71 WASHINGTON ST - BUILDING INSPECTION �: �i,�, E�-o��t l -
� ,'i` ; � � PUBLIC PROPERTY ��� �'�
\� �"`� DEPAR'I'tiIENT
K1�61FJtLEY DRISI;ULL
�IAYOR ��WASHINGT(1N S'IREET��
�N,NtitnCx�Stl'rs 01970
. T�i 978-735-9595 �Fnx;97&7i0.9846
APPLICATION FOR THE REPAIR, RENOVATION. CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
'I.0 SITE INFORMATION ' �� ' "
Location Name: • �A rj � tij Building:
Property Address: ',� w�5�p�(9zC fl � �jf •
Property is located in a; Conservation Area Y Historic D(strict N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land �
Name: ALJ��V1 �r�Vt=. Ct►•!f5 �4�/�ti! �1�!
Address: ��O (_5S�.1C �3C. StyLlflvl 14L�
Telephone: �j�$ �?2J � 5),D 7�
3.0 COMPLETE THIS SECTION FOR WORK IN FYl¢riNc_ gU1LDINGS ONLY
Addition Existing
Renovation f Number of Stories Renovated
Changein Use New
Demolition Existing
Approximate year of Area per floor (s� Renovated
construction or renovation
of existing building New
Brir+f Description of Proposed Work:
Pa��sc� c.ARvC�+rric�' qi.,,N(, w�r.iCkl s-c�WO l�..due A+tu.u�o,�bC.
�,xtctito�. 1�L�Alr� �PA�nr'f��l(, .
�
__ _ _ . _ --- _ _ _ _
___
Mail Permit to: _ —--
What is the current use of the Building? vAN�1�- �A�'"�� � '
Material of Building? MASDt�'R'J� If dwelling, how many units?
WiU the Building Conform to Law? T'�— �bestos? AW
Architect's Name 'A
Address and Phone � �
Mechanic's Name LoMMuPa/J_ 6�-DER.S " M�ti�� �'t-��L�'� —
Address and Phone - � '""""`�, n�C 5��7L �D9 � nlr��'�a�. Ma dz.�b6
Co�struction Supervisors License# ��`�`��7� HIC RegisUation#
Estimated Cost of Project$ 200 , o 0o permit Fee Calculatlon
Permit Fee $ 2��-�'op Estimated Cost X$7/$1000 Residentiai II
EsUmated Cost X$11/$1000 Commeroial �
An Additional $5.00 is added as an �
�
AdminisVative charge.
Make sure that all flelds are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed unde�penalty of perjury /�
Date '� � �2-�'�
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Commodore Mike McLaughlin Y
� .
� Pro' r
li� /ectManager
,��Builders ,
�Project Planners&ConsGvcfion Man�gers �
• � . .�..•.q ,
130 Rumford Avenue,Scite 108,Newton,MA 02466 ,
Phone:617-6143500•Fax:617-965-8354
Mobile:617-A9-7078•www.commodorebuilders.com
Email:mmclaughlinQcommodorebuilden.com
A-� �_�J
_ - - i
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.aA • .. .
ifie 6 Qualities of Excellence
" •The Confidence to iake Charge
� •� •The Capacity to Anticipate
, . jF-�; '.`.: . Y ' ._ .. . . . ' . .
•The Ability to FdcUs on the Details
.�.,sc-� . . : . . ,
, L , . _ . �
•The Spirit to Collaborate
. - " •The Creativity to Innovate
� y,.�:. .. ..: i,L''�': .ti.:`
•The Knowledge to Problem-Solve
CITY OF SALEM
;r• • 4 � PUBLIC PROPERTY
��` DEPARTMENT
Kinmtw.�r n�uscou
�lnroa � 120 WnsHiNcroN Stn�'r�Sn�.��+cx�serts 01970
'[k�:97&745-9595�F�x:97&7i0-9&16
Construction Debris Disposal Affidavit
(required for all demoliGon and renovation work)
�n accordance with the sixch zd'►don of the State Building Cade.780 CMR seation i 11.5
Debris,and the Prongions of MGL c 40, S 54;
Building Patmit# ia issued with the conditioa that the debris resulting&om
this work shaU be disposed of in a pmperly licensed waate disposal facility as defined by MCI* -c
1 l l. S 150A.
The debris will be C'anspocted by:
Gw�.GS t��l.r� -CPvX.�,��1�
(name of haulec)
The debris will be disposed of in :
kuu�S (o��
— (n:+me of facility)
I n�Ann1DCA�/' N� � x��'—
� - - -(addrless of tuiiiry)
signaaue o ptmut applicaat
$- 2�.-�
�
�
I ,irbrisal7.due
r
� CITY OF SALEM
�� � ,�' ' � PUBLIC PROPRERTY
�� DEPARTMENT
K[�4BERLEY DRISCOLL
M`�Y�R 120 W�SHINGTON STREET�SALEM,MASSACHIiSETTS 01970
� Tec:978-7459595 �Fnx:978-7449846 .
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeeiblV
N8R10 (Business/Organization/Individua]): �AMM7VtK�l'. ,'JV�Y�
Address: ��iU RramA4�� l�VLf , S�t� 6b$
City/State/Zip: �1�t�� � Mlb OL�b b Phone #: (o l� - b 1'�- �ob
Are you an employer? Check the appropriat�e bJo�: Type of project(required):
1.� I am a em lo er with 4. �"I am a general contractor and I
P Y 6. ❑New consuuction
employees(full and/or part-ame).' have hired the sub-contractors
2.❑ I am a sole proprietor or pazmer- listed on the attached sheet. 2 �• emodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
workin for me in an ca aci workers' comp. insurance. g
g y p ty. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
mysel£ [No workers' comp. c. 152, §1(4),and we have no 12.� Roof repairs
insurance required.] t employees. [No workers' 13.� Other
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workets'compensation policy infomtation.
t Homeowners who submit[hie�davit indicating Ihey are doing all work and then h've outside conhactora must submit a new affidavil indicaUng such.
zCon[ractors that check this box must attached an additional sheet showing the name of the sub-contractors and[heir workecs'comp.policy informafion.
I am an emp[ayer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: DJ�K,t►.� b S�'��C�
Poticy#or Setf-ins. Lic. #: W C. (oS�'LSb6 Expuation Date: II'Z� '�L
Job Site Address: 1� wASHI��,TOD.I S[. Ciry/State/Zip: SWIL'Y�l E �A D�7d
Attach a copy of the workers' compensation policy declaraHon page(showing t6e policy number and expiraHon date).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead ro the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to�250.00 a day against the violatoc Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby certify und the pai pena[ties ojperjury[hat the information provided above is lrue and correct
Si nature: Date: ' Z Z- �`
Phone#• G17 - �19 ' D7$
Offtcial use on/y. Do nnt write in this aren, to be completed by city or town afftciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
Information and Instruc��ions .
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for the'u employees.
Pursuant to this statute,an emplayee is defined as"...every person in the service of another under any contract of h've,
express or implied,oral or written."
An employer is defined as"an individual,parmership,association,corporation or other legal endty,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representadves of a deceased employer,or the
receiver or trustee of an individual,pazmership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than t6ree apartments and who resides therein,or the occupant of the
� dwelling house of another who employs persons to do maintenance,cons�uction or repa'u work on such dwelling house
or on the grounds or building appurtenant therero shall not because of such employment be deemed to be an employer."
.,7. � , . , , � .
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or ro consfruct buildings in the commonwealth for any
applicant w6o 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 poliacal'subdivisions shall
• enter into any contract for the performance of public work ucitil acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Appticants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liabiliry Companies(LLC)or Limited Liabiliry Partnerships(LLP)with no employees other than the
members or partners,aze not requued 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
Accide¢ts for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the ciry or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regazding the law or if you aze required to obtain a workers'
compensation policy,please call the Deparanent at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Ofticials
Please be sure that the affidavit is complete and printed legibly. The Depamnent has provided a space at the bottom
of the aFFidavit for you to fill out in the event the Office of Investigations has to contact you iegazding the applicant.
Please be sure to fill in the permitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permiblicense applications in any given yeaz,need,only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (ciry or
town).•",A copy of the affidavit that has been officially stamped or mazked by the city.or'town may be provided to the
applicant as proof that a valid affidavit is on fiie for future permits or licenses. A new affidavit must be filled out each
yeaz. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves ete.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
. The Commonwealth of Massachusetts -
' Department of Industrial Accidents � ' � �
Office of Investlgatlons , . •
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-OS Fax#617-727-7749
www.mass.gov/dia
NOTES
7he doors located on either side of the main vestibule are to be locked
_ and kept closed.
Closet
�I >>> coffee LEGEND
/ 0 = New Full Height Wall
� ��� \ � = New Partial Height Wall (40�
� Men \ Note: All daors within partial height wall should as be partial height
118 �
Work Area .—. _ /�/
' 106 � . . � • ' Office . • � � ) . . .
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0
, ' � � ' � �� � �
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'o / ti : .
116 / �
+'-�3' a�-0• e�-e• Women
� 119 Stoir 4
, • ' , „ , Stair 3 •
�29 , . , t_
. . � 109 ` � . ,
/
� Existing
0
� _ a�
I t4 a•
'( Teller Line � Existing
� 4�_�• �.-0. 108 � s� Haliway 1, Office "
0 0 0 0 0 o Existing ' a� Office "
� � � � � � � 115 J 20 128
a� _ ._
.
� H HD � _ .
__-
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i Existing
Existing -
1 O � ..
� � Hallwo 2 '
Reception a 130
OMural by
'�I O 103 Bonk� . _ Office : ,
! ❑ � President�s Office . �27
� � (
I .
121 � _
00 ❑ � �
� Greeter's Area « �a ' ,
� - '
105 �� Existing
8 6
� � �� ��� 19 Main Hall Main Hall �
j,
� 102 102
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Office �
e126
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3 .
Plasma Screen Waiting ' � ,
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D Conference O � Z
�D 104 O� a a Stair 2 _ — — _,�
; "' 112
�� � � � — � —
❑ ❑ H H II
' Vestibule
Lending Vestibule
� Corridor Stair 1 123 124
101 �
114 � 113
�
Office
125
, , .
Reviewed and Approved By
Date
O p
ProjeCt: 2006-031 Seal-Signature Consultant Seal-Si nature Revisions r
� C�� Oo � � � OC� � C�C� g �
SALEM FIV � ,i8,o6
E Salem Five �
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71 Washington Street Architecture - Space Planning - Interior Design - Landscape Architecture � : A �
SALEM, MASSACHUSETTS LandPlanning - ProjectManagement - DevelopmentConsultation FIrSI FIOOI PI�1 1 � � otee�� v
I 200 Baker Avenue Concord, MA 01742 Tel: (978) 369-6565 Fax: (978) 287-0076 No. Date Description
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