5 RED JACKET LN - BUILDING INSPECTION (2) u� zt � s � I � p
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1 - � y"rIfl"t1) SERVICE$
The Commonwealth of 1V�assa'chusrM
Department of Public Safety
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Massachusetts State Building q0A(�P039 Q 2: 31
Q Building Permit Application for any Building other than a One-or Two-Family Dwelling
_(This Section For Official Use Only)
Q Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1
` n � N e '
No.and Street City/Town Zip Code Name of Building(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❑ 1 Alteration ❑ 1 Addition 09 1 Demolition ❑ (Please fill out and submit Appendix l)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 1%
Is an Independent Structural Engineering Peer Review equired? Yes ❑ No E
Brief Description of Proposed Work:. R3
IA"r" rr iLi�i.J'- c /a-af //l .Lair SiP Gu /� l�✓ .,�//1L C.
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 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-1 Cl A-5❑ 1 onal ❑
F: Facto F-I ❑ F2❑ H: Hi h Hazard H-1 ❑, H-2 ClH-3 ❑ H-d❑ H-5❑
1: Institutional I-1 ❑ I-2❑ 1-3❑ 14❑ NI: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and Please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ 11110 IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 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 Site❑
required❑or trench or specify:
Private❑ or indentify,Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: C,.... t_n I •vic. I.r xy,.:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: _ Occupant Load per Flour:
Uoes the buildiny,contain an Sprinkler System?: _ Special Stipulations
N. K�:
SECTION 9. PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner /'
lA�t 3 tea, �AUJ ( n 5jewt- 60 70
Name Print) No.and Street City/Town Zip
Property Owner Contact Information: y
6 Pb4 rrn��
-317- �117 B✓14.r /Ilzt�aoOtJlcttr+ !'
Title Telephone No. (business) Telephone No. (cell) e'thail adr ess'
If�aryp�plicalb�le,t e roperty owner hereby authorizes
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LLJ>' OA1�rJP, '�%/°1 r..
Name Street Address C6/Town State Zip
to act on the property owners 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 under Construction Control then check here D and skip Sectimr 10.1
10.1 Registered Professional Responsible for Construction Control
Name Regisimnt) I hone No. e-mail address :q Registration Number
6.
Street Address - City/Town SLite Zip Discipline Expiration Date
10.2 General Contractor "Ah"t-1 6 e> s
Company Name
Name of Person Responsible for Constru ti License No. and Type if Applicable
G3 (`9a,962 u .94 /T6. Lvn� Z!u W
Street Address - City/Town State Zi
Telephone No. business Telephone No. cell e-mail address
SECTION 11:Lyoi:KEKS'CObO'LNSA IRON INSURANCE AFFIDAVIT M.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: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ J 14,,5-011Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
1.Mechanical (HVAC) S Note:Minimum fee=$ (contact municipality)
5. Mechanical Other - $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
\ a
Municipal Inspector to fill out this section upon application approval: 4ATM �D p
Nance Dale
..62a JA�
GRANT OF EASEMENT
THE HAMLET CONDOMINIUM
This Grant of Easement is made this i St day of gtL,2015
by the undersigned Trustees of The Hamlet Condominium Trust(h inafter,together
with their successors,referred to as the"Trustees")under Declaration of Trust dated
February 24, 1988 and recorded with Essex South Registry of Deeds in Book 9406,Page
397,to Margo E.Palmer and Cris Townsend of 5 Red Jacket Lane,Salem,MA(together
hereinafter referred to as the"Unit Owner").
WHEREAS,the Unit Owner is the owner of Unit A,Building 132(hereinafter,
the"Unit")of The Hamlet Condominium(hereinafter,the"Condominium")located at 5
Red Jacket Lane,Salem,Massachusetts,by unit deed recorded with said Registry in
Book 15196,Page 523 and
WHEREAS,the Unit Owner desires to install a deck(the"Deck' in the
Common Elements of the Condominium immediately adjacent to the Unit;and
WHEREAS,the Trustees have agreed to grant the Unit Owner an easement to
install and maintain the Deck according to a plan and specifications which have been
approved by the Trustees(the"Plan );and
WHEREAS,there are no other units located immediately adjacent to the
proposed Deck and no other unit owners are required to consent to this grant of casement
pursuant to the provisions of G.L.c. 183A,Section 5(b),as amended;
NOW THEREFORE inmutualconsideration,ofthecoveaantscontained _
_._..
herein,the parties hereto agree as follows:
1.The Trustees hereby authorize the Unit Owner to install the Deck according to
the Plan
2. The Deck shall not constitute a Common Element of the Condominium and the
Unit Owner shall be solely responsible for maintaining,repairing and replacing the Deck
as may be necessary from time to time,at the Unit Owner's sole cost and expense.
3.The Unit Owner shall not remove the Deck without the prior written pemrission
of the Trustees,and in case of such removal,the Unit Owner shall restore any of the
Common Elements affected thereby to the same condition they were in prior to the
installation thereof.
4.The Unit Owner shall indemnify and hold harmless the Trustees,their agents
servants and employees,and the other unit owners of the Condominium for and from any
and all damage or loss to persons or property resulting from the installation,use,
maintenance,repair or removal of the Deck.
5. Upon failure of the Unit Owner to perform any of the Unit Owner's obligations
pursuant to this Agreement within ten(10)days after written notice thereof from the
Trustees,including,but not limited to,the obligation to maintain the Deck,the Trustees
may,but need not,proceed to perform said obligations on the Unit Owner's behalf. All
costs incurred by the Trustees in the performance thereof shall be charged to the Unit
Owner in accordance with Paragraph 7 below.Upon such default,the Trustees may also
terminate the Unit Owner's rights under this Agreement by written notice to the Unit
Owner,and require the Unit Owner to remove the Deck on such terms and conditions
specified by the Trustees,and restore the Common Elements to their prior condition.
6. If at any time the Trustees determine,in their reasonable discretion,that the
Deck constitutes a nuisance or hazard to the Condominium or the occupants thereof,the
Trustees may require the Unit Owner to remove the Deck,giving forty-five(45)days
advance written notice thereof;except in case of emergency in which case such notice
may be immediate. If the Unit Owner fails to remove the Deck as aforesaid,the Trustees
and/or their agents may,in their sole discretion,remove the Deck and charge all costs
thereof to the Unit Owner. Such charges shall,together with all costs of collection,
constitute a lien on the Unit until paid. In no event shall the Trustees have any liability
for such removal.
7. The Unit Owner agrees to pay all costs incurred by the Trustees in connection
with this Agreement,including,but not limited to,legal and professional fees as required
by M.G.L. c. 183A. In addition,all costs incurred by the Trustees in the enforcement of
this Agreement,including attorneys'fees,shall be assessed to the Unit Owner. Such
costs,together with any other reasonable costs or expenses assessed to the Unit Owner by
Tnutees_pursuant to.thus Agreement,and all costs of collection(including reasonable
attomey's fees),shall constitute a lien 1.on the Unit until paid,and may be collected by the
Trustees in the same manner as unpaid common charges.
8. This Agreement shall constitute a covenant running with the land,and shall
inure to the benefit of,and be binding upon,any successors in tide to the Unit Owner,
and may be amended only by an instrument in writing signed by the Unit Owner and the
Trustees and their successors in title.
I
Executed under seal this k day of 2015.
2
UNIT OWNER:
Margo E almer
i
's To d
( ( ,
V ZA
TRUSTEES OF Ll-
THE HAMLET
CONDOMINIUM TRUST
( r
COMMONWEALTH OF MASSACHUSETTS
ESSM as Ou this tS-'k day of —6,L 2015,before me,the undersined
notary_public,personally.app
_ eared the above.-named
Trustee as aforesaid„proved to me through satisfactory e4idence of identific tion,
which was M-0, Uc4 Nsa. ,to be the person whose name is signed on the
above-document,and acknowledged to me that signed it voluntarily for its
intended purpose.
Notary publics
My commission expires:A �22 2)C4
s� CAITLIN A.TEE
0��
Notary public
3 COIAIONWEALTH Of LASSACHUSETTS
MY Commission Expires
August 22,2019
QTYOF SALEK MASSAC:HUSEM
BuALDINGDEPARTA ENr
120 WARm4GTON STREET,YO Flom
IkL(978)745-9595.
B.IIvIB FAX(978)740-9846
MAYOR 711CMAS STYMRRE
DIRECTOR OFPLIEMPROPERWA IILDII GOMRAISSIONMR
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 c4O, 5 54; Building Permit g 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, 5156A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signatur of applicant
2
Date
The Commonwealth of Massae#usetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 021I4-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FH,ED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print b
NaMe(Bwinms/Orgw&ation(Individual):
Address:
City/State/Zip: �/Lt4,f Phone#:
Are you an employer?Check the appropriate box:
Type of project(rigtiired):
I.Q 1 era a employer with employees(full and/orpart-time). - 7. Wew construction -
2.0I am a,sole proprietor orpaMership and have no employees working fur me m $, 0 Remodeling
any capacity.[No workers'comp.insurance required]
3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.]I 9. El 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 ere sole 1 LE)Electrical repairs or additions
proprietors with an employees.
12. Plumbing repass or additions
5.n I am a general contractor,and I have hired the subcontractors listed on the attached sheet.
These subcontractors have employees and have workers'comp.mumsucq l 13.Q Roof repairs.
6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have no employees.[No workers'coal:insurance required.]
*Any applicant that checks box n1 must also fig our 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 thou entities have
employees. If the subcontractors have employees,they must provide then workers'-comp.policy number..
I am an employer that is providing workers'compensado, insurancefor my employees. Below is the policy and job-site
information.
Insurance Company Name: ,P
Policy#or Self-ins.L,icc..#: t. 7r i Expiration Date:
Job Site Address: ��I KB�i� r� l/� L i)riJ - City/State/Zip:
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 fonvarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify
/er and the pains and penalties ofperjury that the information provided above Js rue and correct.
Signature: Date:
Phone#• G �
Official use only. Do not write in this area,to be completed by city or town ojfrcial
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or writtert."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple perrmt/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.where a home owner or citizen is obtaining a license or perrmt not related to any business or commercial venture
(i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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