70 WASHINGTON ST - BUILDING INSPECTION (6) ,
; � `'� 2 —" � � Ti3i - iS � � yS� c� �2�ZS�
*� The Commonwealth of Massachusetts
� Y�epaztment of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a Onr or Two-Family Dwelling
(fhis Section For Offlcial Use Only)
Building Permit Number: Date Applied: BuIlding Official:
SECITON 1:LOCA1'ION(Please indicate Block#and Lot#for IocaHons for which a street address�s not available)
� s`�eNa�,� c�-x�..��N6 Cvc�:_
10 �S�F�u�i'tb�l Cir• 5na�-w��?�p- t��5-lo p �2No �uzl
No.and Street City/Town ' Zip Code Name of Building(if applicable�
SECTION 2 PROPOSED WORK
Edifion of MA State Code used_ If New Conshvction check here O or check all that apply in the two rows below
Existing Buflding❑ Repair� Alterafion� Addiflon❑ 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 as part of this permit applicaflon? Yes � No ❑ ' .
Is an Independent Slructural Engineering Peer Review required? Yes ❑ No f�'
Brief Description of Proposed Work: '��/i f7C D0�1� ��C£ i^�TO -�y��O �t,(/� �__.��s__�
0� �S �r-�� C ti' 'Ci1Z� .-�i: v�nU. l.G. 1 ��u�
�1i � (dtc.vq'lor�
SECTION 3:COMPLE'TE THIS SECTiON IF EXISTING BUILDING UNDERGOING RENOVATION,ADDTTION,OR
CHANGE IN USE OR OCCUPANCY I
Check here if an Existing Building InvesHgarion and EvaluaHon is enclosed(See 780 CMR 34) 0
Existing Use Group(s): Proposed Use Group(s): �
� SECTION 4:BUILDING HEIGHT AND AREA
. Exisring Proposed
No.of Floors/Srories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Tota]Height(ft.)
SECT'ION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Ai Hazazd H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: InsHtuHonal I-1 ❑ I-2❑ I-3❑ I-4❑ M: MercanHle❑ R: Residenrial R-1❑ R-2❑ R-3❑ R-4❑
S: Srorage Sl❑ S2❑ U: UHlity❑ Special Use O and please describe below:
Special Use:
SECl'ION 6:CONSTRUCTTON T'YPE(Check as applicable) .
IA � IB ❑ IIAO IIB � IIIA ❑ IIIBO IV O VAO VBO
SECITON 7:SITE INFORMAITON(refer to 780 CMR 111.0 for dMails on each item) �
Trench Permit: Debris Removal:
Water Supply: Flood Zone InformaHon: Sewage Disposal: Licensed Dis osal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
Private❑ or indentify Zone: or on site system❑ �e4uired O or trench or specify:
pemuY is enclosed❑
� Railcoad right-of-way: Aazazds to Air Navigation: MA Historic Commission Review Process:
� Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes� or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building wntain an Sprinkler System?: Special Stipulafions:
�'� C�i� ��"70�3 .� ��J�
SECTION 9: PROPERTY OWNER AUTIIORIZATION '�
Name and Address of Propert�Owner
�/�N�{' PR�p6RTfb5�I� V��RS�t�Eyii�^I �i'1'. �n�'Fa^'I� 1�A• 01 °I'1�
Name(Print) No.and Street City/Town Zip
Properiy Owner Contact/In/f'ormafion:
�i�1/YF�RfL� ��� / Y1Pp(qr1G�P-'-`1'�- �111Z _-= QPoY9P�UP✓r14+rx�nPv�fS C,�i
Tifle"��r t '� Ifelephone No.(business) Telephone No. (cell) J�e-mail address .
If applicable,the property owner hereby authorizes �
IkNYI� C.Y�'1�4'fS�7 'L•�� $�tt'd�.3 Si'. �o. �1Oe�rcyL �u4- 6�84"�
Name Street Address City/Town Shte Zip
to act on the m e owne�'s behalf,in all matters relafive to work authorized b this buildin ermit a lication.
SECTION 1P.CONSTRUCTION CONTROL(Please fill out Appendix 2)
f buildin is less than 35,W0 cu.R of enclosed s ace and/or nof under Construcdon Control then check here�and ski Sectlon 10.1
101 Re 'stered Professional Res onsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town Shate Zip Discipline Expiration Date
10.2 General Contractor
�.�D�w/5 C�, �a�► C .
Company Name
`�p�� C. M�sf S G5- a�s�}35 r--t�:s. Ca,.�r. 5,,��-� r � ,�,M„-��
Name of Person Responsible for Construction License No. and Type if Applicable �
Zmc� SWra�_�I�T 'p�h l�no�i� � o�$4S
Street Address ( City/Town State Zip
�-�0.-5]I- ��1iy IS�•ES� 0.�w�T5<S �MWNdr'��y �a. C-aNi. .
Tele hone No. usiness Tele hone�No, cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152§25C 6
A Workers'Compensafion Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with tivs application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a si ed Affidavit submitted with this a lication? Yes O No O
SECITON 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Esflmated Costs:([.abor �
and MateriaLs) Total Constructlon Cost(from Item 6)_$ 20�o po_
1.Building $ �� .s�• '� Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ vp J. . appropriate municipal factor)_$
3.Plumbing $ rJ(�} .
4.Mechanical (HVAC) $ �p� Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ ' J_ � ��-/� //�
Enclose check payable ro Cv�
6.Total Cost $ Z 0 O D D_ ' (contact municipality)and write check number here
SECTTON 13:SIGNATURE OF BUILDING PERMTT APPLICANT
By entering my name below,I herebj�.� est under the pauvs and penalties of perjury that all of the informafion contained in this
application is true and accurate to 14 t of my knowledge and understanding.
M.f.A�eb.�s C,,�x.
D C, r�rt,r��n�f ti,�l -S5� -��'S2 l-lb-Ig'
Please print and sign name Tifle Telephone N/o. . Date
�O �i�,.RLnI �, �o. �L'JM�lL— j� [I(K 41
Shreet Address City/Town State Zip .
Municipal Inspector to fill out this section vpon applicarion approval:
Name Date
� Massachusetts -�epartment of Public Safety CITY OF BOSTON
LIC. 1 0 g2��=��
Board of Building Regulations and Standards BOARD OF EXAMINERS �s�-
ConstructiunSupen�isur MAYOR f :�ti�=a�,
License: CS-055435
THOMAS M.MENINO � <� ilj ,;i
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ANDREW CMAT�ES _ '�,r � " � �w�� A� _ C _ ES `�:z� .
200 SUTTON ST= ' � w �tmo�vtto6is�orrs oF rNe�¢�
N AIVDOVER MeY 01845 ��°� � ��� oq � HqB m�r+o �
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��„� �jJ� " �"�� Expiration BOARDOFIXAMINERS � ��
Commissioner � 09/23/2014 °��p��oe�H.mna=_ao.�in _
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�_ORce af Consomer Affairs&Busidess Reguladon ��, -, OSHA - ;Q�fl 7(�{1.�3 2 ' ; a��J
q OMEIMPROVEMENTCONTRACTOR �F�, '
h-- �-. �� �egist2tlon 138754 TYPe `° � us oeparo-neMoriacor� .;� •
� xpiration 5/6/2015 . Individual t p��twnalSaferyanaHeannAarninisiratwn ��
ANDREW C.MATSES '- - _ . "�� /�n(JfeW C. MatS@S �' � �
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ANDREW MATSES -- � � ��h's�`'�'fi'�hCO11P���a�ohouroccupational5aleryaritlHealtn� •��:!
F ' �hainingCaursean '� .. . -�.�
200 SUTTON ST. g �- -Q o %x�- �-�s���on Sa(e &Health -� �
NO.ANDOVER,MA 01845 -- ' Undersec�etary t� ` /- ' --, ;.
�� •Ca� _ 5�f`s
�%_ . �(Raucer) '.�o�e) x' I
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From: Jefl 5[ein q�ein�pc�orensic.conu
Subjeci: Re:PSYCH.CONS.SVCS.
0ate: January 16,201412:40�39 PM EST
To: "acma[ses�mcantlrewsco.com"cacmatses�mcandrewsco.corr�
Cc: Etl Nilsson<enilsson�nsaarch cortu
The ownef is:
Vernet Properties .
70 Washing[on St,Sui[e 310 �
Salem,MA 01970
Ph:978744.4272
Farzt 978744.42BB .
EmaiC neoroeQv eto o rtes o .
Dr.Jefl Siein
. Psychological Consulting Services,LlC
70 Washington SM1eet,Suite2t0
sa7em M A 01970
phone: 378-74p3700
tax: 978-740-5656
email: isteinC?pcsforensiccom �
i(rtemet:www.ucstorensic.com
Conll�entlaliry Maice
� lltelnloima5ontraismlttedinUfisz-mvlcaistlWteanelccfroniccomrnunicxSaovAfiinIDewopeot,heElecttonloCcmmuoicazionPrlvecyAoqiBUSOn25ID,an�isintentlalontyfortheperwnoran[ryro
which it is atltlre�aetl as it may wntain coMitlenlial antllor legaily p�iH�et�ed intmmation.Rny reU,ex retransmis�ion,aissaminarion or oiher use of or taking cf any actlon In reliance upon W s ir�lcnna➢on Dy
persons or enttlies mher p�an Ihe intentl�rxiplent Is p•oMbitetl untler f 8 USCA 251 Y antl xny appiicade�axs.
If y�u receiveC this nmeil in artor,pleasx wntect ma sontler and Cmeca ihe e unail antl erry ettac�ea mateCal Imm�tatefy.Thznk yeu-
On Jan 16,2014,at 11:17 AM,s^ma[ @ nntlr m�:c com wrote:
JefflEd,In fillin9 out the 6uildi�g permit app�icaton,it is requesting that we entar the building owner,their adtlress,[elep�one numCer.and errail addrass.We will lhen
naed Ihem to sign ihis appltiation betore I ran tlrop ott.Do yeu havethis information you�au!d torward to me�
7hanY.You.Andrew
aMCA E-M,AIL SIGh�aTURE LOGO.JPG>
� M.C.Andrews Co.,Inc. '
200 Sutton Street �
Nonh Antlover Ma.01845
T:(378)557-7532 -
F�(37a}&35-2357
www. �ndrew�.�+.rom
1vww.2ndrewmalses acndrect com
AnclteW Q M2tses,PreSider,t
On Jan 1Q 2014,a[8:12 AM,Jeff Stein wrote'. �
Thanks Andrew
Dr.Jeif Stein
Psycholqgical Consulting 3ervices,�LC
70 Washingfon Sireet,Suite 210 "
Salem MAots70
phone: 978-740J100 .
fax: 976-740-5656
email: istein@ocsforens'c com
Internet:www.o <foren�i om
Coniitlen6alityNINic2
� Tneintormatio�Vansmit['1iinMise-meilconsnt�teanalcclmNecommunicationwMlnViescopeolfieElecVonicCemmunlcafionPnaecyAcl.tEUSCA2510.ar.dislrtsntletloniyloR.`:epxrsunor -
Eltity to wnl[A ft is aptlte55�85 0 meyconiain collhdMtial atitlb�lega:ty pnNleg�Iniotmellon.Any redew,rePanSnls5loM1 Uisseminanon or mner uSt N or�BKIng of an�l aCllen in iella�ce u00n fils
Informa4on by persons o�enUlies otl�er i�an the interitle0 reclplent is prchibi�etl u`Me�18 USCA 2511 antl any appllctble IaHs.
If you recwve0 ttils eraail m erroq please con�actIDe s�ntlerand de!eie ihe emal�and any anacM1etl meffinal immetllctHy ihans you.
� i� CITY OF S��1LE;�1, �'L'�SS.�CHUSETTS
BtiII.DL�1G DEP�R'I'���iT
• ` �• l?O W.�SHINGTON STREET,3�D FLOOR
•� �d�` � ���a� �as-�s�s
EAx(97� 740-9846
KI\BERLEY DRISCOLL
�fAYOR THoeus Sr.P�texs
DIRECCOR OF PCBLIC PROPER"fY/BCIIDL�IG COJL�RSS[O�iER
Workers' Compensation Insurance Aftid�vit: Builders/Contractors/Electricians/Plumbers
Analicant Information Plcase Print Leeibly
� V8I11C(Busi�ssOrganizatioNlndividual): M� �, �Y`e�l�t(JVvS Cd� "�C _
.�
Addrass: 2-� S�o"{ ST�
City/Sqte/Zip: �d: �.lo6v'C-�-�,MF�- �\84S Phone l#:_.( G�� 1 SS7�5?7� ,
Are you an employer?Cdeck the xppropriate boi: T
ype of project(required):
1.(�1 am u cmployer with 2 4. � 1 am a gcncral contractor and 1 6. ❑New connuuction
employees(full and/or part-dme).• have hired the wb-contracmrs �
2.0 1 am a sole proprictor or partnor- listed on the attached sheet� �• �Remodeling
�hip and have no employ�ea These sub-contractors have S. �Demolition
workin for mc in an ca acit , worke�s'comp.insurance.
g Y P Y 9. ❑ Building addition
(No workcrs comp.insurance 5. ❑ We are a corporation and its 10� E���cal repairs or additions
requireJ.) officers have exeroised their
3.❑ 1 am a homcowner doing all work right of exemption per MGL 1 LQ Plumbing rcpairs or additions
myself. [No workers'comp. c. 152,§I(4),and we have no �2,� Roof repairs
insurance required.J 1 �mployees.[No workers' �3 ����
comp. insurance required.j
•Any applicanl Ilwl checke box A1 musl alw fill uut Ihn sectioo beloW showing Ihe'v wprke�s'compensuion policy infurmuion.
�I Inmeownen who submit Ihia af}Sdavit indieuing�hey a�e doi�g oll wotk and thm hire outside cyn[r�cemp musl auhmil a new aRJavit indianing such
=Comnkyon�hot d�eek ihie bm[mint atlxhed an uWitiad uhm showing Ihe name of Me eub-contrecWn and their wohen'comp,ppliry infomurioo.
i !um an employer rhat is providing workers'rompensaNan insuraece for my empluyees. Below ls fhe polJcy and fob rlfe
injormution. q
Insurance Company Name: �C-1,011�r' ��15. (� ,
Policy�ur Sclf-ins.Lic.H:�1LCI-� - C�?.���i '7 t N— I �- Expiration Date: �Z— I('I�I'. 3—I I' ��-
Job Site AdJress:�� �/dSYhHEYR1e� C'T. Ciry/State/Zip:_��� il�(An O�'7 D
,1ttac6 a copy of the workers'compensation poliry declaratfon page(showing the pollcy number and ezplratlon date).
Failure to x;cure coverage u required unJer Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as wcll av civil penalties in the form of e STOP WORK ORDER and a fine
of up to 5250.00•r Jay against the violamr. I3e advised that a copy of this statement may be forwarded to the Office of
Invcsligaiio •uf t G DIA for insurance covcragc vcrification.
/Jo/rer e !j ander tNr palns and pe��a/rles ojperjary rhat[he injormuNon providrJ ubove Is true und co�rea
i m ire• Datc: , ^ � �''� � ,
Pn��C : �'4'1 a� 55� — �1)"3�—
O�cia!use oaly. Do not wiile in thir urea,to be rompl�ted by crry or rown o�ciaL
City or Tuwn: Pcrmitlt.Icenxe ft
Issuing Au�hority(cirdc one):
1. Duard uf 1lrrlth 2.Building Dep•rrtment 3.CityfPown Cterk 4. Electrical Inspector 5. Plumbing Inspetror
6.Other
Cunlact Person: Phone#•
I
,< CI"I'Y OF S��LE.�1, �'L�SS.�ICHUSETTS
�• ' BtiII.DL�IGDEP�R'i��.�iT
'� 130 W.1SHL�IGTON$TREET,3�O Ft.00R
� �' T�L (978) 745-9595
F�x(978) 740-9846
KI\tBERLEY DRISCOLL
i�1AYOR TrtoatAs ST.PIERRS
DIRECiOtI OF Pl:BLIC PROPERIY�HI:IIDIl3G CO�L�lISSIO.iER
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# is issued with ihe condition that the debris resulting &om
this work shall be disposcd of in a properly licensed waste disposal facility as defined by MGL c
11 l, 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 permit applican[
date
Jcbrisalt:d�x
, al �1
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I � � OFFICE +' 15'-8`± 9'-6"± 9'-6'� 13'- "� t
N N OFFICE �4�- � ���- NILSSON+SIDEN
� . �. _ _ _ . _ _ _ . _ . . ASSOCUTES �N�.
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� New eNrRr ' � OFFICE f OFFICE CONFE E OFFICE I �^���w�
i o0o ro . i NCE
I MAT H EXISTING � ; � RO M � %"'°'°g
�bz�w�
'�/ r� Sakm,MA.01970
I �� I y Tel:(978)741-5777
p Fax:�978)741-0557
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� � - I J\;��Kt.0 i;ir�;�y
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� OFFICE KITCHEN ❑ i i i o W No. 4011�;';
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. . _ _ _ _ � _ _ _ _ O MA55. " .�(.
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AREA OF NEW WORK I WAITIN[, AREA I S��a I o
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PROPOSED FLOOR PLAN � � �
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+� ST RAGE � `, +, I OFFICE Z J w W
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b I ' . 2'_7`+ ; � ARCHITECTS PROJECT
N I � �----_ � I I NUMBER: 2013.16
� F=====__" � REWORK EXI�TING CEILING __ �aawN ev: cew
I l J +I I SCALE: 3/16"= 1'-0"
, ` — - - J u� DATE: 11.11.13
� � I
• - I REVISIONS:
�'
— � - - KITCHEN ❑ • �_� ' ' OFFICE I DRAWING TITLE:
,
I _1 - LGHT�,� PROPOSED
� j , � �� � F„m„� , FLOOR PLAN
� � - DEMO PLAN
� , 1D � �° � �• � N W FFI E � p�ocaR►�vnc RCP
� — i _
SCOPE OF DEMOLITION � - — - -
-_1._ _
' � DEMOLI�ION PLAN � NEW OFFICE ELEVATION _ � REFLECTED CEILING PLAN ■
� SCALE: 3/i 6" = 1'-0' J SCALE: 3/16' = 1' - 0' � SCALE: 3/18' = 1'-0'
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GENERAL CONTRACTOR - CONSTRUCTION
MANAGER - DESIGN / BUILD
LETTER OF TRANSMITTAL
To: Date: 01/17/14
Salem Buildin Ins ector Pro"ect: Ps cholo ical Consukin Svcs.
Pro ect No: 70 Washin ton St. 2nd Floor
Attention: Thomas St. Pierre
Reason:
We are sending you: x Attached Under separate cover the following items:
Co ies Date No. Descri tion
1 01/16/16 Bld . PermitA lication a . wkrs. Com . affidavd licenses
3 11/11/13 A1 Pro osed Plan
These are Transmitted:
QForApproval QApproved as Submitted QRejected
QFor Your Use QApproved as Noted QFor Review and Comment
Qx As Requested QRetumed for Corrections n
REMARKS:
Please let know when the permit is ready for pick up or if you need anything else.
coPv 70: File 8� Field,
SIGNED:
Andrew C. Matses, President