10 ROSLYN ST - BUILDING INSPECTION • The Commonwealth of Massachusetts
t
/ Department of Public Safety
Nlassachuselts State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section For Official Use Onlv)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
o A6f-L Iyeel d
No.and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
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 1)
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 Engineeri ng Pee )Review required? / Yes ❑ No yip
Brief Description of Proposed Work: s &��
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): a'
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 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5 ❑ B: Business ❑ E: Educational ❑
F: Facto ❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 El 1-2 ❑ 1-3 ❑ 1-4❑ M: Mercantile ❑ R: Residential R-10 R-2❑ R-3❑ R-4
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply Flood Zone Information: ewage Disposal:
Trench Permit: LDebris Removal•;
Public Check if outside Flood Lune Indicate municipal
A trench will not beed Disposal Site
required ❑or trench ify:
Private ❑ or indentik Zone: or on Site-system ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: MA I li,ton, C�nnmi.....n Ito,i,•,c
Not Applicable ❑ Is Structure within airport approach area? Is their review completed?
or Cnn>unt to Build enclosed ❑ Ye, ❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code CSe Group(s): T_cpe of Construction: Occupant Lund per Flour:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
c
:Name, 1 Address o Pro,erty Or ner
Name(Print) No.and StreetCity/Town Zip
Pr )perty Owner Cont ct Inf rmati in:
Title - Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town State Zip
to act on the pro perty owner*,,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 35,0110 cu.ft.of enclosed s ace and/or not wider Construction Control then check here❑and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 Gene al Contractor
y
an Comp am
/C t�,. �iG 7i7i/ l � Liz C3 ZP7i6
Name of P rson R puns le for C nstruction Li nse No. and Type if,Qpplicable
eet dr��s__ — 12_Z9�7 City/Tow �y Sta &Zp 4 �Uy�
Tele hone No. (business) Tele hone No. (cell) - S e-mail address
SECTION 11:WORKERS COWIPENSATION 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 $ lla Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipalit
S. Mechanical (Other) - $ Enclose check payable to
6.Total Cost $ �/(� (contact municipality)and write check numbeYere
SECT ON 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
apphcati in is true and accurate to the best of my knowledge and understanding. --'----
Please �ind a��,rrpame / Title Telephone No. Date
Street :Address Cite/Town State Zip
Municipal Inspector to fill out this section upon application approval:
NOW Date
' CITY OF SALLM
,•. I;� ,,�; PUBLIC. PROPRERTY
�.,.,. . DEPARTMENT
.. Iri v'y.'l;. i;.ic • Iry • '3 v: .va,
Construction Debris Disposal At'tid.nit
(required Iirr all demolition :old renu%aion wurk)
In accurdance ith the sixth edition of the State Building Code, 78U CMR section I 1 1.5
Debris, and the provisions uf'vIGL c 40, S 54;
Building Permit M is issued with the condition that the debris resulting front
this work shall he disposed of in it properly licensed waste disposal lacility as defined by MUL c
I 11. S 150A.
The debris will be transported by:
l uamc ul hauler)
I Ile debris will be disposed of in
(uame ul I]alny) �—
I' Luldre.• ull-acJuVl
. .i�nalmC Ir:nnu .q+phi and
'law
CITY OF SMs&M, AxSSACHUSETTS
B2:DDING DEPARTMENT
120''W.SSIlINGTON STREM,-3w-FLOOR- ,
TEL (978) 745-959S
F,+.x(971) 740-98"
KI,BERI EY DRISCOLL
MAYORTmomu ST.FlE&U
DIRECTOt OF PLOLIC PROPERTY/tCIIDING COMMISSIONER
Workers' Compensation Insurance tMdavit: builders/Contractors/ElectriclsnsiPlumbers
r llcant Infnrmation Please PrintLegibly
Naltle IBmin.�a Orman ration In Lvlduall' `—
Address: 3 l l-
City/State/Zin- Phone
Are you to employer'Cheek the appropriate loos: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).• have hired the a&conbactoe
2.❑ 1 an a sob proprietor or portner-
listed an the attached sheep :
�• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
workingfor me in an capacity. worker'comp.insurance.
y p ry. 9. Q building addition
[No workers comp. insurance S. Q We are a corporation and its 10.❑Electrical repair trr additions
required.] 0111cers have exercised their .
3.❑ 1 am a homeowner doing all work right of cxanption per MGL 1 1.Q PI ins repairs or additions
myself.(No workers'comp. c. 152.41(4),and we have no 12. f repairs
insurance required.)f employees. LNo workers'
comp. insurance required.] 1].QOtha
'Any applicant[hid chacb boa 01 must aW fill use the serous bstow allowing lhak wartm'custpuseabte policy infumutloe,
'i ftvwetarrass who tightest this affidavit indicting they are doing all work and thus him onside usntrsesem must submit a new,iltldovil indication web.
(',muawbw thel ciuRk this boa mum anaehad.an additional ohm showing out name of the sub-cosinutors and ihak workers'romp.policy isfgmoual.
I am an employes that tr previdl, avoritrt'compearsadoo Insarance for my employees Below/s the policy and Job rile
infornsutioti e r
Insurance Company Name: .JL
Policy 4 or Self-ins. Lic. p: T I Expiration Date: Jl
Job Site Address: City/StatdZip:
.Snack a copy of the workers'compensation policy declaration page(showing the policy, number and esplrades date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of■
fine up to S 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 m S230.00 a day against the violator. Ile advised that a.copy of this statement may be forwarded to the OfYce of
I n%can Sit iona ul'the DIA for instaance coverage ven fication.
/Jo hereby certify under the pains and penalties o/perfury that rho informetlotr provided above it true end sprees
,zwn iurr. Dote:
PFore ro
OffAial use✓nly. Do not write in thir area,to lot,unrp/•led by rity uptown ofciatt
City or ruwn: Pcrmit/Llcrnst d I
hsuing.%ulhuritylcircleunel:
I. Ituard of Ilrulth 1. Ruilding Deparfmcne ]. Cityfrown Clerk 4. Electrical Impcaor 5. Plumbing Iniptetar
6. 01 her
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYYI
07/27/2009
+ PRODUC R (978) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Lauranzano Insurance
A4 cy HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Beverly MA 01915— INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:BARTFORD INS. CO.
Victor J. Capozzi INSURER U
138 Bridge street INSURER C:
INSURER D'
Beverly MA 01915— 1 INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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.
INSR ADD'L POLICY TYPEOFINSURANCE POLICY NUMBER DATE(MMFDDTIVE POLICY EXPIRATION
LTR INSRD ( /YYI DATE IEXPIRA IO OMITS
GENERAL LIABILITY / / / / EACH OCCURRENCE $
DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $
CLAIMS MADE OCCUR / / / / MED EXP Any oneperson) $
PERSONAL B ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $
POCY JECOT LOC
LI
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALL OWNED AUTOS / / / / BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIREDAUTOS / / / / BODILY INJURY
NON-OWNED AUTOS (Per accident $
PROPERTY DAMAGE
(Per accident $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO / / / / OTHER THAN EA ACC $
AUTO ONLY: AGO $
EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE $
OCCUR F—ICI-AIMS MADE AGGREGATE $
DEDUCTIBLE / / / / $
RETENTION $ $
A WORKERS COMPENSATION AND 46WECLOSS89 10/24/2009P10/24/2009 X WCSTATU- OTH.
EMPLOYERS'UABILTTYTORYLIMTSER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100r000
OFFICER/MEMBER EXCLUDED? / / EL.DISEASE-EA EMPLOYEE$ 100,000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500r000
DESCRIPTION OF OPERATIONS!LOCATIONSIVEHICLES/E)CCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
( ) — (978) 745-1875 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
City Of Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
Washington Street INSURER ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATW9#1
Salem MA 01970-
ACORD 25(2001108) O ACOR RPORATION 1988
q.M INS025(otofip5 ELECTRONIC IASER FORMS,INC.-(800)32T-0545 Page 1 of