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19 1-2 WASHINGTON ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts •� I.,/ j Department of Public Safety \laswtchu>etls State Budding(L cede(%80 C>1R)Seventh Edition City of Salem ✓� Building Permit A lication for an Buildingother than a 1-or 2-FamilyDwelling I his`e- ion For Official Use Only) U,{ [it'll ermlt .Number: D to pphr Building Inspector: SECTION 1: LOCATION (Please in cate lock M nd Lot M ocations for which a street address is snot available) -2 3111\1 u` a � A ll rf� t i\JSA(�1'h 'so,and titreet Citv /Town Zip Code Name of Building(it applicable) S ION 2:PROPOSED WORK If New Cunstructi check here❑or check all that apply in the two rows below Exis epair Alte❑ un ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Changeuf Use ❑ Changeuf Occupancy ❑ Other ❑ Specify: _ Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No A Is an Independent Structural Engineeringeer Review required? Yes ❑ No 4 Brief Description of Proposed Work: IF, Vt n(' 11� ll Q 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 Use Group(s): Proposed Use Group(s): Y 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 ❑ A4❑ A-5❑ 1 B: Business ❑ E. Educational ❑ F: Facto F-I ❑ F2 O H. Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2 ❑ I-3❑ r4❑ M: Mercantile❑ It: Residential R-i❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2 O U: Utility❑ Special Use❑and please describe below:. Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) IA ❑ IB ❑ IIA ❑ 118 ❑ IrIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ I SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: 7L."Debrismoval: r uhlic❑ Check duublde Fb�,��i Znnv❑ Indicate municipal ❑ A trench will not he uwtl Site❑required ❑or trench I'riv,th•❑ ur utdenulc Zone: ur un�rtr.c,trm ❑ permit t*enclosed ❑ I~ Railroad right-of-way: Hazards to Air Navigation: MA Ih•b-n, c OF;olo •nm H,1,—" Pr-—: \ ,! \I•phi.dly❑ I.tilruawc o ilhut mr port oppniach area' I,their w%ictc inml•Ictrd., „r( ovnt I" Budd oid, ,vd ❑ Yr. ❑ \o a SECTION 8:CONTFN'T OF CERTIFICA fE OF OCCUPANCY I..1 it n,n •I ( ,'d, ,..__ L,v(in,upl.c _ —fr pv w ( „r..lru Ituun- Occupant t'd,l per I lour ILA,. the b111,11og iontMil,m 5pnnklvr>t.icm'' _ '�pv, of stipulation, SECTION 9: PROPERTY OWNER AUTHORIZATION Nome and Addrvs.,of Property Owner Nome tPnnt) No.and Street City/Town Zip 1'rola,rty O+c ner Contact Intormanon: Title Telephone No. (business) Telephone No. (cell) e-mad address If opplicoble, the pn+prry owner herebv authorizes .Name Street Address City/Town State Zip w oct on the pro -rty ,%%ner's behalf, moll matters relative to work.tuthurized by this building permit a + plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (11 Kidding is lv s than 35,U0ucu. it.of endox-d s rise and/or not under Construction Control then check here O and siup 5i tion I0.0 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. email address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor y �OCrtf A: I1—fl-t•h V�y Cp v .N Rr-c �1=m�Y'e,M�1C�1 ZA= Nal pf Person Res ins Ip or Cunstru ttun License No. and Type if pplicable j fi Cm_ Ibv Iak _Sur e `� �a I�� / Street Address `t City/Town Stitte Z� ,eV It^Q1. Wa4 CCrr� '� 1�P'✓i2J.n yV2 Telephone No.(business) Telephone No.(cell) e-mail address SECTION 11:WORKERS'C MPENSATION 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 issuance of the building permit. Is a signed Affidavit submitted with this application? Yee O No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) _$ 1. Building I $ 15000 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ J. Mechanical (HVAC) § Note:Minimum fee=$ (contact municipality) S. Mechanical (Other) $ Enclose check payable to 6.Total Cost $ �,��p� (contact munici alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I herebv attest under the pains and penalties of perjury that all of the information contained in this apphcunnn is truelanJd, accurate to the best of my knopvledge an"d onderslanding. f'Ir.r.c print end inn�j r j�,� ritle Telephone.No. Date r }`� SiJ� y i ' 'iIwtq Wdre.. C-ihr'Tnw❑ State p Municipal Inspector to till out this section upon application approval: \ame ate Massachusetts - Dclwilment of Pub-lit 1,ActN , Board of BuiltlinLr Rc_ulation_v and Standards Construction Supervisor License License: CS 53693 Restricted to: 00 x" + ROGER A TREMBLAYJR 29 HATHAWAY AVE BEVERLY, MA 01915 Expiration: 5/9/2011 (lanm i"ionar TO: 14698 DPSCAI 6 40M-0at08-D8SUF0RMCA108212008 ... .. ----------:.----------------- p. C✓k -t°i�iv,».a eu aal!/c o .�aeaac/urorl2 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR {` Regi trap 145375 E Ex-lrat - r 3/2011 Tr# 282954 ' - e Corporation ROGER A.THE _ ORS, INC. ROGER TREMBL 10 COLON!AL RD SALEM,MA 01970 Administrator I CITY OF SiUE.LI, UNSSACHUSETrS BL'ILDLNG DEPsimmV'T j 130 WASHNGTON STREET,3'FLOOR a TEI.. (978) 745-9595 FAX(978) 740-9846 KIJtBERLBY DRISCOLL .NMAYOR T Homm ST.PtERRE DIRECTOR OF PiB11C PROPERTY/BUILDLNG CON MIISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit#I 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 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name of facility (address of facility) Ognature of permit applicfitit MIgrc� a3 9-oT date JcbrisalT.dw The Conanonmealtli of Alassaclutsetts Department of Industrial Accidents Office o/Investigations 600 Washington Street Roston, MA 02111 wvly.nrass.gol/rlia Worliers' Contpensation Insurance Affidavit: [Binders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (ISusinaeJOrg;niiiuliuidlndividuui): ( 1( c /� Address:- - l® Q—AC114-.Q City/State/Zip S4 teVti YV'wA (D Phone # 7q.5 rlre cnii .In enlpinwer' ('herI. Ihe ;Ippropriale Ilu\- _ ��[�J,� d lama cncnll contruclor sill 1 I)pc of pru ccl (I vquirrdl. I,C" tan a culployer vcilh Z-r7 U g- ciuplorecs (full and/or pan 1-unit).* II>roc hired Ihe. sub-conlraclois f' ❑ Nctw consl nicliou 2.❑ 1 am a sole piopric[oiorpmillcr. ltslcd oil Illc ,lllachcd sheet. 7. ❑ Remodeling ship and hare no employees These sub-contractors have g, ❑ Demolition (corking for nic in an> crgrlcip employees and have\workers' coup, insur<uicc 1 9 ❑ Building addition [No \corkers comp. insurance- I required ] ?. ❑ We arc it coiporalion and its 10.0 Electrical repairs or additions 3.❑ I and a homeowner doing all work officers have exercised their I I.❑ Plumbung repairs or additions myself, [No \workers' comp right of exemption per MGL C. 1i2. $1(3 _ 12.0 Roof repairs insurance required.] ) anti\ce hart no cmplo3ccs. [No )workers 13.0 Other comp. insurance required.] \n appii ml Ihil h ak box isl nuisl alsu[ill uul tile. limn beloweho"ingth<irnvurkcrs'compensationpolicy infonuaiion. 0 11W." rl 1 o submit llu,i[Ldacii i ndm tlinw Ihar ti doung Al work;old then Imc nulside contractors inusl submit a nel% afftdavil indicating such. {unhnclurs(het.h.ck Ibis boy nnist au a.lied inn azlJn maul>haet shuwing the name of the zub.eantraelurs mill stac oiclhcr or not Ihasc emilics have nlplm c.•s If the sub-cnntrnetua line ennployees,Iho nnisl pm ire(heir workers•eoinp.policy number. t ran an enrplarer that it providing Inorkers'compensation insurance for nil,enrptgpees. Delon,Ls the police mod job site inforrnarion. /� Insurance Company Nanic: N I& Policy #or Self-ins Lic. #: WC- 35 3 J5� Expiration Date: r ( Job Site Address:r!t Z ''pr, st City/Slalelzi p .&ltrw, Af%rA a 1c,-7 o kitach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to die imposition of crimilial penalties of a nine up to $1,500.00 and/or one-,year iniprisomueul,as well as civil penalues in Ote form of a STOP WORK ORDER and a fine A up to$250.00 a day against die violator. Be advised that a copy of Otis statement may be forwarded to the Office of 'nvestigations of die DIA for insurance coverage Lerification. !do hereby certlfv under the pains and penalties of perjury that the Information provided above is true and correct zipnature Date 311011e#: Ofjlclal use only. Do not rvrlte br this area,to be completed by city or loom offlcial. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Cleric 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: A-C RDM CERTIFICATE OF LIABILITY INSURANCE Dn7/08/ 2009 07/OS/2009 PRODUCER (508)651-7700 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC - Commercial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 West Central Street HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Natick, MA 01760 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED Roger A. Tremblay Contractors, Inc. INSURERA: Selective Insurance Co of SC 19259 10 Colonial Road w$URERB: National Union Fire Ins Co PA Suite 4 INSURER C: Salem, MA 01970 INSURER D: INSURER 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 OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR DO' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE(MMIDDfM DATE MMIDDLYYJ GENERAL LIABILITY S 1842342 04/I5/2009 04/15/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 CLAIMS MADEI OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL$ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _ PRODUCTS-COMP/OP AGG $ 3,000,006 POLICY IFA-11 JECT LOC AUTOMOBILE LIABILITY A 9091419 04/15/2009 04/15/2010 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY - X SCHEDULED AUTOS (Per person) $ A X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) X $500. DEDCUTIBLE PROPERTY DAMAGE COMP./LOLL. (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EA ACC $ AUTO ONLY: AGO $ EXCESS/UMBRELLA LIABILITY S 1842342 04/15/2009 1 04/15/2010 EACH OCCURRENCE $ 2,000,000 Llvvvjvvv A $ DEDUCTIBLE $ hX RETENTION $ $ WORKERS COMPENSATION AND WC3531587 07/01/2009 07/01/2010 X wORTABTU- oTH- EMPLOYERS. LIABILITY E.L.EACH ACCIDENT $ 500,000 B ANY PROPRIETOWPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 SPECIAL PROVISIONS below r OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE H LDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE t. 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 � _ / ,Rosemary �� Fulham/PMA V�. ACORD 25(2001108) FAX: (781)586-8120 ©ACORD CORPORATION 1988