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9 SPRING ST - BUILDING INSPECTION /C� �,",►, The Commonwealth of Massachusetts i', (•.'f l � •�. ,�, Department of Public Safety Nlassachusetts Slate Building Code(780 CJiR)Seventh Edition City of Salem Buildin Permit Application for an Buildingother than a 1-or 2-FamilyDwellin (This Section For Official Use Only) Building Permit Number. Date Applied: a Building Inspector: SECTION 1: LOCATION (Please indicate Block N and Lot M for locations for which a street address is not available) Tt H � C9 No.and Street City /Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (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 req iced? Yes ❑ No Brief Description of Proposed Work: �� � -. _ L I �A 5- �G� rT 2,2. i✓.J J� 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): 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 ffloorsq. ftJ 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 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2 Cl H-3 ❑_ H-4❑ H-5❑ l: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential P:1❑ R-2❑ R-3❑ R-4 ❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 1813 IIA ❑ IIB ❑ IIIA ❑ 1118 ❑ IV ❑ 1 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: Public❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑ Pricy to❑ or indcntilc Zunr: ur on site scstem ❑ required ❑or trench or,pecifc: permit is enclosed ❑ Railroad right-of-way: THazards to Air Navigation: �I:� I BHnrir Cnnmi„inn Hoch„ Proto..; I .Not :Npplicable❑ ructure,crthin airport aruadm area' Is their rec ietc completed?to ISudd rndo,rd Yes❑ or.Nr'❑ 1'rs❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Coda. L,e Groupf+l: Tc�e of Consruction: ) . I C caipant Load per Ilnor: Ines the building contain an Sprinkler Sc,tcm?: 5pccial_Slipula bons: R SECTION 9: PROPERTY OWNER AUTHORIZATION Na rand A, dress of Property Owner J ) or? Nome(Print) No.and Street City/Town Zip 1 ntI,trh w,Oner Contact Information: t I � - Title Telephone No. (business) Telephone No. (cell) e-mail addre-� If applicable,the properly owner hereby authorizes Name Street Address Citv/Town State Zip to act on the pno,erty 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 building is less than 35,000 ell ft of enclosed space and/or not under Construction Control then check here O and skap Section I0.1) 10.1 R//e�� istered Professional Res onsible for Construction Control EG:L IVyaSc Q75 _Z65 _ ygl0 gc:�Gv C).as�Caw�rac4.p�v, nr- Name(Registrant) Telephone No. e-mail address Registration Number it Cos 4 Geis LA (A ote t Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor F[r T'C 4`MaC_ Company Name: Jpp53 I C70 �<.r= Name of Person Responsible for Construction License No. and Type if Applicable It Cxox 4� tub, @a MP _ 01'*/5 Street Address City/Town State Zip -2kL- e/gld =_ .SMyly _ et' dI C�IyA�Cen-FTc�d rn rR e 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 issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ appropriate municipal factor)=$ f,9f 5,O o _ 3. Plumbing $ Note:Minimum fee=$uito _(contact municipality) 4. Mechanical (HVAC) $ 5. Mechanical (Other) $ to Enclose check payable to 6.Total Cost $ 63 K- I (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest tinder 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. (lease print and>ign name Title Telephone No. Date titreet Address Cite'/Town State Zip n ytunicipal Inspector to fill out this section upon application approval: Name Dale .. e `\ CITY OF SALEM �t(�''{• / PUBLIC PROPRERTY DEPARTMENT .ra;: Xlr1 •XI•.r•u 51NlL'T 45.111'11,M.Ni.\I 971J449846 _ Construction .Debris Disposal Al idavit (required lur all demolition and renovation work) In uccurdance with the sixth edition of the State Building Code, 780 CMR section 111.E Debris,and the provisions of MGL c 40, S 54; Building Permit q is issued with the condition that the debris resulting from this work shall he disposed of in a property licensed waste disposal facility as defined by MGL c I11. S 150A. The debris will be transported by: Iflame ut'hauler) The debris will be disposed or in (nrme ut aci Ity) ' (aldrCn of lkilllY) C= — '\igtltfrur nlq nl6;nlpt'wnl --'—"—.... datr CITY 09 S.1I_Em, AxSSACHL;SETTS 13VMD[NG DEPARTMEINT 110 WASHINGTON STREET, 3w FLOOR TM (978) 7.15-9595 FAX(971) 740-99" Kf.,,®EUZY DRlSCOLL MAYORTHOhtAg ST.PIERItIt DIRECTOR OF PLBLIC PROPERTY/BL'RDLNG CONDUSSIONER Workers' Compensation Insurance Affidavit: Ouilden/Contracton/ElectriclanilPlumben kn Ilcant Information (Y �7 n Please Print Le ib Valnetausiray.OrtamrarimrinLbv,dual): ect- I.�ASS. b� CY1Cw C��c� rkr�( Address: II C<ecL C-k , 45- City/StatrJZip: Phone#: g75-;t6;-V110 Are you an employer?Cheek the appropriate has: Type of project(required): 1.❑ I am a employer with 4. 1 am a genersl contractor and I 6. New construction employees(full and/or pan-time).• have hired the sub•aaursctors 2.❑ 1 am a sole proprietor or partner• listed on the attached sheet: 7. Jl Remodeling .hip and have no employees Thee sub-contractors have B. O Demolition working for me in any capacity. workers'comp.itlauraoee. 9. O DuiWing addition 1No workers'comp. insurance S. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or addition 3.❑ I 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 12.[]Roof repairs insurance required.)It employees.ENO workers' MCI Other, COMP.insurance required.] 'Any applicant tNr iiwcb boa II must a4u rill uw the umnae bw"Atneina their wal er'coapnurt"policy iafurnMIM t 1w wuwrees who subnwt this affidavit indicating they an doing all work and then him oanida c'an d caore must submit a new afQdsvil indforind rate► '{'mtr -opm that cheek Ohio box mwt atucho!an 3"lwael awns showing the notes of IIw atk.centmtfam eOad OAek wortam•comp.policy infomedow l am an employes that ir providing,workers'compensadoa lnrarotrea jet my emp/ayaat g,elow 4 the pNley and faI sltr injormwfoa Insurance Company Name: Policy#or Self•ins.Lic.#: Expiration Date: 65h o Job Site Address: 33-H02PAS1• rq wc �: City/State/2ip: �� AIKF• OI??C� Attack a copy of the worken'compaasntloa policy declaratlom pager(skewing the policy number and expiration date)6 Failure to wcure coverage as required under Section 25A of%1GL c. 152 can lead to the imposition of criminal penalties of a nine up to S 1.500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a Rd of up to$250.00 a day against the violator. Ile advistxl that a copy of this statement may be rurwarded to the Oflice of Invaugatiuna al'dte DIA for insurance coveralls verification l do hereby eerti/jy�rs/(aJ�ir rh pains and penalties ojperfary that chi beformadan provided aabovve.,is true Oradea.reel �cnaiure: �-' I Date: Phone 7,S -2tp:WA) iO/flrial me only. Donor write in this area,to ber rwnpintrd by city or rows o f c at City orfuwn: _. __ Pcrmit/Llccnse# � i Asuing.ttuthonly (circle ode): -- - I. Iloard of Ilealth 2. Building Department J. cityrrown Clerk J. Electrical Inspector 5. Plumbing Inspector 6. Other L v enact Period: _ __, __. Phone#: JE�� CERTIFICATE OF LIABILITY INSURANCE OP ID JM DATE(MMR)D/YYYY) 9CBA501 02 22 10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE John J Walsh Ins Agency, Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P O Box 4407 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Salem MA 01970-6407 Phone: 978-745-3300 Fax:978-745-9557 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Penn—America Insurance Co. INSURER B. Granite State Ineuranca co. Eric Chase dba DBA Chase Contracting INSURER C: 11 Cross Street INSURER D' Beverly MA 01915 INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. LTR NSF TYPE OF INSURANCE POLICY NUMBER DATE MM/OD/VYYY DATE MWD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY PAC6852384 09/17/09 09/17/10 PREMISES(Ea occurenre) $ 50000 CLAIMS MADE FX7 OCCUR MED EXP(Any one Person) $ 5000 PERSONAL$ADV INJURY $ 1000000 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $2000000 POLICY 7 PR0- JECT LOG AUTOMOBILE LIABILITY COMBINED ANY AUTO (Ea acadentSINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY mcid nt) $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ $AND EMPLOYERS' LIABILITY A ILIT _ AND EMPLOYERS'LIABILITY Y/N TORV LIMBS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE­­, WC007422579 05/05/09 05/05/10 E.L.EACH ACCIDENT $ 100000 OFFICERIMEMBER EXCLUDED? u (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100000 U yes,desaiEe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS 33 NcLu► si- � SP�•rb S4 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 50 SHALL City Of Salem IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Attn: Building Inspector REPRESENTATIVES. 93 Washington Street AUTHORIZED REPRESENTATIVE INC- Salem MA 01970 Mark W. BettencourCHN ACORD 25(2009101) ©1988.2009 ACORD CO re ed. The ACORD name and logo are registered marks of ACORD Pf88 I %laxvuchusctl!i- Dcpurtotcnt ut'Public$dt'ct', . g(iar(juf Buildint.Re- ulatiijn%-uM4'S(entlyds Constryetion Supervisor Licer}se License: cS° 100531 ReAStricted to:. 0? . ERIC CHASE 11 CROSS ST All BEVERLY, MA 01915 Expiration: 1218I20t1 Tr#: 100531 (�ommi,oionrr b