2 RED JACKET LN - BUILDING INSPECTION . � 2ZE7
RECEIv SERvIGE5 ,
The Commonwealth of 111 ssachusett� ly'
.� Department of Public L14
Massachusetts AM)'t�
assachusettsStateBuiWing Code jt
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Onl )
Budding Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block 8 and Lot N for locations for which a street address is not available)
RED TLACkiIII o ►Y70
No.and Street City/Town Zip Cone Name of Building(if applicable)
SECTION 2:PROPOSED WORK -
Edition of MA State Code used_ If New Construction check here❑or check all that a IPF'Y III the two,rows below
Existing Building Repair❑ 'Alteration ff Addition❑ Demolition (Please fill out and submit Appendix 1)
Chimge of Use ❑ 1 Change of Ochrpancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Indepe1 dent Structural Engineering Peer Review required? Yes ❑ No pi
Brief Descriptionp of Propos d Work: ��
i�/ C'Nc4fr7IVD �1i01/1 �r. C- raLr� r�rrr�
SECTION 3:COM14PLETE THIS SECTION IF EXISTING BUILDING UNDERGOING[;ENOVATION,ADDITION,OR
CHANCE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and is enclosed(See 780 CMR 3�) ❑
Existing Use G oup(s): esti d E - Proposed Use Croup(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 CROUP(Check as a livable)
A: Assembly A.1❑ A-2❑ Nightclub ❑ A-3 ❑ A-I❑ A-5❑ B: Business ❑
F: Facto F-1❑ F2 —High
E: Educational ❑
❑ fL• Hi h Hazard H-1❑ H-2❑ H-3 ❑ - H-4❑ H-5❑
1: Institutional 1-t❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-0❑
S: Storage S-I❑ S-2❑ U: Utility❑- Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a livable)
L\ ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ HIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Zone❑ Indicale municipal A trench will not be Licensed Disposal Site e(
Private❑ or indentify Zone; or on site system❑ required❑or trench or specify:—
Railroad right-of-way: Is Structure within air ort
Not Applicable tuneHaz rds tovithin Air pN 'p%r ve i. V n i litom their review comp 1'
t9/ Navigation: - - -
� edv ,
or Consent to Build enclosed❑ 1
Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type O(Conslruction: Occupant Lord per Floor:
Dues the building cturtain an Sprinkler System?:__ Special Stipulations:
"7 I 3$�{ - 0-721 P f 4 L L _ —
�(--A-U,A, VIA k- rzA�cq' . SEND ' . 0-Q3 5 sL-N�
07
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner _
Name(Print)•+'I p 4 No.and Street City/Town Zip
fd Property Owner Contact hifonn0t_ion:d1j,
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 tinder Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
"he
Na ne U)Znc— Telephone No. - e-mail address Registration Number
,�ra,JlPD stir✓ c� f6
Street Address City/Town State Zip Discipline gpiralion Date
10.2 General Contractor
M F Ph &! e R f S'iS ` M T COATI 5dfcA 4 f Dolt-S
Company Name
CS; O
s-s 6 v
Name of Person Responsible for Construction License No. and Tyk if Applicable
l�3 C'ark/lrJ kAMQM 12D LyA/v✓ B�
Set Address ty/Town State Zip
1 - - �12� N 5 tB r OXA �i 9 MY C�
Telephone No. business Telephone No. cell e-mail address
SECTION 11:VVURI:b:hS'COMI'ENSA1'16N INSURANCE{AFFIUA71- M.G.L.c.152.9 25C 6
A Workers'Compensation Insurance Affidavit from the rvIA 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 budding permit.
Is a signed Affidavit submitted with this application? Yes trlNo O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)
1. Building $ OPO. OC3 Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical S sbw, IND appropriate municipal factor)=$
S, Plumbing $
4. Mechanical (HVAC) $ Note:Minimum ke=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ Zo 0&�,.00 i (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERbIIT 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 best of my k ledge and derstanding.
Please print and sign name Title Telephone No. ate
,t/Wr�GLF i2p. L uirt� l
/0
,43
Street Address City/Town - State Zip
hluniciP al Inspector to fill out this section upon application approvaapproval: `�✓
-�1n n Date
i ,ne
CITY OF SM.EM, NWSACHL'SETTS
4 BUILDING DEPARTMEINT
pt
3 � • g �r��l I?O CU.iSH44GTON STREET, 3sO FLOOR
'tea TEL (978) 745-9595
F.,-x(978) 740.98445
K1%iBERtL.6Y DRISCOLL THOIkfAS Sr.P1FxRs
DIRECTOR OF PUBLIC PROPERTY/81;1LDING CO\L\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
n
V;11nC(nuxiness,{O�rganiralinro'InJividu:J l: ��PM Of —
Address: 7 COY"�M o AI f I�1 /CQ
City/State/Zip: �- W � • Phone At:
Arn employer?Check the appropriate box: 76.Y10
e of project(required):
I. Ira a employer with 2— 4. ❑ I am a general contractor and t New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ lain a sole proprietor or partner- listed on the attached sheet. ) 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. y. Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10.❑Electrical repairs or additions
required.)
}.❑ 1 ran a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repuirs or additions
myself.(No workers'Gump. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.) t employees.tNo workers'
cutup.insurance required.) I l.❑ Other
•,any applicant that Oucks bur At mwr also rill uul the auction below showing their worked cumpenmiiun puficy Infsnnation.
'I Lrmunwrwn.rho suhmil this atndnvit indicating thcy arc doing all work and then hire otdlido canirscton mot suhmit anew anidavil indicating such.
(\imnemrs thin chak this lux mint amaahai an addiiiuml.hml shuwing the none of the aultamrscWn and their workers'comp,pulley;nria malion.
f unr art eutpluyer Nat is providing ivorkers'conipensailua insurance for my employees. Relutty`tls the policy and jub rite
information. k%
Insurance Company Name: raaI''J''c7D`^�nf_^JD r 1 L �.t,J��/
Policy it or Self-ins. Lie.11: /wW C ��'I �U� Exp iralion Date:�b ! r Y
Job Site Address: 2 R�U .� LG t L� City/Statr/Zip: -r�—��
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
railure to secure coverage as required under Suction 25A of%,IGL c. 152 can lead to the imposition ofcriminal penalties ufa
line up to S 1,500,00 und/or one-year imprisoninen4 as well as civil penalties in the form of a STOP WORK ORDER and a fine
arup to S250.00 d day against ilia violator. De advised that a copy of this statement may be furwardcd to the Otlice of
Investigations ofihc DIA for insurance coverage verification. -
/do/ lr� i y unJer the pubis oil ables of perjury that the brfurrnurlart provided above is true land correct.
Si•.nnurc' �Q � Data:
P t ,4: I.? 0/1 2 1/ i
(7f/icrai use only. Do not writ,in this area, to be completed by city or town n/Jleiul
]
City air fawn: _ _. Pcrmit/Lfeetae1f__.
Issuing Authority (circle one):
I. hoard of Ileallh 2. Building, Department I.Ciiyfrawm Clerk 7. Electrical loipcctur S. Plumbing Inspector
b. Oihcr
I
Contact Verson:.__.._..._.____ .. .. Phonc.'t:
1
76ie HamCet
Condominium Trust
August 26,2014
Ms. Jessica Porcaro
2 Red Jacket Lane
Salem,MA 01970
Re: Renovations—2 RED JACKET LANE, Salem,MA
Dear Ms. Porcaro:
Per your request,please forward this letter to the City of Salem to advise that the Hamlet
Condominium Trust is aware that you will be conducting some interior non-structural
renovations at 2 Red Jacket Lane and that you and Scott Sullivan are the owners of the
property.
Should you need any additional information,please contact this office at 978-532-4800.
Sin ely,
Ph Sherman
CRO NSHIELD MANAGEMENT CORP.,As Managing Agent for
Hamlet Condominium Trust
Managed By CrowninshieCdNanagement Corp., i8 CrowninshieCdStreet, Peabody M.1 m96o
Phone (978)532-4800 • fax(978)532-6o23 • wiviv.crowninshieCdcom
CITY OF SALEM, MASSACHUSETTS
' st� BUILDING DEPARTMENT
120 WASHINGTON STREET,3AD FLOOR
TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR TY-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
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:
At5R p (X�
(name of hauler)
The debris will be disposed of in:
S (RA"SiA S W/0)
(name of facility)
(address of facility)
Signai67f applicant
at
(Z2a��yri�2�a2,r.�ea��� a% ,Ci2�as.�ccc�urte��
Office of Consumer Affairs and Business Regulation
10 Park Plaza.- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 158287
Type: Private Corporation
Expiration: 1t3f2016 Trft 247728
NORTH SHORE BUILDERS INC
MARK FOURNIER _
P.O. BOX 8684 --
LYNN, MA 01904
'Update Address and return card.Mark reason for change.
-- Address Renewal 0 Employment E] Lost Card
SCA I Z 20M{ l I
C�/fir.�oinnn;nemr�✓/lz n�C}9/�rxui<�r�.TrL7= i
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
j 0� 111E before the expiration date. If found return to:
9a IMPROVEMENT CONTRACTOR
istration• 156287 Type: OIDce of Consumer Affairs and Business Regulation
hation 1/12016 Private Corporation 10 Park Plaza-Suite 5170
fi Boston,MA 02116
NORTH SHORE BUILDERS INCH
MARK FOURNIER _ -
63 COMMONWEALTH RD.
'' g _
LYNN,MA 01904 Undersecretary Not valid without signature
I�t Massachusetts -Department of Public Safety
�f Board of Building Regulations and Standards
Construction Supervisor S
License: CS4)55614
MARK M FOURIYWR w
P O BOX 8084
LYNN MA otgof r j
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