38 SWAMPSCOTT RD - BUILDING INSPECTION fit• �' ,.. ;• •�
y�
�. ;�• The Commonwealth of Massachusetts
( Department of Public Safety
v.yu.j .Massachusetts State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(This Section For Official Use Only)
•wnJ Building Permit Number. Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block M and Lot 0 for locations for which a street address is not available)
56dA IM f S-Co // leb 5 L BA2 Now �y/7�S�af c.
No. and Street Cih• /Town Lip 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:
Arr building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? ` Yes ❑
- = ALBri Description of Prupi - No ❑
�� 76 qAC4- i;�i
4PIA "AAA- 10! i, 6't •�' A ,TM_ v¢[1L� 7rU.� A+t/LI C'iJ i1t °fC�/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): p
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR34:
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 AA ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 Cl F2❑ H. Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R. Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage -1 ❑ S-2 ❑ U: Utility❑ Special Use Cl and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA 180 IIA ❑ 1180 IIIA ❑ HIS IV O 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❑
Private❑ or mdenuk Zone: or on site scstem ❑ required ❑or trench or specil'c:
permit isenclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \L\ I li,lori,c",nnmi�sim It.•.ir.. Pn ,s:
.Not Applicable❑ I.Stroclure irilhm aoport appru.ich area.' k their review completed.'
I Pr msent I0 Budd enclosed ❑ N'es ❑ or No❑ Yes❑ Nn ❑
SECTIONS:CONTENT OF CERTIFICATE OF OCCUPANCY
F.iiuon of( 1111r: (ae G-up(h): r% e of Cunstrucliun:
P Occupant Load per Flour
Does the building contain an Sprinkler ti�s0.•m.': Special Stipulations:
Ai \\ � ^ ,
1 M.
v
SECTION 9: PROPERTY OWNER AUTHORIZATION
t '
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) r-mail addmss
If applicable, the property owner herebv authorizes
Name Street Address City/Town Stale Zip
to act on the property owner's behalf, in all matters relame to work authorized by this buildin>12ermitapplication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is tes than 351(3011)cu. ft.of enclosed s ace and/or not under Construction Control then check here O and skiI2 Section I0.1)
10.1 Registered Pro ssional Res onsible for Construction Control
Name(Re Yistrant) Telephone No. e-mail address 03d Registration Number
C<fC B �iy�f5lrh•y
Street Address City/Town State Zip Discipline Expiration Date
10.2 GenerE
� G'a�ANCumpan Nl �� �. e&)l CoAYrAAT0l2 1Z�(>Sx7 Ti4- ��nName of Pebl�>r It License No. and Type if Applicable
`C�
City/Town/Town State Zip
Street Address y
AP9
Telephone No.(business) Telephone No. ell) e-mail address
SECTION 11: WORKERS'COMPENSATI - -URANCE AFFIDAVIT(M.G.L.c.152. 25C(6))
A Workers'Compensation Insurance Affidavit fro the A Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affida 't will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this lication7 Yes O No 13
SECTION 12:CONSTRUCTION STS AND PERMIT FEE
Estimated Costs:(Labor Cjpd
Item Total Con uction Cost(from Item 6) _$ 13',and Materials)
1. Building $ a C040 Building Permit F =Total Construction Cost x_(Insert here
2. Electrical $ 15,00 appropria municipal factor)_$
3. Plumbing $ J SbU
4. Mechanical (H.VAC) $ Note: Minimum fee $ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ C 3 ?DO (contact municipality)and write ch k number he e
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICAN
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the info lti( )ntained in this
application is true and accurate to the best of my knq7VICdgeJnd understanding.
I'Ica.e• Flint and i •n� A �+� _ �, f � Icp 0 to _ y�l /
tiUreet :lddress City/To%%n State Zip
Municipal Inspector to fill out this section upon application approval:
.Name [)ate
r�
The Commonwealth of Massachusetts
Department of Public Safety
r,.•� Massachusetts Slate Building Cade(780 CMR)Seventh Edition
City of Salem
Building Permit A lication for any Building other than a 1- or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1:LOCATION (Please indicate Block M and Lot N for locations for which a street address is not available)
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❑ Altrrntion ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ ChangrofOccupancy ❑ Other O Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ Nu ❑
Is an Independent Structural Engineering Peer Review required? Yes-"C - No ❑
Brief Description of Proposed Work:
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): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR34:
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-I ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑
F: B: Business ❑ E: Educational O
Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4 ❑
S: Storage SI ❑ S-2❑ U: Utility ❑ Special Use❑and please describe below:
Special Use: ..
SECTION 6:CONSTRUCTION TYPE(Check as a lieable)
IA ❑ IB ❑ I►A ❑ IIB ❑ IIIA ❑ IIIB ❑ IV O VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
rWater Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Chock if outside Flood Zone❑ Indicate municipal Cl A trench will not be Licensed Disposal Site❑
Private❑ or Indentifc Zone: or nn site ststem ❑ required ❑or trench ur,pecifv:
permit is enclosed ❑
Railroad or
Hazards to Air Navigation: MA I li't"m ( om'111"om R"'.' . f•n rrss•
\tit Applicable 11 I.Struettrze tcnhut uirpnrt approach area.' Is their rec iew completed.'
'( ntscnl to ISudd enclusi•d ❑ Yes❑ or No❑ Yrs❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I[d Won of(-ode: Use Group(s): Tt po of Construction: Occupant Load per Ilnur
III,- the budding;contain an Sprinkler S% tem.': Special Stipulations:
_ ti /
Z v
SECTION 9: PROPERTY OWNER AUTHORIZATION ;
Name and Address of Properly Owner
Name(Print) Nu.and Street Cih'/Town - Zip
Property 0%%net Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building 2ermit a >plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(It buildin•is less than 35,(xx)eu ft.of endoxd s ace and/or not under Construction Control then check here O and skie Section IU.I)
10.1 Registered Professional Responsible for Construction Control
Na e( e is r Tel �hon _ e- . it a dr s Rr istratio u rr
J
Street Address Cit own __ State Zip Discipline Expiration Date
r
10.2 General COnkr3ctor
Comp
Nam of Pe n eslxms' JI/I(GurXClu✓nsflru.tiun Licen No. and Type if Applicable
c r y i� n�_ rat v
St eet Addr ss City/Town State Zip
Tele hone No.(business) Telephone No.(cell)
e-mail address
SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(b))
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 O No O
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)_$
3. Plumbing $ Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) $
5. Mechanical (Other)- $ 7 Enclose check payable to
6. Total Cost - - $ - l t/� (contact municipality)and write check number here
SECTION 13:S GNATURE 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 Stat Lip
Municipal Inspector to fill out this section upon application approval:
Nam Datr
%
ACOF CERTIFICATE OF LIABILITY INSURANCE DATE30/2009
11/30/2009
PR0 CER"603.382.4600 FAX 603.382.2034 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Insurance Solutions Corporation ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
60 Westville Rd ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Plaistow, NH 03865
Marialana D'Agata INSURERS AFFORDING COVERAGE NAIC#
INSURED Stephen Catalano DBA Catlin Company INSURER A: MMG Insurance Company 1S997 _
41 Black Brook Rd INSURERS Acadia Insurance (AR)
Goffstown, NH 03045-2807 1 INSURER C'
NSUREft D:
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 ISSIJED 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.
ILTR NSR TYPE OF INSURANCE POLICY NUMBER DALE MMFDDmVY POLICY
ATE(MMD )YYYYYN LIMITS
GENERAL LUIBILRY SC10948226 02/26/2009 02/26/2010 EACH OCCURRENCE $ 1,000,00
AMA ET6RERTE6—
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 250,000
CLAIMS MADE [XI OCCUR MED EXP(Any one person) $ 5,000
A PERSONAL&ADV INJURY $__ 1,000,000
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG I$ 2,000,00
POLICY PRO-
JECT LOG
AUTOMOBILE LIABILITY KA10948226 02/26/2009 02/26/2010 COMBINED SINGLE LIMIT
ANY AUTO LE.accident) -- $ 500,00
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per person) $
A X HIRED AUTOS BODILY INJURY
X NON-OWNED AUTOS (Per accident) $
PROPE^niYDAMAGE $
(Per accident)
GARAGE UABIUTY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN -EA ACC $
AUTO ONLY: AGO $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $ —
DEDUCTIBLE $
RETENTION $ $ _
WORKERS COMPENSAnON WC282800151401 10/05/2009 TN
10/05/2010 TORY LIMITS Eft _ _
AND EMPLOYERS'LUIBILITY
ANY PROPRIETORS CLUER/E%ECUTIVEY� E.L.EACH ACCIDENT $ lOO,OO
B OFFICERIMEMBEREXCLUDEDP --
(Mantlarory In NN) E.L.DISEASE-EA EMPLOYEEI $ 100,00
byes,describe H) E.L.DISEASE-POLICY LIMB s 500 00
SPECIAL PROVISIONS below ,
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS
Stephen Catalano is Excluded from Workers Compensation coverage
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
North Shore Physical Therapy Associates NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$O SHALL
Attn: Dave Roberts IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
1 Widger Rd REPRESENTATIVES.
Marblehead, MA 01945 AUTHORIZED REPRESENTATIVE
ACORD 25(2009101) FAX: 781.639.2060 01988-2009 ACORD CORPeltATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized
representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,
extend or alter the coverage afforded by the policies listed thereon.
ACORD 25(2009/01)
CITY OF S.U.E.Nf, Axss.kcHusET'Ts
BDL�JG DEPART'N NiT
13O L'D WASHINIGTON STREET, lea FLOOR
T EL (978) 74S-9595
F.kx(978) 740-98U
p.,lBEjtLEY DRISCOLL
MAYOR THohlAs ST.P[EaaB
DIRECTOR OF PUBLIC PROPERTY/BL:I DLNG CONDIISSIONiER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
411011cant Information �� _ Please Print Leaibir
Naine (BusinessO'rganituiomlmhv,dual): 721� (fir- Lit y/ eO
/.
Address: �/ 9M�z U'� Glelo
City/State/Zip: 6C)60`bd l b# 02t phone q: 603 45�08 " 69-6
Are you to employer?Cheek the appropriate boa: Type of project(required):
1.❑ I am a employer with 4. 0 I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the sub-contractors
2-El I am a sole proprietor or partner- listed on the attached sheet : ? Remodeling
,hip and have no employees These sub-contractors have S. 0 Demolition
workingfor me in an cis i worker'comp.insurance
Y P� tY• 9. 0 building addition
(No workers'comp. insurance S. 0 We are a corporation and its
required.]
officers have exercised thew lOEiectrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL I Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] r employees. (No workers' I3.D Other.
insurance mquired.j
-Any applicant the flecks ban At mtal also fix Pat the section below showing their worker'compenryFm policy infomtatlott.
t I bmu%na n m,who submit this aflldsve indicating they am doing all work and thm him upside eaatnchal,mum submit a row attldavil indicating Pack
{,mtriYon that chock this boa mud anxhad an a"liwd rhos showing the tame of ttm eubc mrwowrp and toad wtxker'curry.policy inatrrnmiea.
l ass an employer that k proyidlnB workers'compensadom insurance for my employees,, Below Is the polley aad fob site
information.
Insurunce Company Name: ��+
Policy N or Self-ire. Lie. N: JC I Li '1/9Z,1-6 Expiration Date: 2,12611-0
t
Job Site Address: 2 s 617�tl` �" /`U City/State/Zip: S aceek PtA-`
,\mach a copy of the workers'compensation policy declaration 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 S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lie advised that a copy of this statement may be t'urwurded to the office of
Inccsogaiion t ol'dte DIA for insurance coverage verification.
/da hereby certify at of t pains u /pen lrs f perJu r t rho information provided above is true and correct.
Data,
iOffe's•ial use duty. Do not write In this area, to be cunepleted by city or rouvis nJJiciat
iCity or Town: __ Permit/Lkcrne N__. _
hsuing Aulhurily (circle use): -- _ --
I. ltuard of Ileallh 2. Building Department 3.City/fawn Clerk 4. Electrical inspector 5. Plumbing Inipeetor
6. t)Iher
Luutact Person: _ .—. _. Phone s:
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