45 SAINT PETER ST - BUILDING INSPECTION The Comrnonwealth'•oYMassachdsetts
E; I, Department of Public Safety
�w- i Sia>saduw.clts SI,ite Building Code(780'CMR)Se%enth Edition
r City of Salem t..
feil 1 , Building Permit Application for any Building other than a I-or 2-Family Dwelling
(This Section For Official Use Only).
Building Permit Number: Date Applied: Building Inspector:
('O SECTION 1: LOCATION (Please indicate Block N and Lot 4 for locations for which a street address is not available)
No.and Street Ci h' /Town Zip Code Name of Building (itapplicable)
SECTION 2:PROPOSED WORK
If Nrw,Cbn truction check.heee❑itr.cbeck all that aPoly in•ihe Iwo rows below. P,(
Existing Building* Repair❑ Alteratidn ❑ Addition 9k Demolition V,(Please fill out and submit_Appendix 1)
Change of Use ❑ Changeof Occupancy ❑ Other ❑ Specify: -
Are building plans and/or construction documents being supplied as part of this permit application? Yes M No ❑
Is an Independent Structural Engineering Peer Review requuedl Yes )a No ❑
Brief Descri lion of P oposed Work: / ,
r
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): f
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stgries(include basement levels)&Area Per Floor(sq.Eft.) 6
Total Area (sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as ap licable)'
A: Assembly A-1 ❑ . A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business Cl E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1L 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: .S �,• . ' "
.SECTION b:CONSTRUCTION TYPE (Check as applicable) r
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: Sewage Disposal: Trench Permit: Debris Removal:
PLIH&V Check it uubide Ilrnni Zone ❑ Indicate municipal ❑ \ trench will not be Lict, "I Ui.pos,tl Site ❑
� nr .I'ri%a �%.
to ❑ ur unientil% Zone: or on.its tem rcyuired Our trench peal%.
❑ permit i.encluned ❑ __
Railroad right-ot-way: ,hazards to Air.Navigation: %I:� II>tai; ninni„ern I:r..vo I'n i
Nrt \hldicablu O f •I,titrurlurc rcithin girl+nrt apF,rnaih area.' L. thcu recicrc inntpclud'
in b'/snnvnt ti R Ye, ❑ or .Nu❑ Sr*❑ Nu ❑
' SECTION 8:CONTENT OF CERTIFICATE Of(OICCUffPANCY I[Jio��n ��t 1. �a1e. L,e l;nipt,l: ft peat l �in.tructtim: Lnad per Iluur: _
Une,the buildutt;cunt•on.ut Sprinkler S%,tem': Special Stipulatwns:
SECTION 9: PROPERTY OWNER AUTHORIZATION
N.lme,tnd t\ddr, of Pr t{ t \' 01 011
3�4 7\
Name(Print) ,V•a` .No.andStreel Sly Cih'/Town Zip V
� J
Property l)tv ner Contact Information: a^Ar�' 4� ,/�
Title Telephone No. (business) Telephone No. (cell) e-mail addreNs roh'�
11 applicable, the property owner herebv authorizes
'� a •� �`
Name Street Addres.. City/Town Slate Zip
load on the property otv ner's behalf, in all matters relative to work authorized by this building permit application
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
tlf building is less than 39,MO cu. It,of enclosvd<pace and/or not under Construction Control then check here O and ski I Scdiun 10 1)
10.1 Registered Professional Responsible for Construction Control
g sZ c g1Y_1� 131°� I t�Y�, d�owska@ Ius Attill d jcd 'to V-
Name(Regis tram) Telephone Nu. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Na
Name of P rson esponsibl for Construction ,/f Q/ J icense No. and Type if Applicably
, s v m
�t�./ AddressCit Town Sta�j
}r( �� /1 / ` ��—�� —�=y—_ �!1!A')/fyC( Wit/ ('02a G Zip- L4 4'C/i
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11: WORKERS'COMPENSATION 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
Estimated Costs: (Labor
Item. and Materials) Total Construction Cost(from Item 6)=$ f «1 py
1. Buildfrig $ a6 a � Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ 3161 o e 6 appropriate municipal factor)=$A ftrr4 .
3. Plumbing $ e d
d. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ /� 57 6Enclose 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, I hereby attest Lin e wins and penalties of perjury that all'of the information contained in this
application is true and accurate t best of ! c owl •dge and understanding.
S nu � nn.sa ') �/7 {S3 �Tv
j1'le,t•r print a d >igi name i Ile Telephone\o. Date
itt' own tat lip
I
Municipal Inspector to fill out this section upon application approval: tel
.Name )ate
CITY OF S.1LE.�1, �L-1SSACHL;SETB
BUILDING DEPARTMENT
120 WASHLNGTON STREET, Via FLOOR
'ICI.. (978) 745-9595
FAX(978) 740-9846
Kl-,(BFRi FY DRISCOLL
ST.PtE I
.MAYOR �fOh1AS RRti
DIRECTOR OF PL BLIC PRQPERTY/BC2DLNG CO>L%RSSIO'ER
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers
Annlicant Information /` Please Print Legibly
Name (Busirws Organization Individual): 1 I VFYSS p ,v I.CS aBigiz" �y
Address: 14 L1
City/State/Zip: 0Ph9 bone #:
Are you an employer?Check the appropriate box: Typegeneral New
(required):
I. am a employer with 8
employees(full and/or part-tune).• have hired the sutl-comracton 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed an the attached shceL : 7• ❑Remodeling
;hip and have no employees These sub-contractors have S. Demolition
working for me in any capacity. workers'comp.insurance. 9, Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.91 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MOL I I.M Plumbing repairs or additions
myself. (No workers' comp. c. 152,§1(4),and we have no 12.p Roof repairs
insurance required.]t employees. (No workers' 13.E]Other
comp. insurance required.)
-Any applicant that checks Eoa#t mutt alws fill tut Ilia sectim below showing their worktas'cMpenurid"policy infomtmai
'I humanness who submit this aflldwt indicating they am doing all work and then hue outside enetrselars most submit a new affidavit indicating such.
{'.rate:von that check this bast most anwhod an additional sheet showing the tame of the suhtontracbn and their wurkani comp.policy infosmmim.
!an;an employer that 6 pravidlng svorkrn'cotppsnsr3rlopnanee jo$ rmy plyy rs, Below Is the policy and fob rile
informadon. �1 (��1,,JJ S Ft
Insurance Company Name: c (r+- �� Crt• 4- pr��.
Policy#or Self--ins. Lic. #: 6 46 �i1 7 ?a 1 InJ tMJL Expiration Dater
Job Sire Address: yS 3}. a4. City/StawiZip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date):
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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 to S230.00 a day against the violator. Ile advised tha a copy of this statement may be forwarded to the Office of
I nvesttgations ut'tlie D[A for insurance coverage v 'tie ton.
I do hereby c ertif and e p s trd pa ! er]ary at the information provided above is true and correct
4zi rmwre Dutc:
Official use aidy. Do not wrire in this area, to be completed by city or town oflicigi
City or Tuwn: _ Permit/Lkcmle#
bsuing Aulhorily (circle one):
I. Board of Health 2. Building Department 3.Cityfrown Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
Cuntact Person: _ _ _ __. _- Phone#:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
III v'a.-i; j'e V_ 'lil,.
Construction Debris Disposal Allidavit
(rc\luircd lbr all demolition and renovation work)
In accordance \vitlt the sixth edition of the State � 780 �Building g Code NIR section 11 1.5
Dcbris, and the provisions of*NIGL c 40, S 54;
Building Permit 0 is issued with the condition that the debris resulting from
this work shalt he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The dchris will be transported by:
�" Inamc of hauler)
I he debris will be disposed of in
(name of facility)
t:n us. ufIJCI y)
` enelwe nr p unit .lpllllunl
' lalr
CONSTRUCTION CONTROL AFFIDAVIT
Project Number: DHCD # 258054, SHA # 1025 Date: July 8, 2009
Project Title: Salem Housing Authority Morencv Manor Elderly Housing Development
Project Location: 45 St. Peter Street, Salem, Ma 01970
Name of Building: Morency Manor
Scope of Project: Addition to existing building —elevator and stairwell vestibule
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
Paul Durand MASS. REGISTRATION NO._8615 BEING
A REGISTERED PROFESSIONAL ARCHITECT HEREBY CERTIFY THAT I HAVE PREPARED OR
DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND
SPECIFICATIONS CONCERNING:
Civil Architectural x Structural Mechanical
Electrical Fire Protection Other (specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES
AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO
DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS
APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING
AS SPECIFIED IN SECTION 116.2.2.
1. Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for building permit, and approval for conformance to the design concept.
2. Review and approval of the quality control procedures for all code required control materials.
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in
Appendix I.
PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON COMPLETION
OF THE WORK, I SHALL SUBMIT AL REPORT AS TO THE SATISFACTOR O 1PLETION
AND READINESS OF THE PRO CUPANCY.
ALLISM d, `
Ptb1C
PAUL
Oa YgSA{',MI R. l
MY 3
OWm�hNan E>OPIeM DURAND j
garner t.2515 8615
IN of �4�" Signature
SUBSCRIBED AND SWORN TO B E THIS DAY OF 4t u I
My commission Expires:
Notary Public
1
CONSTRUCTION CONTROL AFFIDAVIT
Project Number: DHCD *258054, SHA #1025 Date: July 13, 2009
Project Title: Salem Housing Authority Morency Manor Elderly Housing Development
Project Location: 45 St. Peter Street, Salem, MA 01970
Name of Building: Morency Manor
Scope of Project: Addition to existing building — elevator and stairwell vestibule
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
Lee C. Lim , MASS. REGISTRATION NO. 26970 BEING A
REGISTERED PROFESSIONAL ENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR
DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND
SPECIFICATIONS CONCERNING:
Civil Architectural Structural X Mechanical
Electrical Fire Protection Other (specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES
AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO
DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS
APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING
AS SPECIFIED IN SECTION 116.2.2.
1. Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for building permit, and approval for conformance to the design concept.
2. Review and approval of the quality control procedures for all code required control materials.
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in
Appendix I.
PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON COMPLETION
OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION
AND READINESS OF THE PROJECT FOR OCCUPANCY. cuck.
Signature
SUBSCRIBED AND SWORN TO BEFORE ME THIS 1344 DAY OF JM- J c _ 2009
f'l�Ac/yl/` L�1 Gt�l�—F My commission Exp es:�hnnCE .....RIE�RAZAo
Notary Public Commonwealth of Massachusetts
My Commission Expires
January 29,2010
CONSTRUCTION CONTROL AFFIDAVIT
Project Number: DHCD #258054 Date: 07/08/09
Project Title: Salem Housing Authority Morency Manor Elderly Housing Development
Project Location: 45 St. Peter Street, Salem, MA
Name of Building: Morency Manor
Scope of Project: Elevator Installation
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
Susan M. Wisler MASS. REGISTRATION NO. 46614 BEING A REGISTERED ENGINEER HEREBY
STATE THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN
PLANS, COMPUTATIONS, AND SPECIFICATIONS CONCERNING:
Entire Project Architectural Structural Mechanical X
Electrical Fire Protection X Other(specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE and the Massachusetts Architectural Access Board.
Susan M. Wisler 46614
Engineer- MASS . Reg. No.
ZH OF,y,�,
o� SUSAN s'o Architectural Engineers, Inc.
At y�, 77 Summer Street- 5th Floor
CD VftLeR
Boston, MA 02110
NO.48814 y
QJ Address
gbNAL E
617-542-0810
Phone
July 8, 2009
Date 1��
Q�
Signature
SUBSCRIB D AND SWORN TO BEFORE ME THIS �d DAY O 2009
My commission Expires: 3
Notary ublic
Js g c3?8
CONSTRUCTION CONTROL AFFIDAVIT
Project Number: DHCD #258054 Date: 07/08/09
Project Title• Salem Housing Authority Morency Manor Elderly Housing Development
Project Location: 45 St. Peter Street, Salem,•MA"
Name of Building: Morency Manor
Scope of Project: Elevator Installation
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
Nicola D. Ferzacca III MASS. REGISTRATION NO. 43208 BEING A REGISTERED ENGINEER
HEREBY STATE THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL
DESIGN PLANS, COMPUTATIONS, AND SPECIFICATIONS CONCERNING:
Entire Project Architectural Structural Mechanical
Electrical X Fire Protection Other (specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE and the Massachusetts Architectural Access Board.
Nicola D. Ferzacca III 43208
Engineer— MASS . Reg. No.
NICOLA D.
FERZACCA III ^� - Architectural Engineers, Inc.
ELECTRICAL y 77 Summer Street— 5t"
N0.43288 Floor
p9pT��o s rep' �`r Boston, MA 02110
FSS�Oya a\
Address
617-542-0810
Phone
July S, 2009
D to
Sig ture
4Notary
RIBED AND WOR I TO BEFORE ME THIS DAY 9
O470
My commission Expires:
blic . Eh
O;It
'.mow 4 4
."mat
L35