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103 SCHOOL ST - BUILDING INSPECTION t. "Number: The Commonwealth of Massachusetts Department of Public Safety \I,ts.achuselt.State Building Code(780 C\IR)Sr\enth Edition City of SalemPermit A lication for an Buildin other than a 1- or 2-Famil Dwellin (ThisSection Fur Official Use Only)Date Applied: Building Inspector: - SECTION 1:LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available) ©3 ScNc,<J tr ��}6ew\ �jQ�fn��elgldb�a t 7YlylizKFl No.and Street City /To\\m Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK f New Co uctiun check here❑or check all that apply in the two rows below Existing Building Repair Alteration ❑ Addition❑ Demolition O (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 Engineering Peer Review required? �,t Yes ❑ No Brief Description of Proposed Work:_174,j(j A 2 p P S Oe-ern i e j XX � d� 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): p 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 ❑ A4❑ A-5❑ B: Business E: Educational ❑ F: Facto F-1 ❑ F2❑ "ii H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1 1-2 ❑ 1-3❑ I-4❑ M: Mercantile❑ NO ential R-1❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 S-2❑ U: Utility❑ Sse❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Capplicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IV ❑ VA VB ❑ SECTION 7:SITE INFORMATION (refer to 780 CMRr details on each item)Water Supply Flood Zone Information; Sewage Disposal: ench Permit: Debris Removal:nch will be Licensed Di+„isal Site Public Check if outside Ploud Zone Indicate municipal �� �'''� iFPrioate ❑ or indcntif\ Zone: ur on site system ❑ red �r trench or specavlZ&f C 2.it is enclosed ❑Railroad right-of-way: Hoards to Air Navigation: \L\ I li�loric C,nn mi+sinn Itrcir�� Prnrvs;:\ppliiab e I+Structure tc ilhin airport appio h aIs their re%ie\v comple le ..,rc( o +cnl ✓ Ycs❑ or No[ Ye. ❑ No L9' SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Ldition of Code: Use Group('): Tcpe of Construction: Ocaipant Load per Fluor: DOn's the building contain an Sprinkler S\'stem?: Special Stipulations: 4+ 7YO� SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Properly Owner Name(Print) Nu.and Street City/Town Zip Property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the properly owner hereby authorizes Name Street Address City/Town Slate Zip to act on the pro pert.owner's behalf, in all matters relative to work authorized by this bu ildin g permit a >>l Ica do . SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (It building is less than 35,LVO iu.ft.of enclosed s wce and/or not under Constmition Control then check here and ski-Section 10.1) 10.1 Registered Professional Res onsible 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 ' iyName: /� S � �r� (�..�5 l il• s�� Name of Person Respu�sible fur Construction ,/ �tcerise No. and Type tf Ap Iicable q Street Add r City/Town State Zip Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506)) 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 is nee of the building permit. Is a signed Affidavit submitted with this application? Yes YY No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate mu cipal factor)_$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note: Minimum fee6 vy (contact municipality) 5. Mechanical (Other) $ Enclose, check p..Y a able to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I herebv 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 zign name Title Telephone No. Date titreet Address Citt'/Town . to Zip Municipal Inspector to fill out this section upon application approval: lime Date a 2 � CITY OF S.IIXNf. NLASSACHUSETTS BL'aDNG DEP.IRT1ENT 120 WASHNGTON STREET. )ter FtGoR TEL (978) 745-9595 v� FAX(97� 7iQ9846 ICI\IBE PY DRISCOIl. 6L°' MAYOR TW&W STYMpla DIRECTOR OP PL BLIC PROPERTY/BCO:DNG CO\0,05510NER Workers' Compensation Insurance AlRdavit: Uuilders/Contractor/Electr(elans/Plumbers Anollcant Information _ / Please Print LrIM Va111C lBusinru.OrQamtarionrlrobvldual): },�gvrlSO wl (,Av (7 � IZa•4 Address: II- A C vrLTtS S-1' City/StatdZip: MArle44r-,u1 mr Phone* 2WgS-l1'-601'e Are you to empkyes'Cheek the appropriate bye: �' T ypeprotest(requlre�: 1.0 1 am a employer with 0 4. I am a general contractor and 1 employees(full and/or pan-time).• have hired the subcontractor caeawcuas _ 2.0 1 am a sole proprietor or partner• listed on the attached sheet : mmlelins .hip and have no employees These sub-contractors have VBZ�ns ' 'on working for me in any capacity. worker'comp.instant x addition (No worker'tomµ insurance S. ❑ We are a corporation andid l or requirad.l 001CM have eaaeised they repairs addition 1.❑ 1 am a horreawmsr loins all work right of esamption per MGL anbins repair or additioromyself.(Nowohers'Comp. c. 132,01(4),and we have no ofrepairs insurance required.)► cmployees.(No worker'cornµ insurance required.) er •Any apputaar is Awclu bolt as owes alwr na w11M reetia•tabs atwiy lacer warhw'cantpwt.d.ta policy Inanreanota 'l l.vrweavou who sabwil ads atttdevis indication dwy an Joins all work aid thm hire tuaido CMAMwe Meet suMnk a new aM h,;r ildecriy r,L :C'"M-yete that'link this tan Inca semis ere*Mlk twt area Jmvina an twee of Ills A41-Co/neon and their wethere•cpq•Petry ierarmwdoe. /on am employer that/r providlnir worker'coarpenradse braanrnra far ary rarplayers. SNaw d Iba pNtry awdJ4 sip information. pp Insurance Company Name:_ . ttnl2w� 'ItJ$a err fz l "J O Policy *or Self-ins Lppie. N:_lc) qW (91*q Expiration Oats d i 20 ) 0 tub Sire Address: LI 3 S U4601 !C�r City/Sutd2ip Yh,ae p t r n9 ,%track a copy of the worker'compeasalbs Polley declarallos pap(ahowlns Ike policy number and espirsdos daft). Failure to secure coverage as required under Seceion 23A of MGL c. I52 can lead to the imposition of criminal penalties ofa fine up to 111.500.00 and/or one-year imprisonment,as wall as civil penalties is the form of a STOP WORK ORDER and a floe of up to S250.00 a day against the violator. Ile advissxl that a copy of this statement maybe rowarded to the Ofllce of Invnogatietu ollhe OIA for insurance coverage rcriticatiott /do her y ua r the paiAs and yenolr/ia of perfury that rho inforntatlon provided above is true end carrreg - ? Dote: �Zt�/ O Ph F1/--k I— _o tlnC�: S- ot� I [6011J) y or fawn: PermitMicenreuingAushurily icircle one):tuard of Ilvulth 2. Audding Department !. Cityfrown Cloth !. Electrial Inspector S. Plumbing Inspector hrr nUct Person: _ ._ Phase M• ACORD. CERTIFICATE OF LIABILITY INSURANCE nwre tM WDOrcrrY) Ol/25/2010 DDUGER (978) 745^6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Ose Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 6 Loring Avenue ALTER THE COVERAGE AFFORDED By THE POLICIES BELOW. .O. Box 958 slam MA 01970- INSURERS AFFORDING COVERAGE NAB# SURW INSURERAGUARD INSURIMCE GROUP arrison Construction Group INSURER kP,Merchants Washington .Square INSURER C. INSURER 0'; larblehead mA 01945- NSURERE: OVERAGES iNE POLICIES OF IN LISTED BELOW HAVE BEEN ISSUED 7O THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED NOE MAY BE TUWTWSMA TANDINRA N G ANY THEM SEVRANCE TER AFFOR EDNBY ITHE POLICIES DESCRIBE OTHER RON IS SUBJECT TO ALL RESPECT THE TERMSVVMjC,EXCLUSI THIS RNS ANTD CONDTIONSEOFNSUCHV OUC ES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCE BY PAID CLAIMS. pOuCY EFFECTIVE POLICY EXPIRATION ISO ADD'L POLICY NUMBER DATE(MMIDOIYYI GATE(MMIOOIYYI UNITS TR NSR TYPE OF INSURANCE 1r000,000 7dOP9090O87 09/01/2009 09/01/2010 EACH OCCURRENCE g GENEFWL LUWLLTTY pAMAGC--TO RCN�IED 50,000 pRFA0BE Ea accernncc 6 5,000 COMMCRCIAL GENERAL LIABILITY / / MED EXP An anb Person) G CLAMSMADE OCCUR 1,000,000 PERSONALAAOV INJURY L GENERAL AGGREGATE 0 2,000,000 PRODUCTS-COMPIOP AGG c 2,000,000 GEN'L AGGREGATE LIMIT APPLIES FBI'. POLICY TCT LOC / / / / COMBINED SINGLE UMIT AUTOMOBILE LIABILITY (Ea P Iwnt) G ANY AUTO / / / / BODILYINJURV 0 ALL OWNED AUTOS (Per Pateon) SCHEDULED AUTOS / / / / BOCILY INJURY 0 HIRE AUTOS IPir eceMnnt) NOWOWNEO AUTOS / / / / ppOpERTY DAMAGE 0 (Per PFalPaal) AUTO ONLY-EA ACCIOEN'r G GARAGE LIABILITY / / / / OTHER THAN EAACC >• ANYAUTO AUTO ONLY: AGO 6 EACH OCCURRENCE EXCE061UMBRELL4 LIABILITY AGGREGATE 6 OCCUR 17CLAIMS MADE 0 DEDUCTIBLE p 4 RETENTION 6 08/31/2009 08/31/2010 S TOY LIMTi6 ER j� WORKBRSCOMPBNEAnON AND PAWCO16729 100,000 EMPLOYERS'WASHJTY E.L.EACH ACCIDENT 6 / / 100,000 ANY pROPH1ETOR/PAl(TNEWEXL-CUTIVE / / ELOISCASE-EA EMPLOYE 0 SOO,000 OFFICEN(MEMOER EXCLUDED? EL DISC-ASC-PDllC LXmIT 2 It 0e8 domf m M101 9PkCWl PROVI9KJH4 YgVUN OTHER PECIAL PktlNB10NS pESCRIPTION OF OPERATIONSILOCATION5NEH CLESIEX0LU4ION6 NDOEP BY EN00RBEMENTiS CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESGRIBCD POLICIES BE CANCELLED BEFORE THE ( SUPER WILL ENDEAVOR TO Mill EAPINATION PATE THEREOF, THE ISSWNG W 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 60 SHALL IMPOSE NO ONLIGATIDN OR LIABILITY OF ANY KIND UPON THE City Of Salem TATNE6. IN9URER,ITSAGENTB OR REpRESEM A TH RESENTAYNE a e%wry C - ®ACORD ORD CORPORATION 1988 peBe 1 W= ACORD 26(2001/09) ...— CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT o,,gpJ rNUT 0 SA P\t,'IAi"t III frt:978-Ni-Y.+95 •Pau:978J40-9846 Construction Debris Disposal Affldavit (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 c 40, 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 disposal facility as defined by MGL c 111. S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in -- (name of face 1ty) (address of acility) signatu6T permit applicant date