4 UNION ST - BUILDING INSPECTION (2) ►. y The Commonwealth of Massachusetts
n�� Department of Public Safely
1`\�7 4, /' % Qp \Ll..,tahu�a•Il.hlatr 8m1111rip C"Ife(.-80C\I14)'wtenlh EJnt,,n
City of Salem
J )� Building Permit Application for any Building other than a 1- or 2-Fimily Dwelling
II I his 1e tion Fur Official U<e Onlv)
0uddmg Permit Number: Date Applied: Budding Inspector: I
SECTION 1: LOCATION (Please indicate Block a and Lot a for localion for which a treet ddress is not available)
g O 15 c' I
No. and Street C itc /Rnvn Zip Code .Name of Budding Uf.tpF+bcablr)
SECTION 2:PROPOSED WORK
It New Construction check here[]or check all that apply in the two rows below
Exximing Budding❑ Repair lvfAlteratiun ❑ Addition❑ Demolition ❑ (Please fill out end submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ I Uthrr CI Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ ,No
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Descrtpli, of Proposed Work:
-. Rc IPre
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 Gruup(s): - Proposed Use Group(s): s'
Existing Hazard Index 790CMR 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.)
SEC270N 5:USE GROUP(Check as applicablU
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ -A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ E2❑ 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 O
S: Storage 5-1 ❑ 5-2 ❑ 1 U: Utility❑ Special Use❑and please describe below:
Gprctal Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ HIS ❑ 1 IV ❑ VA ❑ VS ❑
SECTION 7: SITE INFORMATION (refer to 780 CNIR I1I.0 for details on each item) _
Water Supply: Flood Zone Inform4tion: Sewage Disposal: Trench Permit:
Debris Removal:
1' b1' ❑ Checktl,ni btJr FLnabc.tlr muntcq+,tl❑ \ trench will not be Lirrn�rd Un)n•.,,I"Ir❑required ❑or trench ,-rLmv: r,,n "te•adrm ❑Railroad right-of-way: o Air Navigation: \1-\ Ih•l,•n, , ,,,,,,,,,,,,,,,,u.,,,,, 1',•\rl \ h-&tc❑ ut.n, rla „tudih.,rr.t' Llhvu,c,ic+ :.nn I.IrJ'
." l • , cnl t„ IIutI'l ,m 1„ 'd0 Nr.❑ „t\„❑ le. ❑ \„ ❑
SECTION 8:CON TENT OF CERTIFICA FE OF OCCUPANCY
I ,(,loot •.I l ••.Ic _ .___L-cl�nn,/•,•1 _. ft po„Il-, ndnnlpnt ____ l:rCu)•.u,l l ,,.,.l 1vr ll. ,., _ _
I6•r� il+,•I•u,hlu,;„nn,i,n.m �pnnklrr?l.tc,n' `prcial diF•olah„n. ._ _____.___ __--_____ j
I
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SECTION 9: PROPERTY OWNER AUTHORIZA TION
\'sl l'• J A.I irv(.,..,,I Vroperly Owner
. L �C Cln lCM !�;71TI 11
\.tnte(Print) Nu. and Struel l ih; rinvn - G)•
Pri,pa•rh U,v ner Contact Inlurmaunn: 04- i
r,dr relrphonr No. (bu.tnr..) relephone No. (cell) e mml .iddre..
If apphcablr, Ihr rv{•rrtu"•s•ner hereby authun[ay ` 1 C�
'�--Q•� V"• i F� SSA/ DSOl-y'I'� JI lilh ��SOJ
Name lrr..+ City/Tu,vn Slate Gp
lu act un the ro •weir ,n,ner n behalf, mall rnaaers rviame to trark authorized by this building •rrnttt a t •hc.mnn.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(it t•ud,hn•,s 1c.%thin m,tNUcu.it.,,I rndux•d.+an•and/or nol unJer Con.tnn hon Control Ihrn check here O.md�k, •\•slam It)it
10.1 Registered Professional Responsible for Construction Control
V
Name(RrgistranU Telephone No. r-mail aJJress Registration Number
Street Address City/Town state Lip Discipline E.apimtiun Date
10.2 General Contractor
Co�p.tnm�• 14v
Na a of Person R mntbl r unstructiun Licrnsr No. and Type if-ApR licable
I90 (/ig r � Lam., " ti (l)'b ✓ v� ,o
C� ` Sta+a rp
Telephone No.(business) Telephone No. cell) e-mail address
SECTION 11:WORKERS' OMPENSA ON U ANCE AFFID V)T(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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes"o ❑
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) =E
L Building Is d Building Permit Fee=Total Construction Cost x _ (Insert here
2. Electrical E • 600 appropriate municipal factor)=E
3. Plumbing E
4. A•fechantcal (H VAC) E Note:Minimum fee=E (contact municipality)
5. Ifechanical (Other) E Enclose check payable to
P•Y•
fi. Total Cost E (� (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Rv cntrnng my name below, I herebv attest under the puns and penaltte.of prqury that all of the tntivrrimi„n,i, nbnneJ in this.
.ipplicolnm is true and,tccur.rte to the bent of my knowledge anJ undvrsLmdtng.
KI _i_l 4 L,SE YC&ZE �o ate_- 6 -2331-
I' r.,.c)"nt an.l -ipn •.)mv fitly
�n,ct lddre l rta: rn,n �Ltfa
Municipal Inspector to till out this section upon application approval:
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CITY OF SALEM
a PUBLIC PROPRERTY
*" DEPARTMENT
.,wvyo
\Is1�vl I��Wnvftl\Glad\'$IxfL•l• • SAIY.N, M.1i1.11111 Q'111J197�
Thl.:9711-7 459593 0 1'.ax. 978.74C�IS46
Workers' Compensation Insurance Affidavit: Builders/Cuntracturs/Electricians/Plumbers
it ) )licaut furormation ,� ` Please Prl t Le •hl
ily VnR1C Ilhte ac%siorgcanVallaN 1 individual): `�\„ S ] .S ill �Cv\
1Jdress: (U/ 3 h�,�Ar, ST
City,Slam Zip: G-14h / fl-l . H dO(JI )'honeil: >'F/-S23 -600
:\rv)ou an employer:'Check the appropriate boy - 'Type of project(required):
1.Q 1 cull a cmpluycr with 4. Plain a general contractor and 1 6. Q new construction
employees(full und/ur part-lime).• have hired the sub-contractors
2.Q 1 and a sole proprietor or partner- listed on the anuchcd sheet. : 7• cmodeling
ship and have no employees These subcontractors have 8. Q Demolition
working liar me in any capacity, workers' comp. insurance. _
_ _ —-_-.-9.-Q-OuilJing-addition- - ----
- -- - -- i Kr•workcn'cofnp. uisu�anca—`-3.-Q We arc a cnlporntion and its
required.) ot3iecn have exeta:iseJ their lo.Q Electrical repairs or additions
3.Q I ails a homeowner doing all work right of exemption per NIGL I LQ Plumbing repairs or•additions
myself.(Ko workers'comp. e. 152.¢I(4),and we have no 12.❑ Rouf repairs
insurance required.j t employees. (Ko workers' 13.0 Other
cornp. insurance rcyuirnd-1
•4ny.yphcad iliac chucks ties xt muss atau till out the walun WOW showing their wutk ss cwmpansmiws pulicy infurmmiun.
,I tumerownan whu udtmit this amdavit indiutins they art doing all.vark and 16cn hire wisido ctxum mok mass eutmW an"acndavls indicaainy vaah.
{',wimu,r,1ha chuck this lion must asuched an addisia l..has ahuwine the nano of Has suts•coauaclwe and their wurka17'carp.pdicy insisonaeue.
/sire un eutployar that lw pruri✓lnx tvorhers'rurnpatrnNon insarnxce jar aq etnp/oyerr. Be/osv is the puBcy art✓/ub wife
iu/unnurion. ,
Insurance Cunspauy.Name: _. ..
Policy 4 or Sclf-ins. Lic.0: -_ . .-_ Expiration Date:
lob Site -\ddress: City,State/Zlp:
.\ttach it copy of lite workers'compensation policy declaration page(showing the policy number and expiration date).
[;allure to sccurc coverage as required under Section 23A ul':v1GL c. 152 eau.lead to the imposition of criminal penalties of a
line op lit"11.500.00 and/or une-year imprisonment,as well is civil pcnallics in the t'orm of a STOP WORK ORDER and a fine
of up to i250.00 is Jay against the violator. lic advised thus a copy urthis stutcmcnl may be Iurwarded to the 011ice uC
la%'.,nguoons ul'div. UTA lisr iiistuance eliv efagL'aet'l licalion.
/Jo hereby certify under the painw art✓pero✓tiew of pedury that the iu/urinutlon provided above is true un✓correct
F/ -J / -3
Of/lcial axe on/y. Dd not uvite in this area, to he completed by airy or town a//iriuL i
i
Cite or'fosvn: _- . _ Permit/Llecnse a
Issuing Aulhority(circle noe):
I. IA,ard of Ilvallh 2. IluiWing Duparttncul .1. Cityr'l'ouis Clerk 4. Electrical luspector 5. Plumbing Inspccror
6. Other
('oulacl 1'cnuut - . . Phoned:
Information and Instructions
,,\I:Ibi.lc hUiClU(JCOCraI LJ\VY chapter 132 1'l'yUlfeY:III ell 1plo`C<s to providery lCe of anUlhCrel�ll Itlfrn for their sty cuntmctr flhire.
Pursuant to ties"latule,an emplorre is defined as"...every p• On In the 3
,%press or implied, oral or written."
Y .fin einployer 1%defined as"an individual,partnership,association,corporation ti other legal easedentiry or any two r t more
a the t,gegoing engaged In a Joint enterprise.and Including the legal tell of]deceased employer,or the
receiver or trublee uI an Individual,piutnerAip,association or Other legal entity,employing employees. H ofthe the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
.Iwclling house of another who employs persons to do)maintenance,cunatruction or repair work on such Dwelling hurt"
or oat the grounds Or building appurtenant thereto shall not because of such employment be deemeJ to be an employer." 1
�IGL chapter 152, §2SC(6)also states flirt""very state or local licensing agency shalt withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any
applicant wlio has not produced acceptable evidence of compliance witb th"Insurance coverage required."
Additionally, bIGL chapter 152, 4. 25C(7)states"Neither the commonwealth not any of its political subdivisions shall
he performance of public work until acceptable evidence of cunrpliance with the insurance
corer into any contract For t
requirements of this chapter have been presented to the contracting authority."
AVpltcauts
— Vicaae-fill-out-the-workers' compensation affidavit completely,by checking the boxc�thatapply tot�c�`es)of situation and,if
necessary.supply sub-contraclor(s)nume(i),addrea imit and Phonanuntnershi ola+g- employees ---- -
insurance. Limited Liability Companies(LLCworken'tcom ed lens%oility n insurances(f an)LLC o with rLLP does have
er than the
Imlembers or partners,are not required to carry P
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
,tecidents for confirmation of insurance coverage. Also be sure to sign and dale The affidavit. The affidavit should
ingportmen
he rettimcd to the city or town that the application
e regarding
for the
pemiof o e is ou a required to obtouttu workera't of
Industrial Accidents. Should you have any y t low or if y er
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Offlclals
Please be own that the affidavit is complete and printed legibly. The Department hus provided a space at the bottom
plsure
Plea a affidavit for you to till out in the event the Office of investigations has to contact you regarding the applicant.
1'I:asc be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant
that mutt submitn
multiple penio'licetmse applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town Inay be provided to the
applicant as proof that a valid affidavit is on rile for future permits or licenses. A new atfdavit roust be tilled out each
Year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
I i.e. a dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I ha t)Bice of Investigations would like to drank you in advance fur your cooperation •and should you have sly yuebtions,
please du nut hesitate to give us a call.
The D:partlnclit's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
0Mce of Invesdgadons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-NMSSAFE
Fax # 617-727-7749
;t:.ucd 5.'ons www.mass.gov/dia
CITY OF Siumi, kNL-kss kai sETTs
• BL;UMLVG DEP1R1 MNT
120 W+sHLVGTON STREET.Y°FLooR
TM (978)745-9595
FAX(978) 740-9846
KMjgEX RY DRISCOLL
MAYORTHOs61t ST.P�tRE
DtRwma OF,PCBLIC PROPErry/BCILCILNG COSZIMIONER
Construction Debris Disposal AlTiidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code. 780 CMR section i 11.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
t 11,S 150A.
The debris will be transported by:
ss�
(name of hauler)
The debris will be disposed of in :
(name of facility) w
SyJ>fi�QSCv '. 51c"
address of facility)
Signature of permit applic
- L/
712
tiarC
4.AnvlfJa
77
Apr 27 11 12: 39p Leland Hussey 781 -593-4944 p. l
aw [� CERTIFICATE OF LIABILITY INSU�ANCE
THIS CERTIF CA t S :SSUED AS A MATTER OF INFORMAT Cti CN_� AND CONFERS NO RIGHTS '.,PC N THE CERTIFICATE HOLDER THIS
CERTIFICATE C•. FS NOT AFFIRMATIVELY OR NEGA'1VELr AMEP0, EXTEND OR ALTER THEICOVEFAG AFFORDED BY THE POLICIES
BELOW. iFPS CERTiIr.3ATE OF INSURANCE DOES NOT C NS,TT A CONTRACT BETWEEN THE SSS 'ING :NSUR ERIS!, AUTHORIZED
i REPRESENTATIVE OR °RODUCER,AND THE CER71RCA-E HOLDER. �
IMPORTANT: N ,u the cof calf holder is an ADOIP.ONAL NSUREO, e polley(l a+es) mUSt he tlorse d. If f UHROGAION IS WAlVEO, 5ubjfdt to
the terms and cond'.bons o'tne policy,certain pel<'cles Tray m4uire an er darsemenL A statement tin this certificate does rot confer rights to the
crrl5cate holder h liou of such endorsement(s)
FIAAC
wc,:a;tEx HAW- _
Sabatino Insnrsnce Agency Avo=ter (6i 7� 387-7360 ;i'c r.,:: (61%; 35:-9_RE
561 Sroa:i ay aoQcs.=.._ ---
Everett, Yet '22149
c l:=c-. •s;:Rw A:TRAVELERS
TRAVELERS- -----
5xt:10 Sa rai.o
I1 need hve It[ —
FvArett, M.A v'c119 r•eaR _: ....._-....._..____...___.....__—
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COVERAGES CERTIFICATE NUMBER - REVIS NNUMBER
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F .:.IC=SO ':. a o LO -{ ': T S �'T TO�hE '.N5lF 3
rrC ANY .:rr cr)N^'.TON 4Nv.,CNT4AC i OR 0' 1E4
.:... .iS,.E^. CR :rFV EoT+:•. - :..:RgyC= P 'FC?-EL .. ! PD.CIES OESOt __ '._':. SJc,.-.. _ __ E 1 'S
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tF.5C+1r^Cti GF OPfRATCNS!;CIG1T.f:KS VG?C.�. lA:xfT A?:r4]'Ct.A,rVorW 0.nrte,b 5cf.,dae,ifrnonePtt snaW rid` _--
CERT,E'CATE HOLDER CANCELLATION I
SHOULD AVV CF T, E ABOVE DESVUSED PCUCES BE CANCELLED 9E0RE
i THE Ic%=-,RATION ➢ATE THEREOF, NOTICE WILL HE DELIVERED I9
Leland M Hussey ContSacting ACCORDANCEWITY 'HEPOLICYPROVIS70NS.
409 Washington St
Lynn, Ma 01901 .lrrR2r:]'w wrcrtirATvs. n ^
--
1988-29WACORD CORPORATION. All rights reserved
ACCIRD 25 i2OOW091 Tno ACORD name and loco are realstaruAmertur-a—f ACORD