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1 SEWALL ST - BPA-13-782 RENOVATE AMES HALL _ : '� , . , �� _ �.�/�� � (� $ �o .� ,{�' � The Commonwealth of Massachus s Qvi �� Deparhnent of Public Safety Massachusetts State BuIlding Code(7S0 CMR Building Permit Application for any Building other than a One or T amily Dwe 'ng � � � �� (This Secrion For Official Use Only) Building Permit Number. � Date Applied: Building Official� � SECTION 1:LOCATION(Please indicate Block#and.Lot#for locations for which a street address is not a ailable) J su,.aNsf So.l�.,., oi9�o —�/�,., �/l��'A No.and Street City/Town Zip Code Nazne of Building(it applicable) � � � � ' ���-SECTION 2:PROPOSED WORK � �� � Ediflon of MA State Code used_ If New Construction check here 0 or check all that apply in the two rows below Existing Building�( Repair� Alterarion [� Addition❑ Demolition 0 (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or consfrucHon documents being supplied as part of this permit application? Yes � No ❑ Is an Independent Shvctural Engineeiing Peer Review required?. Yes ❑ No Q( Brief DescripNon of Proposed Work: T <j L .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 Evalua6on is enclosed(See 7S0 CMR 34) jY Existing Use Group(s): Q 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.h.)and Total Height(k.) � �� SECTION 5:USE GROUP(Check as applicable) � � � A: Assembly A-1 m A-2❑� Nightclub ❑ A-3 A-4❑ A-5❑ B: Business ❑ E: F.ducational ❑ F: Facto F1❑ F2❑ .H: Hi hHazard H-1❑ H-2❑ H-3 ❑ H-4❑� H-5 0 � I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: MercanHle❑ R: Residenlial R-1❑ R-2❑ R3❑ R-4❑ S: Storage Sl❑ S-2❑ U: Utility❑ Special Use 0 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�(refec to 780 CMR ll1.0 for details on each item) � Trench Permih. Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: � A trench will not be Licensed Disposal Site❑ . Public❑ Check if outside Flood Zone❑ Indicate municipal❑ - Private❑ or indentify Zone: or on site system❑ required�or trench or specify: permit is enclosed❑ Railroad right-of-way: Huazds to Air Navigation: D4A I-Iismrfc Comnussion P.eview Pr«ess: Not AppGcable❑ Is Stmcture within airport approach area? Is their review completed? or Consent to Build endosed❑ Yes O or No❑ Yes❑ No ❑ . . SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Editlon of Code: Use Group(s): Type of Construction: Occupant Load per Floor: I Does the building contain an Sprinkler System?: Special SHpularions: L - - SECTION 9: PROPERTY OWNER AUTHORIZATION - Name and Address of Property Owner Name (Print) No. and Street City/Town Zip Property Owner Contact Information: ��/'-]�Q� I �, I 1 1 �ceiev� SI'eq 4 •n'�' m-361 -_- SIIQ..teF np0 arA."VMfll. Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes W1 lyy .L bit{ II L lel" -6;,f 4 &,ffj R ealt � d &;? Jaame Street Address City/Town State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building permit application. - SECTION 10: CONSTRUCTION CONTROL (Please fill out Appendix 2) -- :- If bu (ling is less than 35,000 cu. k. of enclosed space and/or not under Construction Control then check here band skip Section 10.1 .10.1 Registered Professional Responsible for Construction Control �a e- — 2 -7111 -7?79 Toa Namegt�St Telephone N0. a -mail alidress Registration Number 2D 9 Street Address City/Town State Zip Discipline Expiration Date 10.2 GeneralContractor 1 Company Name Name of Person'Responsible fdr Construction License No. and Type if Applicable 1 —I Address City/Town State Zip �Sttrrteet /1 /Til 1 -q -Z zzg l �- -�AL 1.91 Telephone No.(business) Telephone No. cella-mail address SECTION 11: W0IZKE?25' COMPENSA110N 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) = $ Building Permit Fee = Total Construction Cost x (Insert here appropriate municipal factor) _ $ Minimum fee = $ (contact municipality) Enclose check payable to 1. Building $ 2. Electrical $ Q1 r 3. Plumbing $ 4. Mechanical (HVAC) $ e—Note: 5. Mechanical Other $ 6. Total Cost $/� L' ,!j (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. 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 Apr.23.2013 16:33 ,k WJJ Planning & Constructi 7819420039 PAGE. 3/ 3 ?z 4S 14 C[TY OE SM -EN[, ,.1�L its&kcHI:SE S BCILDINe DEP,ka-r-, NT 120 %V.%SH44rTON STREET, 30 FLOOR n^ TEL (978)145-9594 Fxx (978) 740-9844 IMBERL.EY DR3SCOU M.1Y01L THostASST.P�RRs DIRECTOROF PUBLIC PROPERTY/el•ILMO CMNISSIO NER Workers' Cainpensation (nsur:xnceAtiTdrvtt: l3ulWers/ConlractorliElectricians/ lumbers A r illeant Informs in (as 1 c ihl Vi1i110lDwineve,l)ry7nia4ddrvinJividuul): Addros: City/Stale/Zip: Phone#: -7 2 27 �%r,,a,yV an employer'? Check therppropdats boxl of of (re I, k.J't am a employer with � 4. © 1 am a general contractor and tE13.030thcr_ uireJ); cont w antploycvs (Nil and/or part -rime).• have hired the aubconuacmryNew comtruc 'an 2.D 1 nm a rola proprietor or Panner- listed on the auachod sheaR Itmadelling All; and have no employeae These sub,commucton have V.molition working fur mu la uny vapacity. workers' comp, Inmrmncm (No workers' comp, insurance S. Q Wd are a corporarlon std its ilding Wil n required.( Olean have axorclsad their ctricst cepa s of additions 7.0 l am a homeowner doing all work right of axemptlun per MOL mbing cup or udditions myself. (No workers' comp, c. 152, 01(4), and we have no oPmpalts insurance required,) t employees. (No Workers. toe comp. insurance roaired.) 'Ant 4tlpkgrs Out v6wke bat t I mwr qlw nil oUl the vrudw bvloW rhawfne thtk rahcn• compsemdas ponry innrgnglloA 'IGtlnuuwnun who mh..it this rtrldgvit lndlemlne lhsy no doing ale "It And then hhv Vutlide aanlnrnor i WIN MAtmll s oar Ind am,140 �(SimroaWnlAVl rhuxk ih6 aua mrrtquochud nq ndladurrl xhwl rhuwlnelM nava uhhq nleWeelntg7rg anJ ihs4 wVfhera'enmp, pVllryi =dWg rwiL /almanoq, f um on employer thaNr provld/nX workerr' rompnuedosr lnraranee jar my empluye'at Below /s the pa//ry u d fob siteirrformadolR In,NurJlile Cumpuny Name: Mluaz rG PUhoy N Ur SCI1.11V. LIC, fI: WG �1 �7?[S— � ?QS�—O/Z _ E,gpirntion Data: " lob S1ie AJJtcss: cb-fr_wr V/W& ,.�CilylSlatr/Zipr % .Utach At vnpy of the ivertmn' companratloo policy declaration pugs (ahowing ihspollay number and Oxilli's lion date), Failure to w4uru covonge as required undur.Suction 23A of 1r1GL o.152 can lead to the imposition of criminal p allies of fine up to 51,J00.00 ander one-year impriaanment, as wall as civil punaihus in the tbrm u(o STOP WORK ORO iiii and aline of up to 5250.(10 a Jay �sainer the viulamr. Ila advlsed that u copy of thissra(ement may Ile Nrwurdcd to the OI)T a of InvcsrigalLma ul'lita DIA for insaraoca covcrngo vorlilratiun !Ito /rvrrby rtrr/ft' rnrJtr rhe pohrr and penahlts gjpar/ury cher rhe 6rfunnur/ar provided o6ova is true mtd rwrr ICL i' t ,d• rlQit•ial use sols, 04notluriloin Ndr r/rrµ rode ruurplrled by tilt' uNowh rrl/Jr/ud I City or'I'utnt: �_.- .._. FVrmItR•Iconne,y h1uing.lmhurily(circlo uac): �---'�-- _ I. I(uuN of Ilruph Z. Iluirding Ilc):trlotem I. Oily/fawn Clerk 1. Glrcirlca! Llyleefur $. PluwbMK Innp 6, Ddter -_... - cror Cnntuct Pcrurno I'Anne;F: -Apr.23.2013 16:32 WJJ Planning & Constructi 7819420039 i WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 10k AR INFORMATION PAGE Issued by LN INSURANCE CORPORATION Policy Number NCS -318-383055-012 RENEWAL OF- NC2-31S-383055-011 Account Number 1-383055 1. Insured and Mailing Address WD PLANNING 1$ CONSTRUCTION LLC 64 HAVERHILL STREET READING, MA 01867 27243 Issuing Office 181 Issue Date 12-13-12 Sub Account 0000 FEIN RISK ID Status 46 - LIMITED LIABILITY CO Other workplaces not shown above: SEE ITEM 4. PREMIUM - EXTENSION OF 2. Policy Period: The policy period is from 11-25-2012 to 11-25-2013 12;01 A.M. Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Com listed here: NA B. Employers Liability Insurance; Part Two of the policy applies to work in each state listed in of our liability under Part Two are: Bodily Injury by Accident $ 11000,000 each accident Bodily Injury by Disease $ 1, 000, 000 policy IGnit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here; SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFOI 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Clasa Rating Pians. All information required below fa subject to verification and change by audit. Code Premium Basis Total Rate per $100 . . _ .. _ PAGE Group Mub bbl CM17 590 time at the 2/ 3 Law of the elates 3.A, The limits 4 PAGE Rates and Annual Minimum Premium $ (NA) Total Estimated Annual Premiu $ Premium will be billed ANNUAL Producer 0004-017109 TRR MCALAUMIN AGENCY 828 LYNN FELLS PARKWAY NELROSE MA 02176 Sales Representative 3D00 Sales Office Name WESTON CD 1987 National Council on Compensation Insurance,lnc. WC 00 01 A All Rights Reserved Ed, 07/ 1 /2011 Iwo Copy 19OLDSTEIN-MILANO Icc Structural Engineers 125 Main Street Reading, MA 01867 781-670-9990 (p) 781-670-9939 (f) CONSTRUCTION CONTROL AFFIDAVIT Project Number: 13050.00 Project Title: Salem YMCA Project Location: 290-292 Essex Street, Salem, MA Name of Building Scope of Project: NIA Ames Hall Renovation Brent R. Goldstein P.E. Christopher P. Milano P.E. Date: April 3, 2013 IN ACCORDANCE WITH SECTION 107.6.2.1 OF THE MASSACHUSETTS STATE BUIDING CODE, I CHRISTOPHER P. MILANO, MASS. REGISTRATION NO. 33917 BEING A REGISTERED STRUCTURAL ENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND SPECIFICATIONS CONCERNING: Entire Project Architectural Structural XXX 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 1 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 107.6.2.2. 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 engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineeri tice standards listed in Appendix I. PURSUANT TO SECTION 107.6.2.2, 1 SHALL SUBMIT PENOF MQ a OGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPj.EC t� MPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFA OR G Lf 1I1{I L N AND READINESS OF THE PROJECT FOR OCCUPANCY. SUBSCRIBED AND SWORN TO BEFORE ME THIS 3 DAY OF An- L 2013 Z"/ UA My commission Expires: zrO13 N tary Public i ICI\BERIEY DRISCOLL MAYOR Project Title: CITY OF SALEA , NLkSSACHUSETTS BUILDING DEPARTMENT 130 WASHLNGTON STREET, 3w F'LooR TEL (978) 745-9595 FAX (978) 740-9846 THomAs ST.PIF.RRE DIRECTOR OF PUBLIC PROPERTY/BVILD114G CONWISSIONER CONSTRUCTION CONTROL DOCUMENT Salem YMCA - Performance Hall Project Location: 1 Sewall Street, Salem, MA Date: 03 April 2013 Scope of project: Restore and repair finishes from the Essex Street entrance, up through the marble hall and into the theater. The backstage space will be increased and balcony may be added. An accessible path will be designated to the theater level and stage level by elevator and ramp and all required life safety components will be added as needed. In accordance with SECTION 116.0-116.4.2 of the 6th edition of the Massachusetts State Building Code i, Mark Meche 1J- — Mass. Registration Number #7083 being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: (] Entire Project p(] Architectural [) Structural [ ] Mechanical [ ] Fire Protection [ ] Electrical (] 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. Furthermore, I understand and ACREE 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 by the building permit and shall be responsible for the following as specified in section 116.2.2: Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for the building permit, and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code -required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a mariner consistent with the construction documents. I shall submit periodically, in a form acceptable to the building official, a comments. Upon completion of the work, I shall submit to the building satisfactory completion and readiness of the project for occupancy. Signature and Seal of registered professional: th pertinent KI.NMERI EY DRISCOLL AUY01 CITY OF S.1LZM, WSACHUSETTS Gt:=LNG DEPAR'I1IE,�iT 110 7ASHLYGTON STREET, 3" Roca TEL (978) 745-9595 F -LX (978) 7-W-9345 DIO.%W ST. PIERRE DIRECTOR OF Pt:BLIC PROPERTY/BL'ILDLYG COSL%IISsIO,NER Construction Debris Disposal Affidavit (required for all demolition and renovation work) !n accordance with the sixth edition of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of tb1GL c 40, S 54; Building Permit Ik 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 t.VfGL c I 11, S 150A. The debris will be transported by: (name of iauler) I'lae debris will be disposed of in : (nano of facilit (Address of facility) siguatu e o permit a Iicant