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72 WASHINGTON ST - BUILDING INSPECTION (2) T'he,Comm onwe'alth of Massachusetts + Department of Public Safety 1'IYI I f ihln.•u.tilatr Uuddin I tr.lr I•-8U C\IR)ti•ra•nth E.Itlwn City of Salem BuildingPermit Application for an Buildingother than a I. or 2-Firrid Dvyellin (1hu 1ccbun Fur official U'.e Only) Building Permit Numlirr Daly Applied: • Building In.prchrr: SECTION 1: LOCA noN (Please indicate Block a and Lot a for locations for which a street address is not ivida I 1 �2 J.✓r+s1..�K' an.-S'f. .SG'�En•t a 147D - �S'oLt ,'C \o.and"Ir"I City r rim it Zip Gate N,tme of Building(it epi+lic,i tile) SECTION 2:PROPOSED WORK It ,New Cun,trucuun check here Our check all that apply in the two rows below - I Ennting-Buildin -FRepairG--AlteaiY - ---Addition 13— Drmuli/Hl FPl (i!IFand-submF.1 1pprnd--t-l— _Change of Use ❑ hange of Occupancy O Other ❑ Specify: Are building plans andlur construction documents being supplied as part of this permit rtpplica ton? Yes No ❑ Is an Independent Structural Enginrrri( 'Peer Review re. iced? Yes No ❑ Brief Denpliun of Pruposed wol^rk: 1��1a^ol-, l r10n-S Q'xtlr}1 L<�(S• .� kr vi _ S S t.1 .1 C-iQ II s^Ce iet"M '1 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 7t)0 CMR 3402.0) O Existing Use Group(s): Proposed Use Group(s): it Existing Hazard Index 780CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(.w). kJ and Total Height(1t.) SECTION 5' USE GROUP(Check as applicable) A: AssemblyA-1 O A•2r O A-2nc❑ A-3 O A4 O A-5❑ B: Business E: Educational ❑ F: Facto F-I ❑ F2❑ H: HI Hazard H-2❑ H-3 O H-4 O H-5❑ I: Instltutfonal I•I O I.2 ❑ I-3❑ I-i❑ M: Mercantile❑ R: Residential R•10 R•2 ❑ R-3❑ R-4 O S: Storage 5-I ❑ }I ❑ U: Utility O Special Use❑and lease drsc•ribe below: Special Use: . SECTION 6:CONSTRUCTION TYPE(Check as a licable)- IA ❑ IB ❑ IIA ❑ IIB O IIIA ❑ 11160 IV ❑ VA ❑ VB ❑ SECTION 7: SITE INFORMATION (refer to 760 CNIR 111.0 for details on each item) I Water Supply: Flood Zone Information: Sewage Disposal: french Permit: ' Debris Removal: Public O (hvck J uulad.•FL.r11 Zunv❑ 1it111ra1e inunicri•,rl O A french will nut lie Lrccn.ed [)"i...... },le❑ Pi I%.I tc❑ ,rr mdvn1,l% Zunv _ nr un.de•r.lvm ❑ rcyuored O ur irc•,tch err.i •cah. lwrnit i.ell,1'. d ❑ 1 Railroad rigid-uf-way: Hazards to Air Navigation: ill I6.r.•nr i . ,,,,, ,,,,g, , „--- 1 :,rnri•Ir I'd• \r•t \i•i•O..ddrO L�Inrllmyti ilim.nriirrl api•nrach•'ri'•t� Llhcir n•l icii . r l'. •nl.rq nr lluJll crpin•c•1❑ I 5r.❑ cl rr tin❑ SECTION i.COIV TENT OF CFRTIFIC.4 TE OF OCCUPANCY .___ L-c l.rr "i"`i _ Iiir..I lun.Irtglir'n ___ Itiiui•.uulr,.i.l ire llra 16n- Ihr l•uil,Lnq,ren.iin.tn � iruikler M�lont' ... _ . .1 `penal`ui•ulefo'n` _____ _._ ______ l SECTION 9: PROPERTY OWNER AUTHORIZATION ffN.'1?kV.110 Addrvll� n,pert% lhvnerL - --- \amrIPnnt) No. and Nreet (lt% , romn "P I+nq,erK U+.n.•r('.,nl.ict Inlorm.mon: role relephone No.(busmc:s) Telephone No. .(cell) e mad.odd ri•.. j I(.t)•phcablr, the pmperh nst ner hembs•.utlhorues Name sirm Adders lohv Tm,n St.ne lip In act on Ihr j,roj,vrlc „u ner'.behalf, on.111 mat tars relauvr ht wor It autht rtited by this bu d.11n •permit a ppdlc.,t1,n+. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) III huddn•is los than 33•laa)cu.It.ul rndaysl s+acc•and/or ma under Con,truclwn Gaurul then chink here O aild�4, +\•J ion hl II 10.1 Re isle--A Professional Responsible for Construction Control GVlO l f y1.t F�FY.�.5/ _ 2�,3 —7 5e'!/ SSG 22 A -- -- Name-CReg"rmq------>—tr rp unr o. r maI ad�ss eglslratiun Number �i� Sire t Address - C'i ty/Town State Zip Discipline E Ira un air 10.2 General Contracwf Company Name: Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No.(bu!'nes52 Telephone No. cell e-mail address SECTION 11:WORKERTCOHMNSAnoN INSURANCEAFFIDAVIT(M.G.L.c.1S2.9 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 D No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6) f 1. Building f Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical f appropriate municipal factor)=f 3. Plumbin f a. Mechanical (HVAC) f dote: Minimum fee.f (contact municipality) 5. Mechanical (Other) I f Endow check payable to T 1 6. Total Cost 1 f (contact munici alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hembv attest under the pains and penalt rs of prqury that all of the nfurmatinn omtame.l in this applicahnn is trur and accurate to the best of mY knoovlcvige and undersLmdmg. ivle.,.c pnnl and•ign name r,de __-- h„ne \„ __— )ale — su rcl 1.l.lrr.. l it1 r n t+rt it \unicipal Inspector In till out this section upon application approval: Name ILi tr A CITY OF SALEM �, PUBLIC PROPRERTY �`- DEPARTMENT y_ TyyD .iw:;N:I'1':)xlsCul I. \Iwo it 12C WAitu.'1t:I u:\5is El:T s SAt erl,MASS.\CIo it.I Is 5197- Tel.:V11-7I3-9595 • Fvc 978-740-9x46 Workers' Compensation insurance :affidavit: Builders/Contractors/Electricians/Plumbers wn iicant Information t / Please Print Leelhl_y Ni1177C X (I)u\iiHaiOr;;anintinrJlnJividuull:t SCilg>n C IP1 Address: 7 2 1 ✓ti51.`y� �71 S� �e 1 (� CityIStacc;%ip Klein ,,lAA09 a Phone0: 979-7gI 22.ZZ Arc vuu an employer' Check the appropriate box: 'Typo of project(required): 4. ❑ 1 am a ncralotactor and 1 contractor I ;,in a employer with. � I e.-ro G. ❑ New construction clllployces(full and/or part-time).s have hired the sub-contractors 7. Remodeling ?❑ I :un a sole proprietor or partner- listed on the attached sheet. ship:rod have no employees These sub-contractors have 8. ® Demolition - working fix me in any capacity. w'orlI camp. insurance. 9. ❑`Building addition I No workers'comp. insurance 5. ❑ We are a corporation and its 10.®Electrical repairs or additions required.) officers have exercised their right of exemption P'sir MGL 11. Plumbing repairs or additions 3.El am a homeowner doing all work _ S P myself. LNo workers' comp. c. 152,gl(4),and we have no 12.❑ Roofrepairs insurance required.) t employees. [No workers' 13.0 Other comp. insurance required.) bpplicaid that CFVCks box Ill must altln IIII out nhe watutl tniow Sh owing their wock"s cumpenution policy inliumatiuo. f lumauwnurs who submit this affidavit indicating they Inc doing all work and then hire outside gwormtom must sulmtit a new affidavit indi"ing ouch. -C'ontrwno Ihat shock this box mull jalwhsd an additional Aofl showing the name of the subcontractors and their wurkerc romp.pt itcy inrurmanun. /am un crnpluyer tGut Ls pruvfJing Evurkers'c•mnprnsntiun iusurrrnce jar lay eurployerv. Belon,is the puthy and job site iujurnmtiun. / . insurance Company Name: t Cr( I tt —. Policy 4 or Sclf-ins. Lic. K:V ILt6 D341� 111. . . ... ._ -_ Expiranun Date: Job Site Address: ?_ "4S�_,tnC'�k1S_. Cityistate/Zip:�� ,ki. M 01970 Attack it copy of Ilia workers' compensation policy declaration pulse(showing the policy nwnber and expiration date). Failure to secure coverage as required under Section 25A of}lGL c. 152 can lead to the imposition of criminal penalties of a tine up w S1.51I0.00 and/ur one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 it Jay against the violator. lic advmd that a copy of This statement may be forwarded to the Office of Imcengawms ufthc DIA for insurance covaragc scrilicanon. ���CCC t l Ilo hereby certij�ler the pains acid lrenaltfe.r of perjury that the infurinuNon pruvideal above is trite and correct. ;iiaitre' _ Date, 3/IH /I Official use may. Oa not ivrile ill rhix area, to be completed by city ur rays official- _ i City or Town: _ Permit/I-icense Al._. Issuinq-Wlhorily (circle one): I. Board ur Ilcaltil Z. Iluildin�„) i)cparuncnl 3. Cil.w Ibwn Clerk 4. L•'lectrical luspcctor 5. Plumbing; Inspector 6. Olhcr Conlacl l'c nose: _ .. Phone p: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fix their employees. Pursuant to this matute,an employee is defined as "...every person in the service of another under any contract of hire, cypress or implied, oral or written." - An employer is defined as"an individual, partnership,association,corporation or other legal entity,or any two or more M the Ibreuwing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an 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 maintenance,construction 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, v+25C(6)also states that"every state or local licensing agency shall withhold the Issuance or renewal of it license or permit to operate a business or to construct buildings in the commonwealth for any applicant who 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 of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." .. Applicants Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)nuna(s), address(es)and phone number(s)along with their certificatc(s)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 date the affidavit. The affidavit should be rcmrned 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 a workers' compensation policy,please call the Department at to number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town OMclals Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom Of the affidavit for you to fill nut in the event the Office of Investigations has to contact you regarding the applicant. I'Icuse be sire to till in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pennie'license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit 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. a dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit. I he Otlice of Investigations would like to chunk you in advance fur your cooperation and should you have any questions, Please do nut hesitate to give us a call. the Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents O11Ice of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax k 617-727-7749 www.mass.gov/dia Proposal Pace 1 of 1 Perry Brothers Construction P.O Box 646 Newburyport,MA 01950—P:(781)233-7511 F:(978)465-0929 www.perrybrothersconstruction.com PROPOSAL SUBMITTED TO: PHONE IDATE Salem Cycle 978-741-2222 1/20/2011 STREET JOB NAME JESTIMATE NUMBER 72 Washington Street 11548 CIY,STATE AND ZIP CODE JOB LOCATION Salem, MA.01970 BACKROOM Remove existing rear bathroom partition walls CA/7 `n �l Frame new partition wall for bathroom per plans Blueboard and skim coat plaster new walls Rework rear drop ceiling-Apply base board trim on new walls / ' % — "9 16 - Paint by others - Remove all debris TOTAL STOCK AND LABOR ON BARTER - $3500.00 We propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of: Three Thousand Five Hundred and 0/100 Dollars ( $ 3,500.00 ) Payment to be made as follows: _ PAID UPON COMPLETION ` All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or - deviations from above specifications involving extra costs will be executed Authorized - - _ only upon written orders,and will become an extra charge over and above the Signature: estimate. All agreements contingent upon strikes,accidents,or delays beyond our control. Owner to carry fire,wind damage and other necessary insurance. Our workers are fully covered by Workman's Compensation NOTE:This proposal may be withdrawn by us if not accepted within days Insurance. . . Acceptance of Proposal - The above prices, specifications, and conditionsare satisfactory and are hereby Signature: accepted. You are autohorized to do the work as specified. Payment will be made as outlined above. - - Date of.Acceptance:- Signature: - — — - - - — — — — — — —I - — — — —I — to II Fl G 8� 1 SALEM CYCLE II APPROX. 2.000 SF EMSTINGTo �G I�VI BE REMOVED l SALES CEILING Il COUNTER 1� 1 I 0'-11- II I, CEILING ' HVAG 11'-6 'I e ill IIi DUCT CEILING / n III II BATHI Q CEILING / / i I I I I CRUIIICHY o GRA )LA _ m BAY OFFICE / ELEVATObS STAIRS . -- o IE LIASEf CLOSE / MASONIC BUILDING ENTRY CORRIDOR MASONIC BUILDING ENTRY 'CORRIDOR ST 1/8"— V-O" LAD-GfaphX Design Consulting COMMERCIAL/EXISTING TENANT BUILD-OUT EXISTING PLAN DWG NO. DESIGN OUT-SOURCE SOLUTIONS - SALEM CYCLE - PROJECT A 1 11 CHURCH STREET#a02 SALEM,MA 01970 9] 53 1530 72 Washington Street Suite 1 NUMBER:0217 ©ALL RIGHTS RESERVED Salem, MA 01970 SCALE:AS NOTED CITY OF SUX.4NI9 .*LvL-ksSACHUSETTS 120 BUUMLNG DEPARTNONT WASjiDiGToN STRErsT, 3�Roop TEL (978) 745-9595 PAX(978) 740-9846 KimBERLEY DR=OLL MAYOR TliomASST.PmRan Diltwroz oF PuBLic PROPERTY/13MMLNG CONNISSIONER Construction Debris Disposal Affldavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5 Dcbris,-and-the provisions-of MOL-c-40, S-54�--- Building Permit At — is issued with the condition that the dcbris resulting from this work shall be disposcd of in a properly licensed waste disposal facility as defincd by MGL c I 11. S 150A. The debris wi I I be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of'racility) Signature of permit applicant