Loading...
1 SEWALL ST - BPA-16-594 CONVERT POOL TO EXER ROOM The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) �— Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) 1 n Building Permit Number: Date Applied: Building Official: U J SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) _ No.and Street City/Town Zip Code Name of Building applicable) 1 SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Buildin I Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes'11 No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No 4 Brief Description of Proposed Work: 1 ct�ce r r C 6 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 enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Sas SF Total Area(sq.ft.)and Total Height(ft.) oI b ID SGS s SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: High Hazard H4 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑ I: Institutional I-1 ❑ I-2❑ I-3❑ I4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION b:CONSTRUCTION TYPE Check as applicable IA Ill IIA E3 1113 IIIA ❑ IITB ❑ 1 TV ❑ 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: Pubhc❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private 13 or indentify Zone: or on site system❑ re ❑ trench or specify: perrmmitit is enclosed❑ Railroad right-of-Way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed E3 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: -61 cxjs - 9Z8' � 5? R -02-L SECTION 9: PROPERTY OWNER AUTHORIZATION'; lNJa��,m, e and Address o1f1 Property Owner � 1M A 'g �a,ih!^'�i`�- ." Quo_ In I .4 4 Q1q:70 Name(Print) No.and Street City/Town Zip Proper Ow o tact Iltfonna�rion:9 9 o p9� 1 G aardu r 'Y CVr TP Mb-- 1 'I- Title [, Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes L,JJJ Ple" g G 4,4 4"�o J — !©Lfl�r1 Name WI( �ruor��q�S Street Address Gty/Tov State Zip to act on the propertyowner's beha®t,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) building is Iess than 35,000 cu.It.of enclosed spam and/or not under Construction Control then check lure 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control eme(R� ekyhon N —e-mail address Revistration Number Street Address Ci State Zip Discipline Expiration Date 10.2 General Contractor l l�d-x— ar,hKiLe Com/pang Name - -7 Il1'1h—)p'b�!'h � S CS -D! z2 (0 " ZS _� ! Name of Person Responsible f4 Construction License No. and Type if Applicable (.I .,ra -11 _(�= 0 PP&7 Street Address City/Town ':State Zip B r oaf to '+_ Telephone No. Telephone No. celle-mail address SECTlONI1:W0RKERS'ML,IPENSATI0N INSURANCE AFFIDAVTT .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,17 No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 3 d 7 f9 Cr?7 1.Building $ 2_( Q0,,500 Building Permit Fee-Total Construction Cost x—(Insert here 2.Electrical $ Jar'Lon appropriate municipal factor)_$ 3.Plumbing � 4.Mechanical Mechanical (HVAC) $ con Note:Minimum fee=$ (contact municipality) , 5.Mechanical Other $ 85®O Enclose check payable to 6.Total Cost I $ :9 000 (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.t Please grin and sign Title Telephone No. Date —rte c MIL of 9,Gr7 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approvaL - Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block# and Lot # for locations for which a street address is not available) Ale_�� � S YMCA No. and Street City /Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No q Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No Ep Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ® Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) IDo TK( S Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing(include local connections) 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 ExistingBuilding Survey/Investiation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR) 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plan are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address Ci Town Slate Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address Ci /Town State Zi Discipline Expiration Date 1 i CITY OF S.U.E:brI, IN-W A.CHUSETTS • BUELDINIG DEPARTMENT • 130 WASHINGTON STREET, 3w FLOOR TEL (978) 745-9595 FAX(978) 710-9846 KINIB6RIBY DRISCOLL MAYOR THOMAS ST.PmRRS DIRECTOR OF PUBLIC PROPERTY/BL'ILDCVG CO%MUSSIONER Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricions/Plumbers Applicant Information p Please Print Leeibly dame(Busit Orgaaizationindividual): vY �� pIQhn.li /�t ` hJsrrJ[_1 LLL'. 1l Address: 6� �, City/State/Zip: ,e2"1 n; Phone #: 6195b7 Are you an employer?Cheek the appropriate box: Type of project(required): I.O 1 am a employer with Z 4. ❑ 1 am a general contractor and 1 have hired the sub-contractors 6. El New construction employees(full and/or part-brae). lle�yy� 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.i 7. Remodeling ship and have no employees These sub-contractors have 8. ti Demolition working for me in any capacity. workers'comp.insurance. 9. El Building addition [No workers'comp. insurance 5. El We are a corporation and its 10.C3 Electrical repairs or additions required.) officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no I2.❑Roof repairs insurance required.)t employees. [No workers' comp. insurance required.) I)'❑Other •Any nt applicaika chceks box r I most also 6n wt the section below stowing their working'mm mmion policy informadoa 'I Iomegwrtena who sulwit this affidavit indicating they are doing all work and th=hire outside mnirseon most submit a new w idavit indicting each. :Conirocton that check ibis box must attached an additional Am showing the name of dw sub-contractors and their workers'comp.policy infomwion. 1 am an employer that Is providing workers'compensadon Insurance for my employees. Below is fhe polley and job site infortnatiota Insurance Company Name: Policy#urSelf--ins. Lie.#: Expiration Date: H—2S 2 r))In Job Site Address: OP City/State/Zip: 561e�ynt 1'✓A Attach a copy of the workers'compensation policy declaratlan 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 S1,500.00 and/or one-year imprisonmem,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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify undhepains and penaldes of perjury that re information provided above/s true and correct . i t I re• Date, Phone#: Official use only. Do nor write in this area,to be completed by city or town offlwaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cily/town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other, Contact Person: _ Phone#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICYLiberty Mutual. INSURANCE AR INFORMATION PAGE 175 Berkeley SOW Boston,MA 02116 Issued by LM INSURANCE CORPORATION 27243 Policy Number WC5-31S-383055-0.15 Issuing Office 016C RENEWAL OF: WC5-31S-383055-014 Issue Date 10-30-15 Account Number 1-383055 Sub Account 0000 1. Insured and Mailing Address WJJ PLANNING&CONSTRUCTION LLC RISK ID 287590 64 HAVERHILL STREET READING,MA 01867 Status 46 — LIMITED LIABILITY CO Other workplaces not shown above: SEE ITEM 4. PREMIUM- EXTENSION OF INFORMATION PAGE 2. Policy Period:The policy period is from 11-25-2015 to 11-25-2016 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1, 000, 000 each accident Bodily Injury by Disease '$ 1, 000, 000 policy limit 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 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per$100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ (MA) Total Estimated Annual Premium $ Premium will be billed ANNUAL Producer 0004-017109 THE MCGLAUGHLIN AGENCY 828 LYNN FELLS PARKWAY MELROSE MA 02176 WC 00 00 01 A 01987 National Council on Compensation Insurance,Inc. WC 00 00 01 B (CA) Ed. 07/01/2011 All Rights Reserved Page 1 of 1 Insured Copy Initial Construction Control Document To be submitted with the building permit application by a s Registered Design Professional for work per the 8" edition of the y< Massachusetts State Building Code, 780 CMR, Section 107.6.2 b•o k Project Title: Salem YMCA—Small pool Conversion Date: 19 May 2016 Property Address: 290 - 292 Essex Street- Salem, MA 01970 Project: Check(x)one or both as applicable: New construction X Existing Construction Project description: Decomissioning existing secondary pool and providing new floor structure at level of existing main floor. Demising as new fitness areas in same building use group(A3)and providing new HVAC, electrical and extending fire protection. I, Mark Meche, MA Registration Number: 7083 Expiration date: 8/31/2016 , am a registered design professional, and hereby certify that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project X Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I(or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 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 if the work is being performed in a manner consistent with the approved construction documents and this code. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. Enter in the space to the right a"wet" or R electronic signature and seal: s Phone number: 978-744-7379 Email: mmeche@wsarchitects.comp X17 pF Building Official Use Only Building Official Name: Permit No.: Date: Note I.Indicate with an `x' project design plans,computations and specifications that you prepared or directly supervised. If`other' is chosen, provide a description. Trial Version 10 09 2012