The URL can be used to link to this page

19 1-2 WASHINGTON SQ - BUILDING INSPECTION (3) i The Commonwealth of Massachusetts Department of Public Safety wits Stale Building Code(780 C\IR)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) Building permit Number: Dote Applied: Budding Inspector: SECTION 1:LOCATION(Please indicate Block 0 and Lot 0 for locations for which a street address is not available) Icl` \1.7r-10�lA1 C�Ff"'x So -1 Lp M -ri le0i, I/�O4c L. ./l ksSP.tJ�n. Nu.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❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied a s part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineerm Pee_g r Review required? �f Yes ❑ No ❑ Brief Description of Proposed Work: IT-1 �_�r �. d1 i'�.1 r . ✓t` ., too] re I✓ , � � 0 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 UseGroup(s): Proposed Use Group(s): i 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 Fluor(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 O I H: High Haiard H-1 ❑ H-2 O H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ 1 M: Mercantile❑ R: Residential R-1❑ 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 ❑ Ifs ❑ IIIA ❑ 111110 1 IV 13 1 VA ❑ VS 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 doulside Fl.u,d Lune❑ Indicate mun,a pal ❑ A trench will not br Licensed Uisir,s,,l Site❑ I'nvate❑ ar u1denulc Zuni:_ or on site scsci ❑ required ❑ur trench ur,pec1fv: ' permit is enclos i ❑ _ Railroad right-of-way: Hazards to Air Navigation: \I:\ I h•h.n, c-..,mm .•n,,,Rv ., Pr. \,q .\ licable❑ 1,"ruClu,r,.ithui a,r rt a i ,ch area.' 1, their re%ictc onn leted.' i 1.1, pit Pi•�u, I' ,r C,n111-nt lit liuild endowd ❑ 1 c•❑ ur Nu❑ Y"❑ \o ❑ SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY l•e f, pm ui Cun,lrutuun: Occupant l�,ad per liuur _ I A4'•the hmldu+�;Cuntam an Spnnklvr�O�Iem': �iM•Cial SUpula hnns SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Ow•nr O / J Name(Print) No.and Street City/Trrwn Lip Property 0%%ner Contact Informatu 4-76 7�y /64Z - - Title Telephone Nu.(business) Telephone No. (cell) a-mad address If applicable, the property owner hereby authunzes Name Street Address City/Town State Zip w act un the property oo'ner's behalf, in all matters relative hp work.utthonzed by this bu ildin • permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (If buildin•is less than 35,000 cu.it.of enclosed+ ace and/or not under Constriction Control then check hem O and skip Se.tion 10.0 10.1 Registered 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 t� S C ny Name: 1 Y..b 9 �►. CS 53�,�3 Name Of Per-, Rrslxrpsible f,,,V ,ruction License No. and Type if Applicable i7 e-blC' uJC )Zd Sua� po 0)" YVV> 0A Street AgLdress City/Town/.¢xs� , Saito 1 �Zi �'S 1-I vw17�a Clvie yt 2A>+^„r A Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(61) 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 0 SECTION 12:CONSTRUC-nON COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)=19751oSJ 1. Building $ 7 So 0.3 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3. Plumbing S 4. Mechanical (HVAQ S Note:Minimum fee=$ (contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6.Total Cost S 7 5'oq3 (contact munici alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the gems and penalties of perjury that all of the information inn to fined m this ry1 lication is true and accurate to the best of mY knowledge and understanding. 1'le.r.e pant and�q;n n. mr Title Telephone Xo. Date �,1� M�.— �a5 street lddress CrtY/T.nrn / State Zip Municipal Inspector to fill out this section upon application approval: 1 / LD \ame 10 tr :Massachusetts - Dcpai-tmcnt of Puh'lic Satct.N Board of Buildim2 Re-_ulations and Standards Construction Supervisor License License: CS 53693 Restricted to: 00 i ROGER A TREMBLAY JR 29 HATHAWAY AVE BEVERLY, MA 01915 Expiration: 5/9/2011 ('onunis�ionor Teat: 1'4698 fi DPSCAI b 4014-08rye-DaSUFORMCA108212008 -_____ _....__----------- Board of Building Regulations and Standards' HOME IMPROVEMENT CONTRACTOR RegIstrat yn, 145375 Ex Irat - _ 3/2011 Tr# 282954 e Corporation ROGERA.TRE ^I _, ¢@ . ( . ORS, INC. ROGER TREMBL 10 COLONIAL RD —,4 C�,,,` SALEM,MA 01970 Administrator \ The Coll unonmealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 wu m.nrrrs'\.govldin Workers' Compensation Insurance AfTidavit: Builders/Couh•actors/El cch•icians/Plumbers A I Alen It information _.�_l—___— _ Please Print Lc ibly Dame (Ills,mass/Olguniv.;lliou/Indi��iduul) D4 11-P1Y� Add( eSS: � �� City/State/Zip,�.(D UZ�j'TJ Phone Arc cnu :ul cm plorcr' Cued, the :Illprupriate huy• .I pc III pro iccl (I equllI'd): l ail a cnynloV�enrill �� 4. (.j 1 am a gcnerll comrotor and l cnlplm ccs (full ,Ind/or p;m-lime).* have hired the sub-contractors f ❑ New construction 2. ❑ 1 am a sole piopricloi or parmcr_ listed on the attached slice(. 7. ❑ Remodeling ship and hog c no employees These sub-contractors have g. Demolition Ivorking for me in any capacil\'. employees and bare workers' No I\orkcrs colnp. nsurance come In surance 9 ❑ Buildingaddi(ion I i � I required.) 5. ❑ We arc n cmporalion and its 10.0 Electrical repairs or additions 3.❑ I am a hrnncoener doing all \cork officers hat c exercised their 11.0 plumbing repairs or additions in)self. [No workers comp. right of exemption per MGL insurance required] c, 152. §1(4), and we have no 12.0Roof repairs cmplo3ccs. [No workers' 13.0 Other comp. insurance required,I `:\m applie:ml Ih;n cbccka hog e I mull ahu lilt nil the s.elion hero„ showing Ihcir wrorkcea compcnsalion puke)'infornl:U ion. I lmneo,cnrr.who anhmil Ilia a ill.161 ind,cnling Ihcc:Ira doing:dl,fork:md Ilan hire uulS iJe coulr•Iclurs nmst submit a new all iJa vil indic;ning such. 'C'ounmlon Ihal.-heck Ibis bo.�natal:nlached an n<IJilinnal shred shoring the ammo of the auhco niracl urs and sane�chcller or not those entities hate uy,lo�ces. Ihhe sub.cnnlrncrora Mace en,ployrrs,the>-anal pro,;de Ihcir workers'comp.policy number. f am an eurplorer that is praridieg n•nrker.c'compensation insurance for n(p emplgpees. Below is the pnlig- and joh site infornmrion. Insurance Company Name: `A`1 C � Policy #or Self-ins. Lic. #: C-3 Ej3 15z —i Expiration Date: tb lob Site Address: ' 2 t 61TK2—,-S] City/Slate/Zip:_ torn ALA 01 Mtach a copy of the workers' compensation policy declaration page (showing tile policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to die imposition of criminal penalties of a !Fine up to$1.500.00 and/or one-year iniprisoruuent,as well as civil penalties in the form of a STOP WORK ORDER and a fine )f up to$250.00 a day against die violator. Be advised that a copy of Qlis statement may be forwarded to the Office of investigations of the DIA for insurance coverage'Lerification. !do herebp cerry(''r under tie pains nird penalties ojperjurr that the lnformadim provided above is true and correct iianature: l(1Lc y�AGt tp� 1 Dace- 2 3— / v "hotted:_ T4 ?e 7yS 3� Official use only. Do not write In ithis area, to be completed by city or toim official City or Town: PermlttLicense# Issuing Authority.(e)rcle one): 1. Board of Health 2, Building Department 3, City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact.Person: Phone#: ACC CERTIFICATE OF LIABILITY INSURANCE GATE(MM DDI010 04/26/2010 PRODUCER (508)651-7700 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 233 West Central Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Natick, MA 01760 INSURERS AFFORDING COVERAGE NAIC N INSURED Roger A. Tremblay Contractors, Inc. INSURERA: Selective Insurance Cc of SC 19259 10 Colonial Road INSURERS: National Union Fire Ins Cc PA Suite 4 INSURER C: Salem, MA 01970 INSURER D: INSURER E'. C VERAGE 1 HE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMISNT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PLY I'AIN,I HE 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. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM[DD� -2UCY EXPIRATION LIMITS GENERAL LIABILITY S 1842342 04/15/2010 04/15/2011 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $PREMISE (Fa 100,000 lCLAIMS MADE L--1 OCCUR MED EXP Any one person) $ 10,00 A X PERSONAL&ADV INJURY $ 1,000,000 _ GENERAL AGGREGATE $ 3,000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AEG $ 3,000,000 RD POLICY X JECT LOC AUTOMOBILE LIABILITY A 9091419 (T4/15/2010 04/15/2011 COMBINED SINGLE LIMIT (Ea accident) $ ANY Auro 11 000,000 ALL OWNED AUTOS BODILY INJURY $ (Per person) X SCHEDULED AUTOS A X HIRED AUTOS GODILY INJURY $ X NON OWNED AUTOS (Per accident) X $500. DEDUCTIBLE PROPERTY DAMAGE $ COMP./CULL. (Par amident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY S 1842342 04/15/2010 04/15/2011 EACH OCCURRENCE $ 2,000,000 X UCCUH CLAIMS MADE AGGREGATE $ 2, 000f000 A $ DEDUCTIBLE $ X RETENTION $ WORKERS COMPENSATION AND WC3531587 07/01/2009 07/01/2010 X TWO STATUS oTH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 500,000 B ANY PROPRIETOWPARTNEWEXECUTIVE OFFICER/MEMBER EXCLUDED? - E.L.DISEASE-EA EMPLOYEE $ 500,000 II yec,desc ribe order SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION Oe OPERATIONS I LOCATIONS I VEHICLES I EXCLOmo`W ADDED BY ENDORSEMENT I SPEcieL PROVISIONS CERTIFICATE EL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE /'� � 4 ^"^', � Rosemary Fulham/PMA ACORD 25(2001 I08) ©ACORD CORPORATION 1988