79 WASHINGTON ST - BUILDING INSPECTION ;>~' The Commonwealth of Massachusetts
I, Department of Public Safety
�.-,.✓ MaNs ichrben!Slate Building Code(780 C NIR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a I.or 2-Family Dwelling
i (this Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1:LOCATION(Please indicate Block#and Lot 4 for locations for which a street address is not available)
79 Washington St. Salem. MA 01970 81 Washington St.
\ No.and Street CRY /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 O Alteration 12 Addition❑ Demolition ® (Please fill out and submit Appendix 1)
ChangeofUse , 0ChangeofOccupancy 0 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes W No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 91
Brief Description of Proposed Work: Tenant hull d out—see attached plan
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): M Proposed Use Group(s): M r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Fluors/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-2nc❑ A-3 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ I H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 14❑ M: Mercantile In R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage Sl ❑ S2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA Cl 110 ❑ IIIA ❑ 11111 Cl IV ❑ VA ❑ VB O
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:
PP Y�
Public® C'heck if outade Flood Zone❑ . Indicate municipal U A trench will not be Licensed Disposal Site❑
1'rr ale❑ onndentifc Zone: or on ate scstem❑ required❑or trench or,pccift•:
permit is enclosed ❑
Railroad right-of-way; Hazards to Air Navigation: tl:\ I liaon, C��mmini�„i Itr+u+, I'o„•..;
\ot :\pphcal+Ie❑ - 1, gruclury acithm.urport.ipprnachmrea.' Is their re%ie+c completed.'
.,r l-on,cnt to Build enclo. d ❑ 1L•,❑ ar No❑ Yes❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I Ll nton of C,'de: ._ L,e Group(,i: ra peof Constriction: Ckcup.ml load pvr Ilnor:
I>.'e,the building contain an Sprinkler?cavm': Specal tiupulanana
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
81 Wa hingtnn St, Beal F t- to TiC 7 Rantoul Ct q,jif-P 1nnR Rp,crl, MA 01 Q15-4979
Name(Print) Nu.and Street Cih,/town Lip
properly Owner Contact Information: -
Steve J. Goldberg 978-922-0800 9-Z8- [ —6'144 sggldbercPkoldber>;oroperties e.
Title Telephone No.(business) Telephone No. (cell) a-mad address
co
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Lip '
to act un the ni urt% owner's behalf, in all matters relative to work authorized by this buildin• Eermit a p alicatiun.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is Itss than.15.000 cu.tt of endued s+ace and/or not tinder Construction Contrail then check here O and ski S"tiun lo.l)
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
Company Name:
Steve J. Goldberg CS65097
Name of Person Responsible for Construction License No. and Type if Applicable
7 Raint ul er quite anOR Beverly MA 01915-4879
Street Address City/Town State Zip
973_997—nRno 9..7R - A?'A fi.31<<i s 1 ati, rao i at, ,-.;o�roAgia
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 D No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item Total Construction Cost(from Item 6)=$ ijb 15CQ
and Materials) -
1. Building $5000.00 Building Permit Fee=Total Construction Cost x—(Insert here
2. Electrical S 1500.00 appropriate municipal factor)=$
3. Plumbing S V00.00
4.Mechanical (HVAC) S 1000.00 Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost S 10,500.00 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
8y 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
Please prinl.nd sign name ride Telephone Nu. Date
,411-cet :\d.l s - Ca.%i Tuwn S!a! if
Municipal Inspector to fill out this se}tion upon application approval: �/✓
.Wane Date
'Iffy-�a
�m CITY OF SALEM
PUBLIC PROPRERTY
A 1l 11 DEPARTMENT
I'.L': M11\ ''llly l'II
II\t..Ilv$IMtI'i to 5.111\I, N III q I
Construction. Debris Disposal AlTidavit
(required lur all demolition lutd renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N . _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
lI1. S I50A.
The debris will be transported by:
Waste Manaeemann_
Inarne of hauler)
The debris will be disposed of in
Waste Mana¢ement of G�pil S Y�
(name o Twiny
23 Kondelin Rd. Gloucester. MA 01930
Iaddrms of I'acllily)
,Isnalure of hermit applicant
27 ADril 2010
date
CITY OF SM-E.`19 NWSACHI;SEM
SUMDLNG DEPAIMMIr iT
120 W.\SNLNGTON STREET, 1a FLOOR
TEL (978) 14S9595
FAIL(978) 1a496"
KIMBER"Y DRISCOLL
MAYOR THOtIW ST.P¢Rltt
DIRECTOR OF IML BLIC PROPERTY/gCRDLVG CO-NMUSSIONER
1Vurkers' Compensatlon Insurance Affidavit: Builderi/ContractonlElectr(elynvJPlumben
%nollcant Information Please Print LeaiblY
N2intiBusmc+rdrpmtation.InJwtdu►11: Goldberg Properties Management, Inc..
Address: 7 Rantoul St. , Suite 100B
Cily/State/Zip: Beverly. MA 01 91 5-482 2 Pborn#' 978-922-0800
Are you o employer?Cbeek Ike appropriate best Type of project(requlrce
1.Q 1 an a employer wick 9 4. ❑ 1 am a gneal conCrww and 1 E O New consuucdw
cmployrea(roll and/or put-time).• have hired the srbcantraca n
2.Cl 1 am a sole proprietor or patter. listed an the attached shed t 7. Rertodsling
.hip and have no amployees Them sub-contractors have a. C3 Demolition
,volking rat me in any capacity, workers'comp insuranaa 9. Building addition
(No waken'comp inwranco S. 13 we to a corpa"And is
Moved.)Moved.) otilleas have exercised their 10.0 Electrical repairs a additions
7.❑ 1 am a homeowner doing all work right of exemptica per um I I.Q plumbing regain or Additions
myself.(No workers'comp. a I A f 1(41 and we have to 12.0 Roof repoin
insurance required]► employees.(No waken' Il.❑Other
comp insurance requiraj
•Any applicant Cho AMIN bm el wlsw ale no uw the rewire bekw lwiq INk-mace Lmsspw@"M envy bsarelwkn
'I I.�*he submit AW anldwk"WkIdq Imy am done an week and dsm tale Mih town ewe wmr wink a row illlbeit Wiariy iud
<',wlni'm1e III/Lank Itl+tell wW aaarhee 81 alatitrwl nhml LAew11Ig 111e nw.f the wt►semrwewe ar�d Ihek wodwe•coop porky iWntWm.
/use An rwPfeyer that IsP VVIIAZAX tewAen'rewpaerdse benasatesJer s4 noWA"" 8411110041 JAWOsl/tyr secdM SW
informadox.
Inwrance Company Name: Ace Insurance
Policy e w SelRins.Lie.e: C45761484 Eapiratioo Dan: 5/1/2010
lubSiteAddicss: 79 Washington St. City/StatwZip:Salem, MA 01970
Anacb a copy d Cho workers'compeaaallea policy deelantlou pap(lbacelog Ike policy number and Aspiration dole)6
Failure to s"urs covenp a required under Seciioa 25A of MGL e. 132 can lead to the imposition orcriminal penalties Ora
fine up to 111.500.00 and/or one•yew imprisonment,as well u civil penalties in the farm of s STOP WORK ORDER and a Ras
,trup to S250.00 a day ipinst the violator. Re advi+ad 1hA1 a Willful`this statement may be forwarded to the Office of
Invaugmium ol'ilie MA for insurance coverap w7iticalion.
/d*hereby rrrtlj a nIn tAe priwa en1 ytnr/Nit ajper/eq-Aar tAe in�wmer/wOnriafd u0�w it tnie Lne/�wrrd
�Pat.xturt- -_ _ queer 27 April 2010
Phone,): 9 7 8-9 2 2—f1800
[117/flvitl use rs/yt, Oo not write;e Mix rrrsq toty or ruwn: Permit/l.lcenseuing.\whunly(circle one):
fuard of Ilvaltk 1. Ruslding nepartmvnl I. oil,trown Clerk 1, flrrtriu) Imprclor S. Plumbing Itnpeeter
geher
itntartPcrion: _ Phone a•
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
-
on
112 Wall
Lay.
Cl. ;
#79
Unit C
aa^
Closet
#77 = Office #83
Unit B Unit D
Gallery Area
rilU-nit-C-oo-Floor-Plan, 3132" = 1'-0" (#79 Washington Street)
F-1
R. Rumpf A Associates, Inc. Jeee
Engineering — Architects 10-027 Unit C•79 Washington Street
P.O. Boz 4483 oaro Pa
AlmlF-]
57 WharfStreet o4rlanoto Kinsman Bulldln
❑ (ale) M—asachuaetta 01970 9
978 7405025 Sol, Sale Washington Street
978 607-0045 fax 3f32-=1'-0- mi 10•027(00010)
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on
112 Wall
Lay.
A el
#79
Unit C
Closet
' ra-
#77 � #83
Unit B Unit D
Gallery Area
�, U-nit-C---Floor-Pian, 3/32" = 1'-0" (#79 Washington Street)
R. Rnmpf & Associates, Inc. ,oba Unit C-79 Washington Shset
Engineering — Architects 10-027
F-11 P.O. Boa 4483 om Prom,
17 Salem,
Matreetssachusetts
oatsnolo Kinsman Building
Almal
F
a 78) M-asachueetts 01970 g
978 740-5023 au'. 7547 Washington atreel
Salem,MA
978 607-0045 fax 3/32^=1'0' a.,o-onlwa,ol