.N h:nc eniphi%re,nhet nam tide their norher..'comp.p diet munher.
l tan an emp)urer that it providing workers,compemo tiun inrurnmceftn ng emplurres. Below is thepothy nntl joh.din-
injnrntminn. The Hartford
Insurance Company Name:
Policet,+or Sell'-ins. Lie. ;i: 08WECC0 7725.,_ �_._.._.. �. .� ...—.-_- . _� lixpiratiun [):tie: 01/0r1/11c:_ ._,
12 Pane St BOS002'IB Salem, MA
Job Site Addres: City,Sl:ueQip: - �...—
Attach a copy or the workers' com pensatioit policy tlecla ra lion pale(s howin);the policy nu in ber and es piration(d:i let.
Failure to secure coverlge as required under Section 35:t of NIGL 152 can lead to the imposition of criminal penahies o1'a fine
up to S 1300.00 and"or one rear imprisonment as ccell as civil penalties in the limn of a STOP WORK ORDER and a fine of
5250.00 a day atgainsi violator. 13e advised that a copy of this statement maybe lonenrdctl to the 011ice of investigations of•the
DIA liar covcmac verification.
t tit)herhf �•ut ter tl • utit�enulfies tfperjun'that the information provided Shure is true tmul correct.
Uurc.
Hay 14 , 2010
`Ct`uunrrer '
Pri'a 1•nmc,: hn Nestor Plruter Ya 781-727-6516
[Official use iml Do uml write itt this nren ra he campletcel h -tiry•tar!men ofTcird
C'ily ur"fmvl: 1'ennit/license Y--:
Is3uin£Authority(circle one):
I.Ilnard of licatlt 2. Building Department 3.City7rown Cleric a. Electrical Inspector 5. Plumbing Inspector
6.01her
Contact person: i'hnne k:
coRd CERTIFICATE OF LIABILITY INSURANCE OPID DC DATE(MODE YYYY)
91mNE01 04/13/10
PRODUCER THIS CERTIFlCATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
John J Walsh IIn& Agency, Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P O Box 4467 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Salem MA 01970-6407
Phone: 978-745-3300 Fax:978-745-9557 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: The Hartford
INSURER B: Landmark Insurance
Nanepashemet Project INSURERC. Citation Insurance Company 40274
Management, Inc.
32 Beverly Ave INSURER D:
Marblehead MA 01945
NSURER E.
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REOUI RENEW.TERM OR CONDFRON OF ANY CONTRACT OR OTHER DOCUMENT W"RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN LTR D TYPE OF WEIIRANCE POLICY NUMBER DATE(MWOONYM DATE MMID LIMITS
GENERAL LIABAnY EACH OCCURRENCE S $1,000,000
A X COMAERCIAL GENERAL LIABKnY 08SBAUQ3098 03/01/10 03/01/11 PREMISES lan e,en. s $300,000
CLAIMS MADE ®OCCUR WED EXP(Any ore person) s$10,000
PERSONAL B ADV INJURY s$1,000,000
GENERAL AGGREGATE Sc$�2,000,000
GENL AGGREGATE LIMITAPPLES PBt PRODUCTS-COMP/OP AGG $$2,000,000
POLICY PRO- El LOC
ECT
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $1,000,000
ANY AUTO (Ea accident)
C Ix
ALL OWNED AUTOS RXQ108 05/21/09 05/21/10 BDOILYINJURYSCHEDULED AUTOS (Per Person) E
C HIREDAUTOS RXQ108 05/21/09 05/21/10 BODILYINJURYC NON-OWNED RUMS RXQ108 05/21/09 05/21/10 (Per accitlaM) $
PROPERTY DAMAGE $
(Per amEeN)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT E
ANY AUTO OTHER THAN EAACC S
AUTO ONLY. AGO $
EXCESS I UMBRELLA iIAWLJTY EACH OCCURRENCE E$5,000,000
A X I OCCUR DCLAMSMADE OSSBAUQ3098 03/01/10 03/01/11 AGGREGATE s$5,000,000
s
DFDDOTBLE $
RETENTION $ E
WORKERS COMPENSATION X -
AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER
A ANY PROIM£b11OREARTNE'c�D9ECUTIVEM 08WECC07725 01/04/10 01/04/11 EL-EACH ACCIDENT s$1,000,000
(Mandalwy in NH) EL DISEASE-EA EMPLOYE s$1 000,000
If yes,(Ie5PROVI under
EL DISEASE-POLICY LIMIT E 1,000,000
SPECIAL PROVISIONS bebw $
OTHER
B Professional Liab. LHR712664 03/01/10 03/01/11 Occ/Aggr $2Mil/$2Mil
A Installation 08MSR02589 05/26/09 05/26/10 Limit $100 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEMCLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVLSUONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION
0001003 DATE THEREOF,THE ISSUING INSIRERWILL ENDEAVOR TO MAIL 10 DAYSWRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO OO SO SHALL
IMPOSE NO OBLIGATION OR LL16aRY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
MetroPCS REPRESENTATWES.
285 Billerica Road AUTHORIZED REPRESENTATIVE
Chelmsford MA 01824 David C Bruett
ACORD 25(2009101) (P1988.2009 ACORD CORPORATION. A8 rights reserved.
The ACORD name and logo are registered marks of ACORD
i
Yta..xchusetP- Department rrf Public �a(eq
yy�5 Roard of BuildinL Re_ulatien,and Standard,
Construction Supervisor License
L-Wense: CS 47636 _
Restricted to: 00 -
JOHN J NESTOR
32 BEVERLY AVE
MARBLEHEAD, MA 01945 s.
�- l-h'� Expiration: 12/6/2011
(..reuun.i.nwr Tra: 10856