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54R TURNER ST - BUILDING INSPECTION
The Commonwealth of Massachusetts 0o Department of Public Safety Massachusetts State Building Code(780 CMR)Seventh Edition City of Salem BuildingPermit Application for an Buildingother than a 1-or 2-Famil Dwellin (This Section For Official Use Only) Building Permit Number: Date Applied: Building Inspector: SECTION 1: LOCATION (Please indicate Block#and Lot# for locations for which a street address is not available) Sy�l RNE A� ,�►ti o (190 RETQ& E 8ECIcF.T S HOO No.and Street Citv /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 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:RE82/LQ CYIAA fJEy 15D P Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ NO,XI Is an Independent Structural Engineering Peer Review required? Yes ❑ No.� Brief Description of Proposed Work: �F 1)(J p OL. D NO/y—(=UA!r j0A1hL CN/Mt(cy FitoAA OO n)H C ,S cr) L(M)C-MoR 1 OF, A)E'Lj Af C. 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) O Existing Use Group(s): Proposed Use Group(s): P 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 Per Floor(sq. ft.) 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❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High 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-10 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 ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ 1 IV ❑ I 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 rspcily:Disposal Site ❑ ePrivate ❑ or indentih- required ❑or trench Zone: Or on site system ❑ permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: M;\ I li,lurk C....I'll im Rooie,c Pni,o..; Nut Applic,i ble ❑ Is Stricture Ic ithin airport approach area? Is their review nanplCted' ur Consent to Build enclosed ❑ Yes❑ or No ❑ Yes ❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY FdiGon of (-OdC. LNe Group(S): Tvpe of Construction: Occupant Load per Fluor: DOCI the building amtainan Sprinkler S stem?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION r Name and Address of Propert. Owner ��q.� U0U5� OF 7 G-G kjc:5 $9TT/ EMA)TE 56©G ��'YTURNER �f i JSALEM ='s+-f 0 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: ANITPi 8( 0(%kr+8r 4PB-?ty- 9O9 xlo? mbinekabyy ablet . oHo Title,X , D( R ECTO/2 Telephone No. (business) Telephone No. (cell) e-mail address TT If applicable, the property owner hereby authorizes IC(c fmQ0 TRONS la gaNHAM Pt> tJ rR c ME QyoyA Name Street Address City/Town - State Zip to act on the pro petty owner's behalf, in all matters relative to work authorized by this buildin • permit a p plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (if building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section MI) 10.1 Re istered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor CJCI4AP-p -T90NS - RESTORHTION MASONS Company Name: C 19 a3 e Rt NRRA ��f2,nIS 6 Name of Person Responsible for Construction License No. and Type if Applicable leNN>9M IRP • "MEKIC-k AL"F-- QU09 ? Street Address City/Town State Zip ag 22i 1.16S51 ao7--A,32- 99-06 Telephone No. (business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the 'ssuance of the building permit. Is a signed Affidavit submitted with this application Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ .r I =_ 1. Building $ 000 Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ appropriate municipal factor)=$ 3. Plumbing $ Note: Minimum fee=$ (contact municl lily) 4. Mechanical (HVAC) $ 5. Mechanical (Other) $ Enclose check payable to �/ a 6.Total Cost $ 1 3 000 (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. QCHHKD N xooNSowner,— B- 'lGSs' 71ID o Please print and >ign name Title Telephone to /-Imp7plicki M Street Addres, City/Town State ip Municipal Inspector to fill out this section upon application approval: Name Da From:RSC Insurance Brokerage 781 963 4420 07/02/2009 09:55 #563 P.002/002 , .4`�o�® CERTIFICATE OF LIABILITY INSURANCE %2/2009 PRODUCER (781)986-4400 FAX: (781)963-4420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Risk Strategies Company ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 15 Paaella Park Drive HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 240 Randolph. MA 02368 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA Technology Insurance Company Richard Irons, DBA: Restoration Masons WSURER B: 12 Burnham Rd INSURER C: NSURER D: Limerick ME 04048 NSUSER 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 OFSUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD' _TYPE OF INSURANCE POLICY NUMBER POLICYEFFBCTIVS POLICYEXPIRATION LIMITS GENENALLIABILITY EACH OCCURRENCE S CA TO RENTED COMMERCIAL GENERAL LIABILITY P MAGE 19ES ..came to $ CLAIMS MADE ❑OCCUR MED EXP Any one paean $ PERSONAL S ADV INJURY $ GENERAL AGGREGATE $ GEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO 5 POLICY I-1 PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea awaIng $ ALLOWNEDAUTOS BODILY INJURY SCHEDULED AUTOS (Perl/ueon) $ HIREDAUTOS BODILY INJURY NON-OVJNE0 AUTOS (Per a=IRn0 $ PROPERTY DAMAGE S (Per accident) GARAGEUASIUTY AUTO ONLY-EA ACCIDENT $ ANYAUTO OTHER THAN EAACC $ I AUTO ONLY: AGO $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE S Is DEDUCTIBLE S RETENTION $ $ A WORKERS COMPENSATION chard Rana is WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR,PARTNERXXECUTNE Y/N ncluded in Coverage E.L EACHACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? (M.nd wq In NH) 3208398 6/4/2009 6/14/2010 E.L DISEASE-EAEMPLOYE $ 50O 000 If Yed ZINPOe under SPECIAL PROVISIONS balrnv E.L DISEASE•POLICY LIMIT $ 500,000 OTHER DESCRIPTIOM OF OPERATIONS/LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Issued as evidence of insurance CERTIFICATE HOLDER CANCELLATION (978)741-4350 SHOULD ANYOFTHSABOVE DESCRIBED POLICIES BECANCELLED BEPORSTHE EXPIRATION House Of Seven Gables DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Attn: Anita Blackaby NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 50 SMALL 115 Derby Street Salem, MA 01970 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTRONIED REPRESENTATWE Michael Christian/SM,9 f - �- ACORD 25(2009101) ®1988-2009 ACORD CORPORATION. All rights reserved. INS026(zoosm) The ACORD name and logo are registered marks of ACORD CITY OF SALEM ram, PUBLIC. PROPRERTY is ' DEPARTMENT Construction Debris Disposal Allida% it (rcyuired lilr all dellWlltIU11 and renucation work) In accordance 1\ith the sixth edition of the State Building Code, 780 C'MR section 11 L5 Dcbris, and the provisions of'v1GL c 40, S 54; Building Permit 0 is issued with the condition that the debris resulting front this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c I 11. S 150A. (Thhe debris will b^e,tra�nsported by: (name ofhauler) ./I the debris will be disposed of in Ulame ul acihty) ry (.�JJrc<. ur l�nlilv�. avnalule nt p:nun allpheanl (� 2009 Salem Historical Commission 120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970 (978) 745-9595 EXT.311 FAX(978)740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving `I Reconstruction ❑ Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: Derby Street Address of Property: 54R `r^rner Street_Retire Becket`House Name of Record Owner: The House of the Seven Gables Settlement Assoc Description of Work Proposed: Rebuild chimney from at or below roofline, reusing as much existing brick aspossible and matching any new bricks. No changes in color, material, design or outward appearance. Non-applicable due to being in kind maintenance/replacement. Dated: July 9, 2009 SALE M H MMISSION . ..,. By The homeowner has the option not,to commence-the•_work,(unlessit-relates to-resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals) prior to commencing work. Construction Supervisor License 6cense•.:CS 19238 Ex ira P Uon: � 71/2/2008� Trk 10128 Restnction: AO _ RICHARD H IRONS 12 BURNHAM RD':: LIMERICK,ME 040g8 . . ' Commissioner " � ,. - -