60 WASHINGTON ST - BUILDING INSPECTION (9) The Commonwealth of Massachusetts
Department of Public Safety
-,,.✓ .\lassachuselts Slate Building Code(780 CNIR)Seventh Edition
City of Salem
Building Permit Application for any Building other 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 It and Lot M for locations for which a street address is not available)
60 /jam!f&ini&Tor-jc
No. and Street Cih, /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 ❑ RepairV( I Alteration ❑ 1 Addition❑ Demolition O (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
We- N�
.sriai NF � �
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OROCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s):�•
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing, Proposed
i
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-2nt❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑'-- H-2-0 H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ 1R: Residential R-1❑ R-2❑ R-3 ❑ R-4 ❑
S: Storage S-t ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
FAO IB ❑ I►A ❑ 11B ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑SECTION7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
r Su 1 Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
PP Y�blic ❑ Check ifoutside• Flood Zone❑ Indicate municipal ❑ A trench will nut be Licensed Disposal Site❑vate ❑ required ❑or trench or>pecily:
or indentik Zone or on site system ❑ permit is0 )r t:)d ❑
Railroad right-of-way: Hazards to Air Navigation: \I:\ I li�tonr C�nnmi.+i �n Ito.6• t.........:
N"t :\pphcable❑ I.Stniduru ailhin airport approach area' In their review completed.'
"I(lin.Cnl h� Budd r"I" -i ❑ Yes❑ nr No ❑ Yes ❑ \o ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Cede: Lx•Group(*): Tcpe of Construction: OCCUpant Load per I looe
DUCP the building contain an Sprinkler S\'stem.': Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION n
Name,pnd Address of Property Owner / O�QD�R��RO��RrrS //�A.12T -4111w-4111?Lyaq O/q/S
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
XTitle Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town State Zip
to act on the pro pert%owner',behalf, in all matters relative to work authorized by this buildin • permitapplication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 35,(IW cu. ft.of encluxd s pace and/or not under Construction Control then check here O and skip Section 101)
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
ale,AO/1 sus �ousrQa �o� r�uc
Company Name:
x ebe o SosA CS 5L 99 #g8
Name of Person Res onsible fur Cunstntctiun License No. and Type if Applicable
17 /3A/LGS' -. U� Q/UE�PI Y AAA• 0f4�f
Street Nddress City/Town State Zip
32i4M
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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor Total Construction Cost(from Item 6) _$
and Materials)
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
- Note: Minimum fee =$ (contact municipality)
4. Mechanical (HVAC) $
'�( 5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ ' QQ (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 my knowledge and understanding.
x f//GTO/P SSA ,el Dw4/6QWK
sign name Title«rRr/� Ed6y/r /titleet Address Citt"/T: wn✓Municipal Inspectorto fill out this section upon application approval:
a CITY OF S:U-&%1, ILALSSAC1 -TTS
.� BL'ILDLNG DEPARTNLE-NT
• 120 WASHLNGTON STREET. 3iD FLOOR
TFiL (978) 745-9595
FA<(978) 740-9846
KIMBERt EY DR1SCOLL I•HOh1AS ST.PIERM
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUMDLNG CONL%IISSIOrER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
4 r licant lnformatfon Please Print Legibly
Nai11c(Business,Organualion'Individual): U/eTOW S,9.9-,4 CaW9 4 611 5 7 10A1 rNc
Address: 7 QiQ/L F"Y /�/✓<E
City/State/Zip:.�L aAfW_Z y in 2 2121'C Phone k: ---
Are you an employer?Check the appropriate box: 'Type of project(required):
4. ❑ i am a general contractor and 1 6. New consirta:tion
1.❑ 1 am a employer with_, _ ❑
employees(full and/or part-time).* have hired the attasub-ched
sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
]No workers' comp. insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption r MGL I i.❑ Plumbing repairs or additions
3.❑ I a homeowner doing all work c b 152 1(4), nd we have no
myself. [No workers' comp. •$ 12.[g Roof repairs
insurance required.]t employees. LNo workers' Il.❑ Other
comp. insurance required.]
•Any appticam tIW dwcks boa MI matt alto fill out the section below showing their worker'=mpenwiun policy nourmutiun.
'I i.aneavmer who submit this affidavit indicating they am doing all work and thm hire"tsidecontractor most suhmil a new afrdaviI indiofing suck
:Cantroctor that cheek shy box mutt anached m adtkfiuted short showing the name of the sub.cantnctom and Choir workari comp.pal iry information.
l um an employer that is providing workers'compensal/on insurance for my employees. Below is the policy and Job site
information. _
insurance Company Name: /
Policy 4 or Self-ins. Lie.H: `7 201 PJ7/+1 Expiration Date:! `�O
Job Site Address: iWA57 1^6.1—VA1 .S% City/State/Zip: 5/f140 10M 0ZQ �
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failura to secure coverage as required under Section 25A of MGL e. 152 can lead to.the imposition of criminal penalties of a
tine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. De advised that a copy of this statement may be forwarded to the Office of
Investigations of tlrc DIA for insurance coverage verification.
l do hereby certifyr the sand penalties of perjury that the otfurmation provided above is true and correct
SiLn,lure Date:
Phone a `778 26S' 71' 3 2
OJjicial use only. Do ,or write in this area,to be completed by city or town ajj7cia6
i
City or Town• __._- .--
Issuing Authorily(circle one):
I. Board of Ilealth 2. Building Department J.City/Tusvn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other .-- ------._ -
Contact i'erson: _ - __.. ... Phoned:
[
Information and Instructions
\1ass.idiuscits Gancral Laws chapter I j2 acquires a I I employers to provide workers' compensation liar their employees.
Pursuant to this siatuie, an empforee is defined as"...every person in the service of another under any contract of hire,
cxpre»or implied,oral or written."
An employer is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more
a the forewing engaged in a joint enterprise.and including the legal representatives of a deceased employer,or the
receiver or trustee ul'.ur individual, partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenunce,cunstruclion or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152. g15C(6)also states thug "every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
;applicant wire has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally. MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
` enter into any contract for the performance ufpublie work until acceptable evidence uf cwmpliunce with the insurance
requirements of this chapter have been presented to the contracting authority."
Appiicmtts
Please till out the workers' compensation affidavit completely,by checking ilia boxes that apply to your situation and, if
necessary, supply sub-contractors)numc(s), address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and duce the uftidavit. The affidavit should
he roomed to the city or town that,the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain u workers'
compensation policy,please call the Department at the number listed below. Scif-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete;md printed legibly. 'rhe Department has provided u space at the bottom
of the affidavit for you to till out in the event the Office of Investigations-has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will by used as a.reference number. In addition, an applicant
that must su6ma6n�n1[ipie,pennitllicease applications in any given year,'iieed•onlysaibanit one affidavit indicating current
Policy information(if necessary)and under"Job Site Address"the applicant should write "all locutions in (city or
town)."A copy of the uftidavit that has been officially stamped or marked by tilt city or town maybe provided to the
applicant as proof that a valid affidavit is on tilt for future permits or licenses. A new af7iduvit must be filled 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. it dog license or permit to bum Laves etc.)said person is NOT required to complete this affidavit.
I lac Oflic:c ut lmvestigatlons would like W drank you all advance for your cooperation and Should you have sly questions,
please du nut hesitate to give us a call
The Ucparunent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents 1 .,
Oiiice of Investiradons
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
X.,.t,cd 5-1e415 Fax 0 617-727-7749
www.mass.gov/dia
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ACORD CERTIFICATE OF LIABILITY INSURANCE i1/16/20'
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Rose Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 958
Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:WESTERN WORLD INSURANCE C
Victor $osa Construction Inc INSURER B:Travelers
7 Bailey Avenue INSURERC:
INSURER D:
Beverly MA 01915- 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.
INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE MWDDY DATE MM/DD/YY LIMITS
N
A GENERAL LIABILITY NPP1260104 02/12/2010 02/12/2011 EACH OCCURRENCE $ 1,000,000
R COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence S 50,000
CLAIMS MADE OCCUR MED EXP Aoy oneperson) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000
POLICY JECT LOC NOWND
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALLOWNEDAUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
NON-0 WNED AUTOS (Per accident)
PROPERTY DAMAGE
(Per accident) S
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHERTHAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S
OCCUR CLAIMS MADE AGGREGATE S
S
DEDUCTIBLE S
RETENTION $ S
B WORKERS COMPENSATION AND 4201P74A 04 20 2010 04 20 2011 }[ I TORVLIAMITS I I OER
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEES 500,000
It yes,describe under
SPECIAL PROVISIONS belay E.L.DISEASE-POLICY LIMIT $ 100,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
030 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
City of Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER ITS AGENTS OR REPRESENTATIVES.
— THOR PR ENTATIVE
ACORD 25(2001108) O ACORD CORPORATION 1988
INS025(oioe).o6 Page 1 of 2
CITY OF S.U.&NI, UxsSACHUSETtS
• BLIMLNG DEPARTMENT .
• 130 WASHNGTON STREET, 3"°FLOOR
dr TmL (978) 745-9595
FAX(978) 740-9846
KIJEBERLEY DRISCOLL
T
MAYOR �Io.+tAs ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BL'I]WNG COMMISSIONER
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 a 40, S 54;
Building Permit# is issued with ilie 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:
t/tPToa sys� caIVO-kycTtod
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit applicant
slate
dcbrw1rd,k
Mwssae'busetis- Department (it Public ' :ACIN
Board of Building Regulations and Standard.
�• Construction Supervisor Specialty License
i License: CS SL 99488
i Restricted to: RF
VICTOR SOSA
j 7 BAILEY AVENUE
I
BEVERLY, MA 01915
2
Expiration: 2JI412012
( „nunisi,ncr Tr;;: 99488 ..�
r