4 PRINCE ST - BUILDING INSPECTION . .. .
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tr� The Commonwealth of Mas�&�6�'@�L SERV�CES
Department of Public Safety
Massachusetts State Building Code(7$��I2����� /�
Bui(ding Peraut Application for any Building other than a �� w Fa8fi1� li
� ('Ihis Section For Official Use Only) �
Building Permit Number: Date Applied: Building Offidal:
� SEC770N 1:LOCATION(Please indicate Block#and Lot#for locaHons for which a street address is not availabl �
y P�tiN �� 5-� �u��
No.and Slreet City/Town , Zip Code Nazne of Building(if applicable)
� � SECTION 2:PROPOSED WORK� . �
Edition of MA State Code used_ If New Construction check here�or chxk all that apply in the rivo rows below
� Existing Building Repa'u Alterarion ❑ Addirion❑ Demolifion O (Please fill out and submit Appendix 1)
� Change of Use ❑ Change of Occupancy ❑ Other ❑-�Specify: `
Are building plans and/or consWction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineerin Peer Review requued? Yes ❑ o � `
Bri f D scriprion of roposed Work: � L '1 � -� .��E
LL L�-�
� SECT'ION 3:WMPLETE TI-DS SECTION IF.EXISTING BUILDING UNDERGOING RENOVATION,ADDTTION,OR
� � � CHANGE IN USE OR OCCUPANCY � � � - �
Check here if an Exis6ng Building Invesfigafion and Evaluation is enclosed(See 780 CMR 34) ❑
E�cisting Use Group(s): Proposed Use Group(s):
- � � � � � � SECTION 4:BUILDWG HEIGHT AND AREA � � � � �� - � � � � ',
Existing Proposed '
No.of Floors/Stories(indude basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.h.)and ToWI Height(ft.) -
� � - �� � � . SECTION 5:USE GROW(Check as applicable) � � � � � � ��
A: Assembly A-1❑ A-2❑ Nightdub ❑ A-3 ❑ A11❑ A-5❑ B: Business ❑ E: Educafional ❑
F: Facto F-1❑ F2❑ H: Hi h Hazud H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Insfitufional I-1 ❑ I-2❑ I-3❑ I�1❑ M: MercanHle❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage Sl❑ S2❑ U: Utility❑ Special Use�and please describe below:
Special Use:
- � � � � SECTION 6:CONSTRUCTION T7PE(Check as applicable) � �� - � �
IA ❑ IB ❑ IIA O IIB O IIIA ❑ IIIB ❑ N ❑ VA� VB
�� - � -� � SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details�on each item) �� � � .
Trench Permit: Debris Removal:
Water Suppl Flood Zone Informafion: Sewage Disposal: Licensed Dis osal Site❑
Public�. Check II outside Flood Zone❑ Indicate municipal� A trench wffl not be p
required O or trench or specify:,�
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazazds to Air Navigation: MA I-iisroric Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Buffd enclosed❑ Yes O or No❑ Yes❑ No ❑
� . -� < � SECTION S:CONTENT OF�CERTIFICATE OF OCCUPANCY� -` � � � - .
Edi6on of Code: Use Group(s): Type of Construction:' Occupant Load per Floor:
Does the building mntain an Sprinkler System?: Special S6pulations: -
� � . � SECTION 9: PROPERTY OWNER AUTHORIZATION � .
'Name an ddress of Pro erty Owner
M� . L !L � �/Z/�� S7" S�4(�/�/ i�(�
Name( nnt) No.and Street City/Town Zip
Property Own��er/C/ont ct Information: M ����[[[ C
� IUL � �-�� _ _ �
Title Telephone o.(business) Telephone No. (cell) e-mail address
�II ap licable,the property owner hereby authorizes
�b t<ol�,� �7LD/,L-� � P7/21�X�,�� ���c�IJ��4-�4
Name � Street Address City/Town State Z�
to act on the ro e � ownei s behalf,in all matters relative to work authorized b tMs buildin ermit a licafion. �
� . SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) �.
If buildin is less than 35,000 cu.fr.of enclosed s ace and/or not under Construc6on Control then<heck here O and ski Section 10.1
10.1 Re 'stered Professional Res onsible for Construction Control � �
� - Nazne(Registrant) . . . . Telephone No. . e-maIl address . Registrafion Number �
Street Address �� City/Town State Zip Discipline Expiration Date
10.2 General Contractor � � - . � . � . � �
-��� �7�S��oIV �J(,1(l � l-�'�
Company Name '
�1�H- K I/��".Nl�/�� GS x
Name of Person Responsible for Construcrion License No. and Type if Applicable .
7 �2(Q��``I �lU�.�Cf�- ' � a B z
Sneet Address City/Town State Zip
��� --- Kk!/I�f���2��erMQi! � co�c-/
Tele hone No. usiness Tele hone No. cell e-mail address
� SECTION 11:WORKERS'.COMI'EnSAT]ON WSURANCE AFFIDAVIT(M.G.L.c.152.§75C(6)) � � � � �
A Workers'Compensarion Insurance Affidavit from the MA Department of Industrial Accidents must be wmpleted and
submitted with tMs application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a si ed Affidavit submitted with tMs a licafion? Yes❑ No ❑
� � � � �� �- SECTION 12•CONSTRUCTION COSTS AND PERMTT FEE � - � � � � . �
Item � � � � Estimated�Costr:(Labor p��n�
and Materials) Total Construction Cost(from Item 6)_$�9 l-C�L-'
1.Building $ Q
Building Permit Fee=Total Constrvction Cost x_(Insert here
2.Electrical $ �(�� appropriate municipal factor)_$
3.Plumbing $ :�.t"O
4.Mechanical (HVAC) $ Note:Minunum fee=$ (contact municipality)
� 5.Mechanical Other $
Enclose check payable to
6.Total Cost $ b (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 penalfies of perjury that al]of the informarion contained in this
application is true and accurate to the best of my knowledge and nnderstanding.
17qU�17 jUNh�L1.4 ,��e�u,�,�� � �17�_ (�1_ 7�'�
Please p � t and si name � c Title Telephone �
zP��i n6��"�T�,, ;�ir���,�— ��
Street Address � City/Town State Zip
� Municipa(Inspector to fill out this seMion�upon�applicafion approval:. � �
� � � � � � � �� � � Name � - Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety. I
Please fill in the information below and submit this appendix with the building permit
applicaHon. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location(Please indicate Block # and Lot # for locations for which a street address is not
available)
� P�/Nc�. sT ��AE2, 4�1-��M
No. and Street City/Town Zip Name of Building(if applicable) I
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No �J Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicabie)
Appendix 2
Construction Documents are required for struciures that must comply with 780 CMR 107. T'he
checklist below is a compilation of the documents that may be requued for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
Iresponsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark'k"where a licable
No. Item Submitted Incom lete Not Re uired
1 Architectural
2 Foundation '
I 3 Structural �
4 Fire Su ression
5 Fire Alazm ma re uire re eaters
6 HVAC
7 Electrical j
8 Plumbin indude local connecHons ��
9 Gas Natural,Pro ane,Medical or other
10 Surve ed Site Plan UtiliHes,Wetland,etc.
11 S ecificarions
12 Shuctural Peer Review
13 Struchual Tests&Ins tions Pro azn
14 Fire Protecrion Naaative Re ort
15 Existin Buildin Surve /InvesH ation
16 Ener Conservation Re ort
17 Architectural Access Review 521 CMR
18 Workers Com ensation Insurance
19 Hazazdous Material Miri aHon Documentation
� 20 Other S c'
21 Other S c�
22 Other S c�
'Areas of Design or Construction for which plans aze not wmplete at the time of applicarion submittal must be idenrified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to hipie the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registrarion Number
Street Address City/Town State Zip Discipline Expirarion Date
Name(Registrant) Te]ephone No. e-mail address Registra6on Number
Street Address � Ci /Town State � Zi Discipline ExpirationDate
IName(Registrant) Telephone No. e-mail address Registration Number
. Street Address Ci �/Town State Z9 Discipline ExpirationDate
I
�?��b��s��; The Commonwealth of Massachusetts
,� rs,, Department of Public Safety
"�� ' R: Massachusetts State Building Code (780 CMR)
�`� ���s Buildin Permit A hcation to Construct, Re air, Renovate or Demolish an
$3tiw�;��- B PP P Y
Building other than a One-or Two-Family Dwelling
Code and Other Requirements for Building Permits
The Department of Public Safety has issued these building permit applicarion forms so that municipalifles
across the state can move toward use of a singie permit form and consistent permit applicarion process.
The MA State Building Code specifies the requirements of building permits and the applicant is advised to
review and be familiar with these requirements in order to avoid some of the common permit application li
problems. Likewise the applicant should be aware that some municipaliries require that the owner confirm,
• even prior to acceptance of the building permit application, that no outstanding property taxes, water fees,
Ietc. exist.
Filing Instructions
1.Please contact the city or town where the work will be done to ensure that the city or town will accept
this application form and if any additional information is required, and obtain the correct mailing
address. After doing so, print the applicarion, fill in completely and then submit to the local city or
town where the work will be done.
2.A11 applications shall_be considered complete and will be reviewed if construcfion documents,
specifications, fee, and other materials that may be required as indicated in the Building Permit
Applicarion are included with the applicarion.
3.Please include a check for the Building Permit fee. The fee may be calculated using the informarion to
be supplied in secrion 12 of the Building Pemut Application. The check is to be made payable to the
local city or town where the work will be done.
I
I'
• 7 Bridge Street, Suite 9
t� Billerica, MA 01821
�, tel. 978�67-79711fax. 978�70-8138
. e-mail. tbcarchbuildCa�qmail.com
April 4, 2014 We���• �Wmcarchbuild.net
Mr. Martha Quirk Adaptive Services Coordinator
Massachusetts Rehabilitation Commission
600 Washington Street
Boston, MA 02111-1704
RE: Michael Cyra, 4 Prince Street, Salem
Dear Mrs. Quirk:
I tbc Design Build, LLC is pleased to offer the following proposal for renovations of
the above referenced property. Our proposa� is based upon the scope of work
shown in drawings and specifications prepared by Alex Svirsky, dated March 24,
2014. The scope of renovations is as follows.
1. Remove and replace existing tub with shower $10,800.00
2. Hoyer Lift (model not specified) $2,000 to $7,200.00
Thank you for the opportunity to provide you with this proposal. We hope it meets
with your needs, and look fonvard to working with you.
Best Regards,
pav�d �. �,�wse�la,
David A. Kinsella; Manager I
CC: file
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m 1888-2009 ACORD CORPORATION. All righiv reserved.
ACORD 25(2009709) The ACORD name and bgo are registered marks of ACOftD
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Construction Supervisor License .
License: CS 104127
KEITH KIRCHNER �,::,;;;
1949 MIDDLESEX ST. APT 11 -
LOWELL, MA 01851
�--� �' �`yj� . Expiraiion: 712&'2013 -
( ��nuni..i.�nrr Tr='. 104127 , "
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� I PROJECT NOTES /�ND 1NSTRUCTIONS: SCOPE OF WORK.SUMMARY:
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i. hll WDrk shall be pe,^ormed ln 2ccordance wiih �he Cammonwealtn or' M�ssachusetts - � ' z o � =
1. Rernave <xisting bzhtub, grab bzrs ana flooring zs shown on cne arawinas. < < � m
Sta[= Builqing Gode 2ne all otner =ederai, State ana �cal Godes ano Regulatfons. use la[esi _ ��la,�ge framing if possible �0 6B"widtn. � � � � ^ m
edltions. -
>. Ins:all level pluwood undertaumeni pl�form and ramo 25 shoum. z m� �� �
�. ben=ral Con*r�,�or shall apoly for all permits ard shall p� zil rel�ied �ees. All - ��. ins�ll r.:,� compllen� roll-in sncwer, grab bzr and sezt. . , ay o � P
, � neaess2ry permics shall be ootained prior to t;�e start of work. �Tne Gener{ Gontrac�or sn2�l = � Re^2ir wzll bo2rG<_ as reeceG, patch 2nd pain[. � " � i o m
be responsible �or obtaining the 'Occupancy Permi['. �- 6. Insiall virul �ioorina znd cov=_ b�se, anG seal seams wiih existina. � � - ^ s
3. Tne GonScruc�ior Si�e shcll be moir.tainea in ac;orGance wicn [he s�[_= cnq loc.al codes � �. Glecn che site. m � Q � �
anc shall be kept =r=_e of �rzsh anc debris. P.I! was�= ma�erals end demolition deoris sh211 be � � . � L o � I
. removed prior t� �h= s:ar � n=w cor,scructior:. 52fey anG care o�. adjacent properties anc � The a�ove Semmary is no: a comolete Gescriotion cr'work_ Refer to 7rswing5, X = � r
of natural resources sFall be maincained.� � _ m m . ,
No[rs anc speciflc Insallaiion Ins[ruction5 r'or ,'ull Scope o; ;NOCk. - � � e _ F
4_ Generai Gor:iraccor.and all Sub-Gorrtractors shall _=xzmine all drawings, notes and details � �
anG become pr�icien; wiih :h<- full scoce of project. ;,ny questions, Giscreoancies or more �
- sui*2ble alternativ=s snall be.brought immedisiely t� the atertion of the ,�rchiUct. � � .
S. 6eneral Gortrac�r and all Sub-Coniractors shall verifu *he exfsiir,a condi[ion5 aFte,-
cemclition and make report of anu zr.0 ali alscrepancies or incons4stencies � She ,4rchi:ect. - ` -
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� 6. ;111 Gonirac.or anG Subs_.ontracr�r >hall verlfy al! dimensions ard condiiions prior [o . � � � - -
- the sc.ar[ of new cons:rucion. finu v2ristior ih�� requirzs pnysial change shall be immediatelu �� � � . � � I�
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brougnt to the at-=n�lon or' the s,rchltec�. ,a,nu changzs, noc aporove4 bu �he ,+.rchizec� are � . o U � �
:he ;ontrac:�rs owr. risk. DR:�WING LIS I' - � z �
�- A;I Tr2des, Gortrac�r anc Subz.orrracc�rs shall guarantee in writiny all labor ana . .. _
m2�rizis �o be free �rom defeds znd error:, in worknansnio�or ins�:lla�ior for the period o; � �` � - =XIL11'ig afld P'0�052C� P�8f15 BYIG NOLBS � a �
one �'=zr srom :hz d�e oP acc2pwnce. ?� = - Sf:OW2Y �Ievoi.lOns 8nd D2C211 � Q � �
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� b_ All-Dra�,�ings and Soecir'icaions 'o be uszr ;or biddirg or cons�,-�c:ior shall bear che � - � a
laiest d3e � issue � veri�ied bu Archi:ecc. _ . ,Q Q _ �
9. i.,e 6ene�al ..r.ortc-�c�r shail be r=sponsiole �or trar,smr�ing these and other � � � �
. reauir=ments *� �II Trades anG Sub1_.ortrac�rs � - o � �
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, � The Comii�on'wealth of assachusetts
� E�ecutlrTe Offrce ofHealth and Human Ser-�nces
� Massachusetts Rehabilitation Commission
600 t��ashington Street ��,Z �� .�
DEVAL L PATRICK BOSCOI2 lYlll OZ111�1/OY T E'i ,P����fi� �r--�—
GOVERNOR f �
TIMOTHY P.MURR4Y
LIEUTENANT GOVERNOR
JOHN W.POLANOWICZ
SECRETARY f 617 i'Oa-3600
1 (R001'-45-6�43
CHARLES CARR � Voi;.e/I�DD(617j 20S-3obi
� COMMISSIONER F'�«'���r�-���4 �
DATE: March 27, 2014 I
To All Eligible Vendors TTENTION QUOTE REQU ES
Dear Sir/ Madam:
This is a Request for Quotes for housing modifications for an MRC/ABI Client;
Client: Michael Cyra 4 Prio.ce�treet Place Safem
Contact Person: None applicable
Case Manaqer: Joe Martinez- Mass Rehabilitation Commission
For questions regarding this request, please contact the above Case Manager.
<.
The quote shall be received by and will be opened on or after:
Please submit the quote by facsimile to 617- 204-3877 or by email to: April 10�' 12PM
Ma rtha.Q u i rk(a�m re state.ma.us
The following list of modifica6ons is requested:
New Roll in Shower
Hoyer Lift— Bedroom
All proposed additions should be itemized separately. If you have any questions,
please contact me at( 617 ) 596 - 2294
PLEASE NOTE ONLY ABI APPROVED VENDORS ARE ELIGIBLE TO BID ON THIS JOB.
in er ly, �
,;
�i�� --
Martha Quirk
Adaptive Services Coordinator