57-2 WARREN ST - BPA 15-651 REMODEL K&B � zy Z.`�" ��- i � 2
' CA N.O�
': � �' � v tiv� i�e Commonwealth of Massachus � �f�,
. §{ �`�.�� T S Department of Public Safety g�'�PEc�o�,a� s°eRy
, ::�iassachusetts State Building,Code(780 CMR) �CE$.
4�'�� Building Permit Application for any Building other than a One-or 7�cg-F i Dwelling
(This Section For Official Use Only) �
Building Permit Number: Date Applied: Building Official:
$ECT'ION 1:LOCATION(Please indicate Block#and Lot#for locaHons for which a sfreet address is not available)
� S7--L �vA+2.16,u s r• s.9Ge� C�19 i1'
� No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK
4
� Edition of MA State Code used�� If New Construc6on check here O or check aIl that apply in the two rows below
� . Existing Building❑ � Repair❑ Altera6on.� Addition❑ Demoliflon ❑ (Please fill out and submit Appendix 1)
I . CUange of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
� Are building plans and/or construction documents being supplied as part of tlds permit application? Yes ❑ No ❑
� Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Btief DescripHon ofProposed Work:
2�.�No✓� i4rot�1, f BN �.v.t
��I�nl.�GPA �ir_�..�..._ �lni��lsC6 ���� .r /�i4T/f
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SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR �
CHANGE IN USE OR OCCUPANCY
Check here if an ExisHng Building InvesfigaHon and EvaluaHon is enclosed(See 7S0 CMR 34) O
- Existing Use Group(s): Proposed Use Group(s): '
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
� No.of Floors/Stories(include basement levels)&Area Per Fioor(sq.k.)
� � Total Area(sq.h.)and Total Height(k.)
� SECTION 5:USE GROUP(Check as applicable)�
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educarional ❑
F: Facto F-1❑ F2❑ H: Hi Hazazd H-1❑ H-2❑ H-3 ❑ H-4 0' H-5❑ �
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercanrile❑ R: Residenrial R-1❑ R-2❑ R-3❑ R-4❑ '
5: Storage Sl ❑ S2❑ U: UHlity❑ Special Use�O and please describe below:
Special Use:
SEC'I'ION 6:CONSTRUCTTON TYPE(Check as applicable)
IA ❑ IB 0 IIA ❑ IIB O IIIA ❑ IIIB ❑ IV 0 VA ❑ VB ❑
SECITON 7:SITE INFORMAI'ION(refer to 780�CMR 111A for details on each item)
Water Supply: Flood Zone InformaHon: Sewage Disposal: Trench Permih Debris Removal:
'' '''' ��// A trench will not be Licensed Disposal Site❑
Puqnc�}a� Check if oukside Flood Zon Indicate municip ..
v requir or trench or specify: /��s ,�
Private❑ or indentify Zone: or on site system O
permi is enclosed❑
Railroad right-of-way: Hazards to Air Navigarion: MA Hisroric Commission Review Process:
Not Applicabl� Is S7ucture within airport ap roach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or N� Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY � ��
Edifion of Code: Use Group(s): Type of Construcfion: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Speciai Stipulations:
�r`�)� � �-Jl� 1J N cT``G, � l Z.
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner �
i M�' PA2fr�� L�e l6 i�/-�r�i s%� ���� /k�� �'JlT`7�s
i* y
Name(Print) No.and Street City/Town Zip_
' Property Owner Contact Informaflon:
�.,�s � �=,.,�w 9'�' _�izZ o3"�' ��5�� �N�n-�ls�s � -�-
Title Telephone No.(business) Telephone No. (cell) e-mail address
ff applicable,the property owner hereby authorizes
�, Name StreetAddress - City/Town State Zip
to act on the ro owner's behalf,in all matters relative to work authorized 6 this buildin ermit a lication.
SECITON 10:CONSTRUCI'ION CONTROL(Please fill out Appendix 2)
f buildin is less than 35,000 cu.R of enclosed ace and/or not under Construcflon Control then check here O and ski Secfion 10.1
10.1 Re 'stered Professional Res onsible for Construction Control
Name(Registrant) Telephone No. �mail address Registration Number
Street Address City/Town State Zip Discipline ExpirafionDate
, 10.2 General Contractor �
G/�YaJ �i7/d0�' ��i1l�l "
Com any Name
��„rt� F G.�.�. C S ��O 3�l�33
Name of Person Responsible for Construction License No. and Type if Applicable
� �
L� /�N-�- �'� • �:t� � �L5/S
Street Address CiTy/Town� State Zip
�� 2- �32 � �'/7 �i Y� , ,�-.�nw�:1 s�� u� iIGG ' °c�
eT le hone No. business � Tele hone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATiON INSURANCE AFFIDAVIT M.G.L.c 152.§ 25C 6
A Workers'Compensaflon Insurance Affidavit from the MA Departnient of Industria]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 si ned Affidavit submitted with this a licaflon? Yes❑ No 0
� SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Cosis:(I.abor
and Materials) To�l Construcflon Cost(from Item 6)_$ ZZ �G
1.Budding $ / GG G guilding Permit Fee=Total Construction Cost x �t' (Insert here
2.Electrical $ pG appropriate municipal factor)_$��.�1�
3.Plumbing $ Q (,G �
4.Mechanical (HVAC� $ Note:Minimum fee=$ (wntact municipality)
5.Mechanica7 Other $ Enclose check payable to �� �A' �J9'�P/`� �
6.Total Cost $ ��� �GG (wntact 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 penaldes of perjury that all of the information contained in this
applic rion is We and accurate to the best of my owledge an derstanding.
��J� � . ��tiI'1/
--Ns F �u- L�c • ��e �'Zz �,� �
Please print and sign nazne Titte Telephone No. Da e
�l �'�r sl'• ��e�,�� ��[_Y/�
Street Address � City/Town State Zip
� I/ `
Municipal Inspector to fill out this section upon applicaHon approval: � � ( ` �J
� Name � � �� Date
;.� CITY OF S�1I.E:tii, �L3SS.-1CHL'SETTS
' • BtiIIS)L\GDEP�R'I'J��iT
� • � N 1?O W.�SHINGTON$TREET,3"D F100R
`� �e'j T�L (978) 745-9595
- FA.�c(978) 740-9&16
(��{gFRi FY DRISCOLL
411►YOR THo�►s�s Sr.P[Fxx&
DIRECTOR OF Pl:BLIG PtIOPER'iY/BL'IIDLVG CO�L�IISSIO�iER
�Yurkers' Compensation insurance Aftidavit: Builders/Contractors/Electricians/Plumhers
Annlicant Information Plcase Print Le iblv
�
VHt11C(BusiMSs:Organiza[ioNlndividual): ��w � �� '
Address: /� � � / '
Ciry/State/Zip: tA� /tl/� Phone If: C%C�1 L.�
Are you ao employer?Chee�the appropriate bai: Type of project(requlred):
!.� 1 am a emptoyer with 4. Q 1 am a grneral contractor and I 6. ❑New constiucAon
employees(full and/or part-time).• have hired the su�contractnrs
2.Q 1 am a sole proprictor or partner- listed on the attached sheet.� �emodeling
�hip and have no employec5 These subconVactors have 8. � Demolition
working for mc in rny capaci[y, workers'comp.insurance. g, � Building addiaon
[No workcts comp. insurance 5. ❑ We are a cor�wrrtion and ics
required.j officers have exemised their �0.� Electrical repairs or additions
3.� i am a homeowner doing all work right of exemption per MGL t I.❑ Plumbing repairs or additions
myself. [No workerx'comp. c. 152, §I(4),and we have no �Z,�Roof repairs
insurancn required.]f employees. [No workers'
comp. inwrance required.] 13'0���
'Any appliranf that chixks box HI must alsu fill uu�the sec�ioo hlowshowing their wMkers cpmpenwion policy infum�a[ion.
t I Inmeuwnefs whu su6mit this andavit indicaling�hey ue doing nll worlt y�A thrn hirc outside rnntracrora must su6mit a new aRJavit indicuing such
-ComnkYon ihnt cheek�hi�box m�e[atl�chad an aJdi�iurul choet showing Ihe name of the sub-contwcb(s and�heir worken'comp.puliry infomution.
!um an emp(ayer that 7s providing�vorkers'rompensatfon insnrance jor my empluyers. Beluw Is fhe pu/!cy and Jab rfle
informulion. , - D �/� .
In,urenceCompanyVame: 9U�i��.�—{�1��//�� TC
Policy N or Self-ins. Lic.ti: L..I� �� �ik t� Expiration Date: ! yZ
1ob Site Address:�'�7 LC�/�1Z-/IPivt S 1': CirylStatc/Zip: .��`�'i'-t f'//'�
,�nach a copy of the workero'compensation polfey declaratluo page(showing the pollcy number and exptratfoo date).
Failure to xcure covncage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penaltiea of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil pen�lties in thn form of a STOP WORK ORDER and a fine
of up to S2i0.00 a Jay against the violatoc 13e advised that a wpy of this statemcnt may b�: forwurded to the Office of �
Imcs�igatiun,af Aie DIA for insurance cover�gc veriticatiun.
/da lrereby certijy under�hr puins m�d yena/tles ojperjury ehut the injormu�iox providrJ above is� ue mrd corrrcA
Si�n uure � � tt r _��/��
, Phone X: ZZ "'�} 7 ,
� O�cial ust uuly. Do eot write in Mis u�eq m bt conrpleled by erty or town a�eial
City or Tuwn: Pcrmitll.icenye M
lssuing Aulhori[y(circle one): � � .
I. I3urrd uf Ifeallh 2. Ruilding Departm�n[ J.City/1'own Clerk 4. Electrical I�spector 5. Plumbing Inspec[or ���
6.Olher -
Contact Pcrson: Phonc#:
'.' ..
�� Massachusetts -Department of Public Safety
Board of Building Regutations and Standards
. Construc[ion Supen-isor
License: CS-03�3
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F FINN r �_ '�
DANIEL r y
16 FRONT ST - -
�.e�y Mp o1913
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''t .,���n`� Expiration
�,,`... ��` 01/28/2016
' Commissioner
i
- � '`b CITY OF S��1LE��1, 1�'L-1SS.�CHL'SETTS
' BLu.D�:c DeP.+nr�.�r
e ° N• l?O W.1SH4�IGTON STREET,3�D FL002
� �"�'� T�L. (978) 7�5-9595
F�x(978) 7�i0-9846
ICIi[gERI.EY DRISCOLL
i�1.�YOR THon(.+s ST.P�xx&
DIRE�OR OF PCHLIC PROPER"IY/Bl'II.DLNG COSL�RSSIO�iER
Construction Debris Disposal Af�davit
(required for al] demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section i l I.5
Debris, and the provisions of MGL c 40, 5 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properiy licensed waste disposal facility as defined by MGL c
1 I 1, S 150A.
The debris will be transported by:
�� ,
(name of hauler)
The debris will be disposed of in :
, - (name of facility)
(address of facility)
signature of mit applicant -
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Drawing:
All dimensions of built-ins must be verified on site.Verifications of dimensions and inspections are the Scale:
• - ---�-
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�' U��fC �p,fq/„���� 1,�/ p � �* responsibility of others. All changes must be approved by the designec This is an original design and
f�i_ � � A�s l�=_ 5� VY�C�4�.��__S� V�1� � J��_�-- -- ' Date: /� ( q �G��
; -- -- — - - __ -�-- --_ _ � _— -- may not be released or copied unless fee has been paid or job order placed. +P � / �
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: July 1, 2015
Inspectional Services
City of Salem
120 Washington Street
Salem, MA 01970
RE: 57 Warren Street
To Whom it May Concern:
As a trustee of the Trace Condominiums located at the above referenced address, I
acknowledge that JMF Partners has applied for a building permit to do work on the
interior of unit 2 at 57 Warren Street The Trace Condominiums will allow the work to be
done to remodel the kitchen and the bath.
Sincerely,
� �
��
Kimberly Sparks