118 WASHINGTON ST - BUILDING INSPECTION (8) *L
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The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR) -
Building Permit Application for any Building other than a On or Two-Fam'
(This_SectibrvFor;Official Use Only),, ,
Building['enmt Number '�ga[e'Applied " Budduig,� ,fi tali'
.:.
SECTION,1:LOCATION(Please indicate,Blbck#and Lot#for 1,ocations'for „hick a street" dr as not '
No.and Street - City/Town Zip Code N. of! ding(if applicable)
SECTION 2:PROPOSE WORK
Edition of NIA State Code used If New Construction check here❑or ch k that apply in the two rows below
Existing Building.I Repair❑ 1 Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑/
Is an Independent Structural Engineering Peer Review{equated? Yes ❑ No i-
Brief Description of Proposed Work: AOW OP l u�b:n, Wi� �ei. A e r.. >rru-... o-.. sA ti ,
inrw }+".N ca r /� to 1l �• , n-c / 6 —�fsi
An ✓-['� I S 4, d
SECTION 3:COMPLETE THIS SECTION.IF EXISTING BUILDING-.UNDERGOING RENOVATION;ADDITION,OR
'; CHANGE IN USE'OR OCCUPANCY "?I .. ., . .
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA:
Existing Proposed
No. of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a pliceble) ;
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ I B: Business (W E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 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 Flood Zone® Indicate municipal A trench will not be Licensed Disposal Site Cl
Private❑ or indentify Zone: or on site system❑ required N or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: %4A Historic Commission Review Pnrs:ss:
Not Applicable® Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes or No® Yes❑ No ❑ g1/A
SECTION 8:CONTENT.OF CERTIFICATE OF OCCUPANCY.
L"dition of Code: Use Group(s): - Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
''SECTION 9:,PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner r
Name (Print) No. and St� City/Town Zip
Property
'�Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
s�l A4 0 � 9 ?
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10 ,CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildin is less than 35,000cu:ft.of enclosed s aceand nor notunde%Construction Eontrol then efieck h`ere:Oand ski .Section 10.1
10.1 Registered Professional Responsible for Construction Contiol `
001nwldl
Name (Re iistrant) 1Tj
-elehone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2General Contractor`
Z ` VJ
Company rrye /4 � 3 eu G 13 aol4 CS vn " tQVU 069
Name of Person Responsible for Construction License No. and Type if Applicable
19 6ldvr.,,L� 019D0
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:W C FF ORKERS'COMPENSATION INSURANCE AMAVIT 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❑ No ❑
;'SECTION 12:,CONSTRUCTION COSTS;AND PERMIT FEE,
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$ ( $. .S 0-6
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ jtp-) appropriate municipal factor)_$
3. Plumbing $ 000
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ (S s (contact municipality)and write check number here
SECTION 13:SIGNATURE OE'BUILDINGIPERMIT 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 t e best of my knowledge and understanding. �-��
_5C'MLS WI4� TrecG.,Ln4. 14-�-RQ16
Pt�leeda�se print�a�nd sign na;e l Title /.1Y,1�rTelephoneANo. Date
�'\ �4 S't�4VF �✓ (+ 6IO�1 LrJ�/ � CYI`ZJ(�
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name. Date
c
CITY OF SiuI E',I, L USACHUSETTS
Bt:MDLYIDEP.IR NZNT
120 W:LSHLNGTON STREET, 3'FLOOrt
- TFL (978) 745-9595
K1\tBERL EY DRISCOLL F.ALX(978) 740-9344
P L�Yo.t T110.%G i ST.PIE RAa
DIRECTOR OF PUBLIC PROPERTY/at:IMDjG C01W155I0 ER
Construction Debris Di
sposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section l 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
inanll•Uf hIIUllr)
The debris will be disposed or in
` ac
(name of Yac 11 'ty) -
(ad�ress oT Faciluy)
ct
'iSnamrc ofpermil applicant
date - --
CITY OF Siu_Em, AUSACHUSETTS
! i B1:11DING DEPAItI-M&NT
120 WASHIINGTON STREET, 3"FLOOR
" TFL. (978)745-9595
F.'a(973) 140.9844
KIS[DERLEY DRISCOLt
�UYOR TkobLvs ST.FtE.alts j
DiawrcitOF PUBLIC PROPERTY/31:IID4`IG COMI[SSIONER
Workers' CotnpensatIon insurance Affidavit: Buil(fers/Contractors/Electricians/Plumbers
Arsnlleant Information + Please Print Legyibly
Nam t:lOusioess Orpnizatiorvindividual): lry,,,,,, -,
Address: t�a�1 Ccs)�cvw Qr ,ve
City/Srati: Zip: r 10lLt- r M <. 0157(1 Phone#: Q7e 9hk
Are you an employer?Cheek the appropriate boxi Type of project(required):
1.0 i am a employer with 4. 0 1 am a general contractor and 1
employees(tall and/or part-time).* have hired the sub-contractors tS. ❑Now construction
2.18 1 am a sole proprietor or partner- listed on the attached AUL t 7. ❑Remodeling
ship and have no employees These subcontractors have g. 0 Demolition
working fur ma In uny .capacity. workers'camp.Insurance. 9, 0 Building addition
(No workers'comp,insurance S. 0 we are a corporation and its
required.) Officers have exercised that 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MO L 1 I.Ce Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.C]Roof repairs
insurance required.) It employees.LNG workers, 13.[]Olher
comp,insurance required.)
11
;Any upplicam Ow 0mits bass I must alto Oil our the mcauo bClote showing Ihd a r"trust,Compensation pally inl'unnullom
Ihvnuuwm"who submit this an,ekvit indicating shay am doing all well and thee MN Quids Cantnetan mutt submit a rate amdavil indicuin11 luck
Cunimton ihol Chock this box must anwhud an addtllunol shma showing the noted of the n+lravntncton and their wurken'comp pal ley Inramudon.
1 ran an employer that Is providing Yorkers'compenrodan hrruranae jar my employers Br1aW/x lhr policy and Job slle
hrformullom
Insurance Company Name:
Policy a or Self-its. Lic, d: Expiration Date:
Job Sir*Adcruss: City/Statc/zip:
Attae is a copy of the workers'compensation policy declaration page(showing the policy number and expiration data v
Failure to sucuru coverage as required under Section 25A of vIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51,500.00 and/or one-year imprisonntenq as well as civil penaltas in the farm of STOP WORK ORDER and it tine
of up to$250.00 a day against ilia violator. Ile aJvlsed chat a copy of this matamt:nt may be forwarded to the Oflie*of
Invesligatiuits ui die DIA roe in.mnnce coverage vedIleatiuit.
/Ju hereby certify under rhr Mara penuldrr ulparJury that the ht�unrratlar provrdrd about is trot cord curvet
:iL=trd1 Data: 3-a5- )Lt)13
Chong,i•
iOl)ia•rul use Duly. Da not rvrite in tidy areµ to br runtpleted by city of sawn a//1du(
Citynr'I'uwn: _ Permit/f.lceme,y
iIsrulnq,%ulllurity (circle one):
I. Iloard of llcuhh 2.Iluildlm2 Ucpartmunt I.Cilyrfnwn Clerk J. Fleetrical Ltspectur 5. Plumbing fuipector
I
— --_-- Conrad I'Cnnnt " thane U: i
DLA
ARCHITECTURE FOOD SERVICE RESIDENTIAL HISTORIC RENOVATION
TRANSMITTAL
March 7, 2013
The Naumkeag Ordinary
118 Washington Street
Salem, MA 01970
TO:
Jamie Wood
186 Main Street, Suite 38
Gloucester, MA 01930
WE TRANSMIT:
(X)herewith ( )via: Pick Up
( )in accordance with your request ( )under separate cover
FOR YOUR:
( )Approval (X)distribution to parties (X)information
( )Review and Comment (X)record
(X)Use ( )other
THE FOLLOWING:
(X)Drawings ( )Shop Drawing Prints ( )Samples
( )Specifications ( )Shop Drawings Reproducible ( )Products
( )Change Order ( )Photos
Copies Date Revision Description Action
4 02-28-13 03-01-13 Drawing Set (24x36) B
Action Code:
A.Action indicated on item transmitted D. For signature and forwarding as noted below under REMARKS
B. No action required E.See REMARKS below.
C. For signature and return to this office
REMARKS:
COPIES TO:
FROM: Donald Lang AIA
TRANS 03-07-13 Wood
P 617.969.8400 F 617.332.5461 WWW.DLABOSTON.COM 1643 BEACON STREET STE. 22 WABAN, MA 02468
ARCHITECTURE" FOOD SERVICE RESIDENTIAL HISTORIC RENOVATION
TRANSMITTAL
March 11, 2013
The Naurri Ordinary
118 Washington Street
Salem, MA 01970
TO:
Michael Lutrzykowski
Salem Inspectional Services
120 Washington Street, 3`d Floor
Salem, MA 01970
WE TRANSMIT:
(X)herewith (X) via:USPS
( )in accordance with your request ( )under separate cover
FOR YOUR:
( )Approval (X)distribution to parties (X)information.
( )Review and Comment (X)record
(X)Use ( )other
THE FOLLOWING:
( )Drawings ( )Shop Drawing Prints ( )Samples
( )Specifications ( )Shop Drawings Reproducible ( )Products
( )Change Order ( )Photos ( X)Construction Control
Copies Date Revision Description Action
1 03-08-13 Construction Control Affidavit B
Action Code:
A.Action indicated on item transmitted D.For signature and forwarding as noted below under REMARKS
B.No action required E.See REMARKS below.
C.For signature and return to this office
REMARKS:
COPIES TO:
FROM: Donald Lang AIA
TRANS 03-11-13_Lutrzykowski
P 617.969.8400 F 617.332.5461 WWW.DLABOSTOM.COM 1643 BEACON STREET STE.22 WABAN, MA 02468
CITY OF SALEM, NL LxSSACHUSETI'S
BtILDNG DEPARTMENT
• ! 120 WASHNGTON STREET, 3PD Ft00R
T EL_ (978) 745-9595
R x(978) 740-9846
KItfBERLEY DRISCOLL
MAYOR THoNw STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONWISSIONER
CONSTRUCTION CONTROL DOCUMENT
Project Title: QG_ C I � Or iAa Date: //^{^ _.
Project Location: V71dti ^1 !_.......
t tt
Scope of Project: s-. 5 tPP10Cq� �
In accordance with SECTION 116.0-116.4.2 of the 6th edition of the Massachusetts State Building Code :
1, ��j1ll � Mass. Registration Number
being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised
the preparation of all design plans,computations and specifications concerning:
( ] Entire Project Architectural [ ] Structural ( ] ;Mechanical
[ I Fire Protection ( ] Electrical [ ] Other(specify)
for the above named project and that to the best of my knowledge,such plans, computations and specifications meet
the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all
applicable laws for the proposed project.
Furthermore, I understand and AGREE that I shall perform the necessary professional services and be present on
the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the
documents approved by the building permit and shall be responsible for the Following as specified in section
116.2.2:
1. Review of shop drawings,samples and other submittals of the contractor as required by the construction
contract documents as submitted for the building permit, and approval for the conformance to the design
concept.
2. Review and approval of the quality control procedures for all code-required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine, in general, if the work is being performed in
a manner consistent with the construction documents.
I shall submit periodically, in a form acceptable to the building official, a progress report .pertinent
comments. Upon completion of the work, I shall submit to the building official a final
satisfactory completion and readiness of the project for occupancy.
O
Signature and Seal of registered professional: No. 46
M
1643i,eii ON STREET STE. 24 WABAN, MA 02468 BCGTON IMA GaF�i ;:DIU
,
ARCHITECTURE
FOREVER 3
Michael Lutrzykowski
Salem Inspectional Services
120 Washington Street, 3`d Floor
Salem, MA 01970
;_1971013.4S S" 141Ei lij diJ�Ilii1ifi IGlliili,ullllltlllihl"illl'fi.pl
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