96 SWAMPSCOTT RD - BUILDING INSPECTION (30) � oo���
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, ;►. " The Commonwealth of Massachusetts
�. �� ,1� Departmenf of Public Safety
� ..,,,.f � . \I.i..�ahu.a•II.�I.urBu�lding(���dr1;iJOC�iNltirrrnlhEdihun
City of Salem
� Buildin Permit A lication for an Buildin other than a 1• or 2-Famil Dwellin
1 ihis Srctiun F�r Uf(ici.il U�r lhdv)
� IiuJdinti Prrm�t>lumbrr: Detr Appliral: Building Ins�ctur:
_`, SECTION I: LOCATION IPleaae indicate Blocic N and Lot 11 for Ixations tor which a slnet addreas ia not available)
�l� S.�A�sci� SH�� `7�+��LNIS ��ak�eS
N��. end titrrrl Cih' /Ri�vn ZipGK1r N.imruf Budding Uf.ipplic.iblr)
SECTION 2:PROPOSED WORK
If Nrw Con+lrucliun chrck hrrc O ur chrck,ill th.it appty in�thr Iwu ruws brluw
Existing Building O � Rrpair❑ Allrraliun O Additiun O Drmuliliun ❑ (Plra�r fill wt.ind,ubmit Apprndix I)
ChangrufUsr O ChangrofOccupancy O Othrr �prci(y:CaNs'1'2�+.c(" rZoor GKi �IAgG
� .Arr building plans and/ur cunstructiun ducuments bring�upplird as part uf�hia prrmit applicatiun? Yrs 0' Nu ❑
Is an Indrpendrnl Structural Enginrrring Prrr Revirw reyuirrd? � .. YrY f� Nu O
Brief Drscriptiun uf Pru .ea1 Wurk: L"�-' il � ¢' C 'i- �i i�++N '
'Z -y :..rY1NS �'.�
1�7,�i�iZlA2/�-C_ m . j '- ��yy,
PL�I�
SECIION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDI770N,OR
CHANGE IN USE OR OCCUPANCY
Check here i(an Existlng Building Evaluatlon is enelosed(See 780 CMR 3402.0) O �
Existing Use Group(s): Proposed Use Croup(s): f
Exiating Hazard Indez 780 CMR 34: Proposed Harard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND ARHA
- Existing . � Proposed
Na of Fluurs/Stories(include baaement levrls)&Area Prr Floor(sq. (t.)
Tutal Area (.sq. ft.)and Tutal Height(ft.)
SECTION S:USE GROUP(Check a�a Iicable)
A: Aesembl A-1 O A-2r O A-2nc O A-3 O A�O A-5❑ B: Buslnee� O E: Fducattonal O
F: Facto F-1 O F2❑ H: Hi Hazard H-1 O H-2 O H-3 O H-4 O H-5 O
1: Instifutlonal 1-1 ❑ I-2 O 1•3 O 1-{❑ M: Mercanttls❑ R: ResldenHal R-lO R-2 O R-3❑ R-1❑
S: Stonge S I ❑ S2 � U: Utilitr❑ Special Uee O and Irasr de�cribe beluw:
Sprcial U+r: .
SECTION 6:CONSTRUCI'ION 7YPE lCheck a�a Ilcable)
IA O I8O IIAO IIBO IIIAO 11180 IV O VAO VB �
SECTION 7:SITE INFORMATION Ire(er to 780 C�1R I I1.0 far details on each item►
LVrfer Supply: Flood Zone Informafion: � Sewage Difpo�al: Trench Permif: Debria Removal:
Pul+h.❑ Chv.k 11��ut.idv flnud Lunu O In.lic.rtr mumcipal ❑ '� trrnch wdl nut be Licrn.raf Di..�w.d�itr O
, . rcqu�ndOurtrcnch ur.f�itiiR�:
� I rn�.ili•❑ � ur mJvntdc.Zunr: nr un .rtr.��.trm❑ �.rrmrt i.vn.lu.ral ❑
Railroad righbaf•way: Huard�ta Air.Wvigation: �i,� i i�.i�.n, �-„mnu.,��„�It.•.�.�.� 1'r�,.��..:
� \n1 :\�•��hc.ibla•O I.�Irwlur¢�cilhin.ur�.urt.tF�F�rn.�ah.vra.' I.Ih.•i�rr��irwium�•Ivlvd.' .
,�r l��m.cnl In Hud.l cnCL�vd O Yc.� �a\n❑ 1'r>� \n � -
SEC`iION H:CONTENT OF CERTIFICA IE OF (KCUPANCY
I�,hlinn ��ll���dr: ____ C.c(�n�uF•l.l: I'�F�v��IlLn.lniiliun:
. �k.uF+.inl I.u.�d ��cr IJ��,�r:
� Ih�v. ihcl�iulJin�;.��ni.un.intiF�rinAlcrti�.lcm': ?��vti.�l?fiF+ulatianv
5
SECiION 9: PROPER7Y OWNER AUTHORIZATION �
N.ime.ind .\.Idrr>.ol Prnperlv V��•nrr ..�L (� I �
mA�Z�' �}AZ�-t a(L Sl.tbr9MSfolT 7Z="- ShlCM
.V.�mr(Pnnt) .Vu..�nd 51n�r1 Cil�•/fuwn L�p
PruFvrK� lh.nrr<'�mt.�rllnlurmauun: � .
n1afNBiZ ._ _ - - .
Tidr TrlrphunrVu. lbu.mrn�l TrlrphunrNu. Icrll) r-madeddr•�..
If.��+•lic.iblr, Ihr��rnprrtc u�onrr hrrcby.uuhunzr.r �
-�Ft r�c s �c�l-k eZ-�, �t3 r.�l l s V 7 l lrlqs tz.� l'��s�c2 /� r� D?J�3C
X.imr � Sln�rl Addrr�v lity/Tu�vn titalr Lip
n�acl �m ihr �ru �erh'�a��nrr'.brh.ilf, in ell meitrry n•I.�Nvr lu wurk.iuthuntral bv thi.buildin �rrmif a � �lic.itiun.
SECTION l0:CONSTRUCiION CONTROL IPieaae fill out Appendia 2)
(I(lnuldin iv I..x Uun 35.UW.u.�t uf.�nd�n.J s ace anJ/or nul um1�•t C.�a.Muclion C.mlrul then chec4 hrre O.�nJ.ki S�v�lion IU.11
10.1 Re istercd Pmfesdonal Rea on�ible for Construction Control
wzn,f�o�z1-I. �r„��t2s�t3. ysz_�.�. 1�,G6`�
Namr(Rr•islranq Trlrphunr Nu. r-ma�l addms Rrgislralion Numbrr
JZ rt'�A-�fo/rn Ik�,t D2 .t/t,._�Kn�pcm�" 1R 1 So
5trrr� Addrr+s Ci�y/Tuwn State Zip Discipline Expirotion D.itr
10.2 General Contractor
�1'h t`�. Co N S-1-fL�lt �i V./ GO. -__ -
Company Namr: '^� � -
c�M'IM�S M L )h�PiL�T OI �U '�'J�q
Nama uf Prrwn Revpm+iblr fur Cu�na�Fuctiun r License No. and Type if Ap licable
�( 3 wei(7v �l�c '�u cc,cs�-cti � D.3o3�
Street Addrese City/Town State Zip
_ `(��-�` - SI`1£? T�'�cont � A-cl , co�.ti
Tele honr IVo.(business) Tele hone No. cell e-mail address
SECTION 11:WO KE ' O RVS NCE AFFIDAVI (M.G.L e.152. 25C(6p .
A Worknrs'Compenyation Insurance Affidavit from the MA Department of Industrial Accidenb must be mmpleted and
�ubmittrd with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a si ned Affidavit submitted with thia a licationT Yes O No O
SECI'fON 12:CONSTRUCf(ON COSTS AND PERM17'FEE
Item Estimated Custs:(L.abor
and Materials) Total Construction Cost(from Item 6) =S �/ �� ��.GU
1. Building S � U� ��00 Building Permit Fee=Total Construction Cust z_(Insert here
2. Electrical f appropriate municipal factor)=S
3. Plumbing 5
4. Mechanical (HVAC) S Note: Minimum fee�S�(contact municipality)
5. Mrchanical (Other) f Enclusr chrck payable to
6. T�rtal Cuvt f y � 000 ,OU � (�i���i�� munici alit )and writr check number hrrr
SECIION 13:SIGNATURE OF BUILDINC PERMIT APPLICANT
Bv rntrnnK my namr brluw, I hrrr y.iurnt undrr Ihr pains and��en.�ltirx uf perjury that all u(thr infurmatiun cuntamrJ in �hi+
� aF.�licaUun iv trur��nd.ucur.ifr lo tf brsl� � v 1 nu Irdhe and undrrcfandin�;.
J+'tm-e5 c,� �_ _ nj yl�,�. �P7�'_ G97. S1Y13 � �5( �
I'Ira.epnnt.�nd .��;nn.�mr fillr . �cicphnnr.\'u. Uale
�t3 c.�lls v� I(� t z c��s.�e.� L!{{_ c�36
. I �trcrl .\.I.In•.. Clh�i L��cn �Ltt Lip
I Siwii.ipal Insprctur to fill out this section upon applicofion approval: ' "� ��
� \amr I>a�r
4�
�t- �
� s ' �'� - �"5b
�
� ' - � CITY UF SALEM
� .y ��
�,,. -;�, ;,; i PUBLIC PROPRERTY
�'��;`�� DEPARTMENT
'.J\IR'.RLIIY URISCI�LL
\1.�riac 12C W,�sr�i�i;ic��S'rxe[�' � S,�u:u,M:�Ss,�c�n:sicrisGl970
'f�:l:978-7ii9i95 � Pnx:978•7i�7tlaG
�Vorkers' Cumpensation Insurance :V'tiduvit: Builders/Contractors/Electricians/Piumbers
��nli�ant Infonnation Plc•rse Print LeeiAlv
-� M< S L�a�.c.��-�, ��4 �M I� La�v S�2(c�o,�tl Co. -
V�II'1C lBucincsslOrean'v.atioNlndiviclual): �
:�ddress: �3 U< l l 5 �J 1 I � ^ �� fZJC
City;S[acc;"L.ip: C— •, S.(.yl Nj'f l'hone ''': 97N ��/� S/`ffJ'
:�re uou rn cmployer?Check the appropriate bux• '1'ype�>f project(rcquired):
I.� 1 am u cmploycr wiih 4 am a gcncral couiractor and [ G. ❑ New con,truction
employces(fuil aneVur part-time).` have hircd the sub-cuntractors 7. ❑ Remudeling .
�.0 1 ;�m a sole proprictor or partncr- listtd un the attached shcet. �
ship and have no umploycus These sub-contractors have 8. ❑ Demolicion
working fi�r mc in any capacity. worken' comp. insuranm. 9. � puilding additiun �
�Ko workcr+' cum insurance 5. ❑ We are a co�poration�nd its
I P• 10.0 Eleccrical repairs�r addi�ions
� rcquircd.] . ot�iccrs havc cscrciscd thcir
3.❑ I um a homcowncr duing all work right of cxzmption per MGL 1 I.❑ Plumbing rcpairs or udditions
myself. [No�vorkers' cump. c. 152, s l(4).and we h;ivc no !2.❑ Ruuf renpairs
insurance myuired.J t cmployccs. [Mo worktts' 13.0 Uther S'4M1"`�"�'�' ��',l A�E
. comp. insur�ncc requirod.]
-n�p�u,plicum tlmt chccks box HI MIIS�eISU IIII UUI IMC[CLI�OII I)UIUW 5IWW111(�IIICR WOfI(UY cumprn>alion puliry inliurtwliun.
� 1 Wmcuwnen whu u�6mit ihis at7Javi�iudicating Ihcy arc doind ull wodt anU then hirc uuKide euNmewn mus�suhmii a oew aff:davii indiuling sueh.
�Caarxtun IhW chcck Ihis bo�mtut auxh�d an addilimal xh�1 shuwing Iho namc of t14)SUb�conireclJrs and ihcir worken'cump.pulicy infortnariun.
/aur un emplayer tltut ix pruvidinx ivorkers'compensnlinn i�isur�urce jor iuy emplopees. Belniv is dre pa/icy und Job sile
iufonnulion.
In.urance Cumpany Vame: ----- -_ _ _.... .. ._..- --- .
Policy�i ur SelGins. Lic. r: ---..._._... .. ___._---- Expiration Date:
Job Siw :lddress: . Cily/S�att/"Lip:
A[tach n copy of tbe�rorkers'cumpens•rtiun pulicy� declarulion puge (showing U�e policy number rnd ezpiratiun drte).
Pailurc w sccure coverrge as required widcr Seclion ZSA uf�IGL c. 152 can lead to the impusition of criminal penalties of a
tina up to S1.SOO.OQ uniUor une-year imprisonmcnt, as w'cll❑s civil penultics in�he f'orm uf a STOP �VORK ORDER and a fine
of up�0 5'_50.00 a day,�gainst tlie viola�or. 13e advised that u copy uf N�is,mtement muy be lurwarJed io �he 017ice of
Ine�r�iig��ions of thc DIA for insurar.ce covcr�gc vcriticaliun.
/Jo herrhy crrli uudc�d+e pn s� id prrtallice uf prrjury�hut Ibe i��fu�inulian pruvided uIGo.•e is nue«ird carract.
Si�naiiirc: I)atc' O !Z ����
�
Ph�n:c:Y:
Ofjiriul ese uidy. Do nnt rvriu iu d�ix ureu.ro be camp/c�rd by ciry or�orvn oJjicrul.
Citv or'1'own: Pcrmit/I.iccnse�----- -- .___ .. _ .
Ixauing Auliiorily(circic onc):..
I. ISuorJ u(il.ultb 2. Iluilding Dcpartmcnl 3. Cily/fo�rn Clcrk a. Clectrical Inspcctor i. plmnbing Inspcctor
6.O�her ---_ - .
Coutact Pcrsou: ____ . _ . . ._--- Phonc d:
� , ` .,
Information and Instructions
\t:usachu;etts General Laws chaptar t�2 reyuirrs�II amployers to provide wurkers' compensation tix thcir employees.
Pursu:uit w this stamte, an rmplu�•re is dcfinzd as"...zvzry person in tha scrvice uf'�nother�mder any contract of hire,
ezpress or implied,oral or written." . � �
:\n einploycr is dctined as"an inJividual, partnership,association,corporation ur other legal enrity, or any two or more
of the foregoing eng�ged in a joint enterprise,and including the legal rzpresenta[ives of a deceased employcr,or the
fCCCIVCf Of[COSICC p� :t0 111(IIVIa1U3I,paimership� �SSOCl�1[IOQ OI O[I1CC ICb':SI CIIUIy,employing employees. Howcvcr the
owner of a dwelling house having not more thun three apartrnrnts and who resides therein, or�he occupant ot the �
dwclling huusz of anodier who employs persons tu do maintanuncr, cunstruction or repa'u work un such dwelling house
or un rhe groundc or building appurtenant thereto shatl not because of such employmcnt be deemed ro be an employec"
MGL chaptar 152, �25C(6) also statzs that"every state or local licensing•rgency shaU w�itl�hold the issuance or
rene�val uf u liccnse or penuit tu operate n business or to canstruct buildings in the commonweult6 for any
applicant who has not produced acceptable evidence uf compli•ance with the insurance coverage rcquired:'
additiunalty, �IGL chxpter 15?, §25C(7) states"Neither the commonwcal[h nur any of ils political subclivisions shall
rn�er inm:u�y coner�ct for the perfommnce uFpublic work until accep[eible evidence of compliance with tht insurance
requirementsof�his chaPter have Lieen presented to the contracting uu[hority."
Applicants
Please fill out the workers' cumpe�uation affidavit completely,by checking ehe boxes that apply to yuur simation and,if
� necessary, supply sub-contractor(s) n:ime(s), address(es)and phone number(s)along with their certificate(s)of
insw�ance. Limi[ed Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employces uther�han the
members or partners, are nut required to carry worktrs' compensa[ion i�vurance. if an LLC�or LLP does have
- employzes,a policy is required. Be advised that this atYidavit may be subinitted to the Depurtrnent of [ndustrial �
Accidents for contimtation of insuranee coverage. Also be sure tu�ign anJ dute the uftidavit. The al'tidavit should
be rctumed m the ciry or town that the applicxtion for the pennit or license is being requested, not the U�partment of
tndustrial Accidanu. Should you have any questions rtgarding the law or if yuu are reyuirzd to obtain a workers' �
cumpen,ation policy,please call [he Dep•rrtment at the number listed below. Self-insurod companies should enter their
self-insurance licen,e number on the appropriate line.
City or Town OfOcials � . �
Piclse he sure that the affidavit is complete and printed legibly. The Department lias provided u spaca at[he buttom
of cha affidavit tor yau to till out in the event the Oftice of Investigations lias ro conWct yuu regarding the applicant.
Pl.ax be sure to till in ihe permitllicense number which will ba usad us a reference number. In addition,an applicant
�h�t must submit multiple pennib'lice�vsc applica[ions in any given ye1r,need aily submit one.�ftidavit indicating current �
policy infamation(if necrssary):uid undet'7ob Site Adclress" the applicant should write"all loca[ions in (city or
eown)."A copy of the aftiduvit that has been officially sWmpeJ or marked by[I�e ciry or town may be proviJed to[he
applicunt as proof tha[a valid affid�vit is on file for futuro permits or licenses. A new affid�vi[must be tilled out�ach �
yaac �Vhere a hane owner o�citizen is obwining a license or pzrmit no[related to any business ur commzrcial venture
(i.e. a dog license or permit to burn leaves ete.)said person is NOT required to complete this affidavit.
� l�hc Otlice oF(nvesti��tions would like io dmnk you in udv.uice fur yout cooperation and should yuu hurc ;my questions,
pla�se do not hesimte to give us u csil. -
� Thc De arnnent's addrass rele hone�nd fax number
r . �
� The Commonwealth of Massachusetts
Department of Indusuial Accidenu
Office of InvestlgaHons
600 Washington Street
Boston, MA 021 l I
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
a.���.�a ;_zr,-as
Fax #617-727-7749
www.mass.gov/dia
' .;; CITY i)F SALL•'M
s
� ` � =�+��,:. Pt1BLIC PRc.�PRERTY
�"'= •-_ ��` DEP.�K"I'LIENT
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.i .. ,: i:: �� „�n��..,�.�i�i.ir � �.ui �i. �i�.,v . . i . :r� -
� lil- '�-8.•I;.�l:��; � I �C: 'i-V.•�=�•�dJi� �
Cnnstruction Dcbris Disposai a►ftidavit
(r����uirr� liir all dairoliti��n :inJ rcnuvaliun �vork)
In :iccurdancc ��itli thc sixth rdition ofthc Statc Duilding Code, 7S0 CMR scctiun I I 1.�
D�bris, anJ thc provisiuns uf'�iGL c �10, S 54;
[3uilJiny Pcrmit N is issucd with thr condition that th� dcbris resultin� tiom
this �vurk shall bc di,puscJ of in a pruperly liccnscd waste disposal tacility �s JcfincJ by MGL c
1 t L S I S(�A.
T'hc dchris will bc hansportcd by:
�,�cn�^'�PS�� Z�dUS i �. k�t �A�r1�cj�.�lcS ����5
Inama of hudtr)
I'hc Jcbris will be dispused of'in :
(nwnr ul laeil�ty) .
�;�Jdress ul'I�acility) .
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CONSTRUCTION CONTROL CERTIFICATION
Scope of Project: Buildina Column Framin�Modifications
Project Owner: Jacaueline's Gourmet Cookies
Project Location: 96 Swampscott Road. Salem, MA 0197Q
In accordance with section 116.0 of the Massathusetts State BuilBing Code, I, Kenneth Dennison Mass
Reg.#8669 being a registered professional engineer/architect hereby certify that I have prepared or
directly supervised the preparation of all design plans,computations and speciflcations concerning:
Entire Project Architectural Structural X Mechanical
Electrical Fire Protection Other:
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 applicable laws and ordinances for the proposed use and occupancy.
�
I further certify that I or my qualified representative shali 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 forthe building permit and shall be responsible
for the following as specified in section 116.2.2:
1. Review of shop drawings, samples and other submittals of the contractor as required by the
construction contract documents as submitted for buiiding:permit, and approval for
conformance to the design concept.
2. Review and approval of the qualiry conVol procedure for all code requiretl controNed materials.
3. Special architecturel or engineering professional inspection of critical construction components
requiring controlled materiats orconstruction spedfied in the accepted engineering prectice
standards.
Pursuant to Section 116.2.2, I or my qua9ified representative sha(i s�bmit periodically,a progress report
together with pertinent comments to the building inspector. Upon completion of the work, I or my
qualified representative shatl su'bmi[a final report as to the satisfactory completi4n and read'+ness of the
projecttoroccupancy.
. oy��,ktH OF ry7q�,�a
g KENNETH cs'N �.�.-y��/ /
� DENNISON m '" '-
� STRUC7URql y � Signed: .;;`f �= -
�7y N0.8669 . � Date: �'-z c.�_.�� ,
. �"PF`�FGlSTER� �'� '
E �
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