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SALEM WILLOW - BUILDING INSPECTION I+ , l C 11Z - Lf1,0235 o Z4q RECEIVEn 02�� OZ� 1 The Commonwealth of MassadhWM&NAE SERVICES WOQDepartment of Public Safety / ALssachusellsState Building Code(780CMH'�S �PRF, q IV4b Building Permit Application for any Building other than a One-or'Two-l?amily Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: ? Building Official: rSECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) © 5�Lt4 W (U.Ovs 5A-Lj�r 61 j 7a �PM+tllor� (� No.and Street City/Town Zip Code Name of Building(if applicable) [�(I SECTION 2:PROPOSED WORK Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building let Repair lill I Alteration ❑ 1 Addition❑ TDernolition ❑ (Please fill out and submit Appendix I) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No j5- Is an Independent Structural Engineering Peer Review required? Yes ❑ No im Brief Description of Proposed Work: r r)J'E `7 � elacc -t�et%� 4Y WAS IK t 1N T 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 enclosers(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Granp(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-I @ A-2❑ Nightclub ❑ A-3 Cl A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ 1 It:'High Hazard H-t ❑ H-2❑ H-3 ❑ H-4❑ H-S❑ L- Institutional I.1 ❑ 1-2❑ 1-3 Cl [4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) IA ❑ Ill ❑ 11A ❑ 111) ❑ 1 IIL1 ❑ 11111 ❑ I IV ❑ 1 VA ❑ VB ❑ SECTION T SITE INFORMATION(refer to 780 CNIR 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: j hazards to Air Navigation: V\I l pl , A-mpgi"i n It;� .�_Pro" Not Applicable❑ Is Stmdure 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 Floor: Does the building contain an Sprinkler System?: _ Special Stipulations: --- 6Y1 i t L Qb 't-0 M cY 5Ne7-N. S'IV T N/ I f-a 1 0 1 C 0 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner . G1-c-( 0 r SA«`'r 11> tu.ot,Zs Name(Print) � '. 'No.and Street City/Town Zip Property Owner tContact Information: Title Telephone No.(business) Telephone No. (cell) a-mad address ff applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf, in allmatters relative to work authorized by this budding 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 O 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 General Contractor C Aft-fs�CS2C� Co,SST Company Na g Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 91. Telephone No. business Telephone No. cell e-mail address SECTION 11:WoRFF:RS COAiPENSA I'iON INSURANCE AFFIDAVI I' M.G.L.c.152.9 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 0 No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE - Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ I. Building $ Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost S *,V (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 penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. SotJ .�`ran rv(�i2� zti Please print and sign name Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date l CITY OF SALEK MASSAC HUSETIS r BLU DING DEPARTMENT 120 WASHNGTON STREET,YOFWOR nL(978)745-9595 KIIvIBERLEYDRISOML FAX(978)740.9846 MAYOR TrIOMm ST.PIERRE DIRECTOR OF PUBLicPROPERTY/BUILDING COIwsslomR 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, 5 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: 4 (name of hauler) The debris will be disposed of in: G (name of facility) (address of facility) 7Sinrure of app cant <I Da te tit Massachusetts -Department of Public Safety 1 �f Board of Building Regulations and Standards, , Omeeof Consumer Affairs&Business Regulation Cel.,.true;nn S..penlmr L) i§30ME IMPROVEMENT CONTRACTOR ' .j �� !ration License: CS-092108 egistran 161159 Ton: yPe• tax _yY P 9/29/2016 Individual ; Jon J Gantenherg! - a - 224 Nahant Road JON GANSENBERG ,' �;r - _ ! i W Nahant MA 0191 (� } (\ /` II( JON GANSENBERG Y 36 ROYAL CREST DRIVE Expiration NORTH ANDOVER MA 01645 0112=017 i . Commissioner Undersecretary) tv ul L3 CERTIFfCAM OF TRAINING fliE $ k nnal$.,Fety and Hearth Adnvnnaratm^ twscmnn�sxx: { Jon J. Gansenbelta, Jon Joseph Gansenberg ,y i 104 w occ a'•• onma.ucue.xwmar. ru.xxn+n r« .. 1 r.-r .nq Course in asopr�.*mva erepuN mf mvcammamkr,q a: Construction Safe -rait• _ _. nwmWrmnmumart w�.mcex3 I - --- — 4:ti3rnonwukrmmvy a /tit (•t t, _ \t cFRlrrx:•IrEofcomrPLErioN h '� LEAD-SAFE RENOVATOR SUPERVISOR - Fif rbuummagrnw: ,,.-, _ .t Refresher Course(English) 70NGANSENBERG aoo wmwrR. eEVERLY,AG 0191f �'—' nmmmmrdNmnWlamme 't �� y" - J 8hovEPAmadel mvne S s j Lead Renovator Initial -- op.mmEnSart ArvoovEanu C.Dine 3OW010 t r'+•:ar+ .... �.�. _ � `.I',� E Eo. inn lbx:3RY_'010 �— yuaIirtontMe:LS11013 Cwifl ii,Number. V-1-18499-10-04679 f '- rsLn �k Jon Ganseuberg _.f Has completed ' Laser Safely Awareness Febraagv 6,2011 Armand Bisson.Contractors Risk Management,Inc.ConCOnI NH 603.22;-33 33 vc,. r . �♦ �TT i GANSENBERG CONSTRUCTION ip 2 1 r Lincoln Rd. Salem Ma 01970 978-335-4742 #cs092108 PROPOSAL SUBMITTED TO: hic 159161 WORK PERFORMED AT NAME: Tom O'Shea Salem willows City of Salem DATE OF PLANS: ADDRESS: Fort Ave tba PHONE: 978-423-4689 INV#... COS-32715 We hereby propose to furnish the materials and labor necessary for the completion of: 1. Remove 2 comer post—repair concrete w/rebar-- replace post with bolt down foot and new upper elbows $ 1,800.00 2. Remove existing pine trim and replace with lx10 pine and waved trim boards paint same (prime plus 2 coats paint) $ 2,500.00 All materials are guaranteed to be as specified, and the above work to be preformed in accordance with the drawings or specifications for above work, and completed in a substantial workmanlike manner for the sum of ....$4,300.00 FOUR THOUSAND THREE HUNDRED Respectfully submitted: Note-this proposal may be withdrawn if not Accepted within 30 days ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment to be made specified Signature date The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibI Name (Business/Organization/Individual): Address: 2( L I /�J C ✓" �p City/State/Zip: Phone#: �( 7 3-3 Z Are you an employer?Check the appro riate box: n, Type of project(required): L�m a employer with _employees(full and/or part-time).* T ❑New construction 2&1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] ❑ 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. . 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.= airs VZS 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 1` 152,§1(4),and we have no employees.[No workers'comp.insurance required.] Any applicant that checks box#I must also fill out 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 forwarded to the Office of Investigations of the DIA for insurance coverag ificatiorl. I do he by rtify or der he pains a d enalties o perjury that the information proviideed bov is trupand correct. Si atu e: Date: 1 � t Phone#: Official use only. Do not write in this area,to be completed by city or town official. 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 written." 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 permit/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 permit not related to any business or commercial venture (i.e. a dog 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