75-87 WASHINGTON STREET - BUILDING INSPECTION 1
The Commonwealth of Massachusetts
Department of Public Safety
�' �/ �...�..f \lasx,tchuscus tilatr Building Code(780C\IR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
(this Section For Official Use Only)
Building Perms Number: Date Applied:plied: Building•Inspector:
P�
SECnON l: LOCATION (Please indicate Block 0 and Lot 0 for locations for which a street address is not available)
75 — 87 Washington Street, Salem 01970 81 Washington Street
No.and Street Cite /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❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents bring supplied as part of this permit application? Yes ❑ No
Is,m Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: Make repairs to crown sections of parapet wall in front
of building. Will be erecting stagging to protect pedestrian on sidewalks.
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) O -
Existing Use Group(s): Proposed Use Group(s): M
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Pro
No.of Floors/Stories(include basement levels)&Area Pei Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A-2r A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑
F: Facto F-I ❑ F ❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 H-4❑ H-5 O
L•- Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile , R: Residential- R-1❑ R- R-3❑ R-4❑
-Sc Storage 5-1-0 S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IAO IB ❑ IIA ❑ IIB ❑ IIIA ❑ 111813 IV 1 VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flond Lone❑ . Indicate municipal ❑ A trench will not be Licensed Disposal Site❑
required Cl or trench or specif.%
I'nea h•❑ or mdenlifc Zonr:, or on site seslrm ❑ permit is enclosed ❑
Railroad right-of-way: to Air.Navigation: �I:\ I L�lun. ct�nnni�.i��n H........ 1'r.......;
\ul ,\pplitebla•D F—Haij,rds
ruclurnhin airport appnoch area.' In their review ounplvied.'
.n ( "mlcnt to liudd endo,vd ❑ Ye.❑ ur No❑ Yes ❑ \o ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
IfJawn o1 C. L,e Ciouplsl: r%pe of Construcuon: l)ecupant Lund per Boor
Doe,the bulding contain an Sprinkler Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION ,
Name and Address of Properly Owner
75-87 Washington Street Salem nlo7n
Name(Print) Nu.and Stnret City/rown Lip
Properly 0%%ner Contact Information:
81 Washington Street LLC 978.92Z.0800 978.423,6344 ;go1dbPrg@galJhPronnrnort esre
Title Telephone No. (business) Telephone No. (cell) a-mad address .coin
If,applicable, the property owner hereby authorizes
11 Name Street Address City/Town SOte Zip
to act on the pro pert%owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(It building is Icss than 35,1xx)cu.tt.of enclosed s.ace and/ur not tinder ConAnaUion Con WI then check here O and slap SMiun I0.0
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
GoldbergProperties Management Inc.
Company Name: 065097
Steven i_ Goldberg C,S -
Name of Person Responsible for Construction License No. and Type if Applicable s
7 Ranrnnl Srraar sntro trims, ReNT,rly MA 01915
Street Address City/Town State Zip
979-.977_nRnn 978- 23z 6244 sgoldberg@goldbergpropertiesre.com ,
Telephone No.(business) Telephone No.(cell) e-mail address >.
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.9 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and i
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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Gusts:(Labor Total Construction Cost(from Item 6)=S
and Materials)
1. Building $ 8.000.00 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical 8 appropriate municipal factor)=E
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=S (contact municipality)
5. Mechanical (Other) S Enclose check payable to
6.Total Cost 8 8,000.00 (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 of my knowledge and understanding.
Steven J. Goldberg Owner 978_922..0800 9.03. 10
I'Ieaac print .and .ign name ritle telephone No. Date
7 Rantoul Street Spite 100B Beverly MA 01915
*40vel :lddre'.s - C1n/Timn fit. Lip
Municipal Inspector to fill out this section upon application approval:
'. lame I)a
CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
1'.li: Nlf • .'ll
11 .1.4M I.0 vt'.l all LET 0 5.u1 M. w a 1...t•1 .
. 1'R.y:t.7�y�;•�! e P 1!c:v7t•7�S•I:NA
Construction . Debris Disposal Affidavit
(required flit all demolition aural renovation work)
In accordance with the siadt edition of the State Building Code, 730 CMR section I I 1.5
Debris, and the provisions of MGL c 40.S 54;
Building Permit 0 is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as dafined by MGL c
l 11. S 150A.
The debris will be transported by:
Waste Management Inc.
I lwme lit'hauler)
1•he debris will be disposed Orin
(name ul aci Ity .
IaJdm�lut IxJuy)
.Itn lire, t Ilermir applicant
September 3, 2010
date
h Iv.•.0,!..
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
a um:x:Fy:rxliCutl.
�4wrtx f1�WnshtnxdfO.N SrSEET * SAL E.M.MASSACI It iE1-is01970
1'iai;1)79-745-9595 • FAm 97x-740-9S46
Yorkers' Compensation Insurance A ff[davit: Builders/Contractors/Electricians/Plumbers
k ) )licant Information Please Print 2ibly
Name (ausincssiOranintioNlndividuul): �~
Address:
City S[a[ci%ip: r Y'�/� 01 c [ Phone •'': f . C(2 2 QGOL
:\re you an employer'.' Check the appropriate box: 'Type of project(required):
4. ❑ 1 am a gcncml contractor and 1
I.❑ 1 :can a employer with 6. ❑ Kew construction
employees(full and/ur part-ante).• have hired the sub-contractors 7. ❑ Remodeling
2.❑ i ;can a sole proprietor or partner-
listed on the attached sheet. :
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
No workers' cum 5. `�We are a corporation and its
P- insurance officers have exercised their 10.❑ Electrical repairs or additions
rcquircd'] 11. Plumbin g repairs or additions
3.❑ I ant a homeowner doing all work nigh[of exemption per tv e n ❑ b P'
myself. (No wrn'kcrs' conip. c. 152, §1(4),and we have no 12.❑ Ruuf repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
•Airy e,phcaut that checks box 01 must also ill Uol the,clio,Wow Slowing their wotims'conlpenydion pUllch infurmmium
I lummtwmn who submirthis ntl[davit indicating Ihcy are doing all work and Ihen hire outside cuntrxtom must.ulm+it a new arrdavit indicating sell.
!\mmtetorx that check this box most attached an addilimal sh..rot showing the name of the sub-connxrrn and their wurken'cramp.policy infurmariun.
f our fill euytlayer that k providing workers'compensation insurance for ury employees. Below is the policy pnd job.site
iuforinutioit.
InsuranceConipanyVatne: --_-.- - ..... ....----------.._.----.-----
Irolicy is or Self-ins. Lie.i:: ..___ Expiration Date:
Job Site Address: — CityiState/Zip:
Attach it copy of the workers' compensation policy declaration page(showing;the policy number and expiration dale).
failure to secure coverage as required under Section 25A c. 152 can lead to the imposition of criminal penalties of a
line up to S1,5110.00 and/or one-year imprisonment, as well us civil penalties in the furni of a STOP WORK ORDER and a fine
Of Lill In S250.00 a day against the violator. lie advised that a copy of tins statcnncitt may be ibmarded to the 011ice of
Invcangaunns ol'the DIA for insur:mcc coverage vcrilication.
I do hereby certify i rlvr the mitts told penalties ofperjury that the information provided above is true and correct.
Si�I:ruuro:
Date'
Ph,we;;.
Official Ilse only. Oo rlat unite in this area,to be cmapleted by city or town aJJic•iul,
City or fosvn: _. Permit/License ti.-_-_.__
Issuing Authority(circle one):
I. Board of health 2. Building Dcpartinent 3. Cilyi fon a Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other .__
Coalact l't:tsmn: __ -_-_ Phoned:
Information and Instructions
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emplaree is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or Other legal entity, or any two or more
of the foregoing 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."
.\1GL 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 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 not any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance w ith the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
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 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
he returned 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 the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be 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 out in the event'the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilicense applications in any given year,need only submit one affiduvit indicating current
policy intormation(if necessary) and under"Job Site Address" the applicant should write "all locations in - (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.e. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lic 0I-I lei'(it Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us a call. ,
The Dcpartnent's address, telephone and fax number The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigadons
600 Washington Street
Boston, MA 02111
Tel. li 617-727-4900 ext 406 or 1-877-MASSAFE
i2cviscJ 5-26-05 Fax #617-727-7749
www.mass.gov/dia