Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
1 SEWALL ST - BPA-13-239 NEW ENTRY
Oq The commonwealth of Iimassac se Department of Public Saf- . ' • �' \la++drhu+cllz StJh' IhIilJin);Cut (,"Viii.\IK) Building Permit Application for any Building"tile han a One-or ' VO-F, fly Dwell' t (Ihi.s Section For Offici,J Use C IlV) Iluilding Permit Number __._. -_. _.-.. Dah'hpphed: ____ luflding C)ffi.. . SLCnON 1: LOCAI ION(I lease unlicate(Bock M and Lot N fur locatit s h le street address is nu available) Xftld - �/ fake_--�+t �L9�n— _S✓ Yv.�(� _ \u..md Street CRY Lotto Zip Cute N.tnte of Buildm)((itapplirablc) SECHON 2: PROPOSED WORK Wiliun of .MA Stak.Cade used -_ If New Cun.slruc tion check here❑or check all than apl+ly in the Itvu nnt's bvluw _- F\islin); Iluilding❑ Repair❑ AIWr,itiun ❑ \JJilion ❑ Ucnwlilioo ❑ (Plodse till out and submit.\ppenJ i.r l) Chan);e of Ulu ❑ Change'(Occu)...ltcy ❑ Other ❑ Specify: Are building plans and/or cunslrut fill tit hwnenls befngsit pplled as part of this permit to Yes ❑ No (g7 Nall 111,1gvildent Structural Engineering Peer Review rcyuired? Yes ❑ Nu AP Brief Descriptii/o��n of Proposed CAIN SECTION 3:COMPLETE FIIIS SL'CI-ION IF EXISTING BUILDING UNUERCOING RENOVATION,AUDITION,OR CHANGE IN USE OR OCCUPANCY - Check here if an Existing Building Investigation and Evaluation is enclosed(See 7111)CMR.1.I) p C-\ivling Use Group(s): ------- — Proposed Use SECTION J: BUILDING MIGHT AND AREA Existing Proposed No.of Flours/Stories(indude basement levels)4 Area Per Fluor(sq. ft.) Pohl Area(sq. ft.)and rutal Height(ft.) SECI-ION is USE CROUP(Check as a licable) A: Assembly;\-1 ❑ A-30 .Nightclub ❑ :\,l ❑ A-I ❑ A-i❑ B: Business ❑ E: Educational ❑ F: Facto F-I ❑ 17 011: Ili h Ilu,trJ 11-1 ❑ H-2❑ H-t ❑ 11-4❑ Ii-S❑ I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ ;\I: Mercantile❑ li: ItesiJentiJl R_-I❑ It-+_❑ It-3❑ R-S C3ti: Storage S-I ❑ 5-'_❑ U: Utility❑ SpeciJI Use❑and please describe below: Sprcial Use SECTION 6:CONS I'RUCrION INVE (Check Js a Ifcabie) I:\ ❑ IB ❑ lit IIB ❑ III:\ ❑ 11113 13 IV C3 VA (3 \'11 ❑ -_- _ SECTION 7:SINE INPOI(,%U\ZION(refer to 780—I I LU for tlCfali9 on 61Ch Irerlr) Water Su pply: Floud Lone Information: tiewage UispusJl: Frclwh Permit I)l'hris I(euuwJl: I'ul+lir❑ Chv�k d au blJv PIuuJ Lunn C, InJit ale nnmicip,ll ❑ .\ Ire it,It will nol be I icvnsrd [)i+),t,+,ti site C]I'm.i -❑ ar iudcliltk Luneenm +1te st grllt ❑ napim-d ❑or trench or tprr It% prnnit i+rnJesrJ ❑ I1,liInlaJ ri ght-ut-was I l.vards to .\ir..N,1% gatiun: \'ot .\)'),ht.Ibh'❑ I 1,`Inn Lure o 1111111.nrp„rt oppn'.1t h .area' Is Ihrir rreu t.,rnul drhvl' t , r(„n.rul to lluddr I,Io+rJ ❑ I It+❑ nr \•,,❑ l,+❑ V. ❑ IION 9: CONII.NI'OFCUP.\NCY 1 ,11nrn , l 1,vlc l.r ) I+1 Itl•r„I l•v•In1t 11, n tL,ul,.urt 1 , .ltl prrll, , r It„r. lh,• budJw)�„'ntdln.m�pnnCL•r tit.grin' �inv 1.11'�hpul.l"„n+ r ___-- SP:( Ill)N 'I: I'ROI'r It TY 111VNIfR :\Uflil)IiIY,NTIU, uoe and 1d In ss of I'ngn rly the tier /'-v"-"".--(tt�![_._ lip N 1111¢ (Print) Nn unl Street . I'roperty Uwnrr LimLl,l lulonnatirnl: .____ .____ ✓ I ide - - lclophone No (business) Rdcphone No. (cull) II applicable, the property owner haredty aulhurin's _.---- ------ -------Stroet Address --- -City/lawn---- slate Zip Name to a,t,+n the pro peri ownrr's behalf, mall matters relative to work authorized by This buil)in g +omit a +plication. 5ECr1ON Ill:CONS','RUCTION CON"1'ItUL(Please fill out Appendix 2) If building is Ievs than 35,001 cu.ft.of endosc,I s pace and or not under Construction Control then check here O and skit,Section Ill.! t B.1 Registered Professional Res unsible for Construction Control I'olc hone Na, entail address Registration Number Name(Registrant) P titrrct Address City/lawn Stale Zip Discipline Expiration Date 111.2 G�/nnV f ICerraal Contractor (_9 f ` S 1�Company Namebi A)-154- I �3©loko Nance of Person R1�esponsible lar Construction License No. and Type if Applicabhe �p� n�- Stre�e/qt Address q / city/Town State Zip rot-phone No.1111,siness Telephone No (cell e•otail address SECTIONIL•te, �rf.rl:: , t'Nil•rv.etµ 1\St ..vtlt,,;\'II M.G.C.e. 152. 25C6 .> lVurkars Compensation Insurance rliffidavit from the\IA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will«salt in the denial of the Lssuance of the building permit. Iso signed Affidavit submitted with this o p lication? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERh111 FEE Estimated Costs: (Labor Item and ::Materials) !oral construction Cost(!rum Itrm(7) 'S-_— I. Building 5 Building Permit Fee'Total Construction Cost x—(hoot here 2. Electrical 5 appropriate municipal factor) 'S 1. 111111 )int; b Contact nwnici +ality Note ..\lininnnu (ce 'S--( 1 ) I. \lMwItical (I IvAC) 5 .. 1?nclose aheA enable to I i. McChanlCal l)ther I,.' n. I'olol Cost 5 .tlu .cz (contact nnutiC ipality)and %,rite,In-A number hrre SECT , i\PURE OF BUILDING PEICNIrr APPLIC'AN'r 14v cowring nw nam,brlow, I hcrt•bv ,utcet uneler dee pains and pvnaltics of perjury that:ill of the information„mt,uncd in this .,pl,lii/nuiuu is true and de,n AC to the 1•as1 of my km n.Ire!ge and tinders and/illy,. q �i rte.. - -- - 7--qo 96Z _ gl31161Z I'Irasc pnnt .uul at',It,11111110nlelrlrphooc %o (tato SozIcr_ 144/Y Di17v •Inr1 \,Ll rts Cil\', I'�n.n �tatr /,p I - \lunicipal Inspector to fill out this section upon application approval: - . \'.inti' To:+1-9787409846 Page 1 of 2 2012-09-04 16:05:17(GMT) Lauranzano Insurance Agency From:Larry Lauranzano r � ACORD CERTIFICATE OF LIABILITY INSURANCE OATS09/004/20124/2012 PRODUCER (978) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Lauranzano Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4 Y 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.Western Heritage O'Neil's Handyman Service INSURER B Liberty Mutual Group 98 Keslar Avenue INSURER C. INSURER D'. Lynn MA 01905- 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 AODT POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICYNUMBER DATE (MMIDONY) DATE(MMIDDIW) LIMITS A GENERAL LIABILITY SCP0907392 06/14/2012 06/14/2013 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISEB Ea ocuu*ante $ 100,000 OLAIMSMADE F—IOCCUR / / / / MEDEXP(AnVonsperson) $ 1,000 PERSONAL&ADV INJURY 1: 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS-COMPIOP AGO $ 1,000,000 POLICY jE° Loc AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANYAUTO EaaCCldenl) ALL OWNED AUTOS / / / / BODILY INJURY SCHEDULED A1FOS (Per person) $ HIRED AUTOS / / / / BODILY INJURY NON OWNED AUTOS (Per uodent) $ PROPERTY DAMAGE (Peraccidenp $ GARAGGARAGE LIABILITY AUTO ONLYEA ACCIDENT $ ANYAUTO / / / / OTHER THAN EA ACC E AUTO ONLY AGO $ EXCESSIUMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMSMADE AGGREGATE $ $ DEDUCTIBLE / / / / $ RETENTION $ $ B WORKERS COMPENSATION AND WC2-31S-372123-021 10/12/2011 10/12/2012 $ WCSTATU- OTH- EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICERIMEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE$ 100,000 V yes,describe under SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Salem YMCA CERTIFICATE HOLDER CANCELLATION ( ) - (978) 740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City of Salem; Building Inspector FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE ATTN: Tom Pierre INSURER,ITS AGENTS OR REPRESENTATIVES. 120 Washington Street AUTHORIZED REPRESENTATIVE Salem MA 01970- ACORD 25(2001/08) ,1)ACORD CORPORATION 1988 �,_,-IN 5025(0108)05 ELECTRONIC LASER FORMS.INC.-(800)327-0545 Page T cf 2 F CITY OF SALEM, XL L-3sSACHUSETI'S BUILDING DEPARTMENT A• 130 WASHINGTON STREET, 3w FLOOR TEL. (978) 745-9595 F.tx(978) 740-9846 KINtgFRT RY DRSSCOLL MAYOR THOMAS ST.PIERAR DIRECTOR OF PUBLIC PROPERTY/BCILDNG CO%WISSIONER 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 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 G (name of facility) ,I W (address of facility) - 0 L sign re ermit applicant ��3�LdlL date tai>d,�sa,x i CITY OF S:uzm, lr'L1SSACHUSETTS BUILDING DEP M.LENT d 130 WASHINGTON STREET,3"a FLOOR TFL (978)745-9595 FAX(978) 740-9846 KINtgFRT FY DRISCOLL MAYOR THomAS ST.PiERRB DIRECCOR OF PUBLIC PROPERTY/BUILDIING CONMUSSIONER Workers' Compensation insurance Aff[davit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Leeibiv t Na111ctousiiiu+sorgannizati°tvindividuai): 011le—II5 A2,1j4l,1AQA P"VIU0 Address: q'6 twal- ✓-4-C City/Stateizip:LTt MO Olgot' Phone #: (9-10612— 07-U Are you an employer?Cheek the appropriate boat I Type of project(required): I1�f 1 am a employer with t 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).• have hired the subcontractors - ?• (Remodeling 2.El am a sole proprietor or partner. listed on the attached sheet: ship and have no employees These subcontractors have S. ❑Demolition working for me in any capacity. workers'comp. insurance. 9• ❑ Building addition (No workers comp.insurance S. ❑ We are a corporation and is officers have exercised their to.[] Electrical repairs or additions required.) 3.❑ I am a homeowner doing all work right of exemption per MGL I If]Plumbing repairs or additions myself. [No workers'comp. c. 152,$1(4),and we have no 12.0 Roof repairs insurance required.)t employees.INTO workers' comp.insurance required.) 13.❑'Other •any apphcum that chwka boa#I moat al:w nil out the section blow skewing Choir workers'<ompenwinfor ivn policy matloa I Lvneuwnon who submit this affidavit indicating they aro doing all work and then hire wtaidecommctors most submit a taw amdavil indicating such. :Cuntmtars that chick this box mtnt attachod an additional AMC showing the nome or rho sut+eontrutors and their workers'comp.policy infemunon. lam an emplayer that hrproviding Ivorkers'compearsadon insurance foamy employees. Below is the policy and Job site Jnjonnatfoa Insurance Company?lame: Policy d or Self--ins.Lic.h: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 23A ofMGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S'_90AO a day against the violator. Ile advised that a copy of this statement may be forwarded to the Off ice of Investigutiots of die DIA fur insurance covcrago veriScalion. Ida hereby certify adder the uhrs set penalties of perjury that the hifornrutlo«provided above is true and c'orrec4 Si,!n.tlufe� � Data' �3�2�IT. Phonc 3: Qj]iriul use only. Do not write in this area;to be completed by city or Iowa a/Jlciad I City or'fown: ____ Permit(Hccnse# Issuing Authorily(circle one): 1. Board of health 2. Building Department 3.Citylfown Clerk 4. Electrical inspector 5. Plumbing Inspector 6.Other Contact Person: _. Phone ti: