152 WASHINGTON ST - BUILDING INSPECTION Cam# y403
The Commonwealth of Massachusetts
I
' Department of Public Safety
MiSSdehmSCUS State Building Code(780 CAIR)
Building Permit Application for any Building other than a One-or'Iwo-Family Dwelling
("I"his Section For Official Use Only)
Building Permit Number: Date Applied: __ Building Official: _
SECTION 1:LOCATION(Please indicate Block If and Lot N for locations for which a street address is not available) -
4 No.and Street City/Town Zip Code Namc of Building(if applicable)
SECITON 2:PROPOSED WORK
Edition of MA Slalo Code used If New Construction check here❑or check all that apply in the two rows below
\\ ❑?�� Existing Building❑ Repair❑ Alteration Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) —
,�1,\f19_ Change of Use ❑ Change of occupancy ❑ Other ❑ Specify:__
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering Peers,R��i-eview retLLL. 1? Yes ❑ No Cr—
Brief Description of roposed Work:_ ;464%T G'.r�� 2')re— �QGTIJ'�.�l�✓/T'
,97
�1 Sly'
\ �. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
/ Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 34) ❑
I Existing Use Group(s): -- — Proposed Use Group(s): ---
((f SECTION 4: BUILDING HEIGHT AND AREA
Existing- Proposed
J 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 applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4 ❑ A-i❑ B: Business E: Educational ❑
I^ Facto F-I ❑ F2❑ H: Fli h Hazard H-1 ❑ H-2❑ 11-3 ❑ H-4❑ 11-5❑
I: Institutional 1-1 ❑ 1-2 0'1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 It 2❑ R-3❑ R4 ❑
S: Storage SI ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use _
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ [ilia ILA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ V13 ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
— '
Water Supply: Flood Zone Information: Sewage Disposal: french Permit: Debris Removal:
Public 0'_ Cheek if outside hood Zane❑ Indicate municipal A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone. or on site s%Stem❑ required ❑or trench or specify:_-- ---
. permit is enclosed ❑
Railroad right-of-way: [lizards to Air Navigation: ,.i,..,
Not Applicable❑ IS Structure tcithin airport approarh.ved? IS their rev iew,an P lc led.'
or Cnnseol to Build enclosed ❑ 1 cs❑ or.No❑ Yoa❑ No ❑
SEC HON 8:CON'FE'NT OF CFR TIFICA I'E of OCCUPANCY
I lditwil of Code --------------L'So Group(s): _ _. I'vl h of Construe lionr. .. . 0,k upont Ladd per Moor:
Does the building Contain am Sprinkh r tiestrm' _ Speri,hl Stipulations:
r
SECTION 9: PROPF.R'I'Y OWNER AU'I'IIOI(IZA'IION
Nurse and Addrf of Properly Owner —
Name(Print) No.and,Street — — City/Town Zip
Property
/eOwner Contact Information: F
'I itle Telephone No.(business) Telephone No. (cell) a-mail address
It applict,blc, the property owner hereby authorizes
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 building is less than 35,000 cu.ft.of enclosed s pace and or not under Constmction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-rimil address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Cam my one
met evWzLyeg
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Tole,hone No. business Telephone No. cell a-nail address
SECTION11: IV(7ntinKlc,.ran'tVS:VnrN1N10J1tAN( :AJ ua\vl1 M.G.L.c.152. 25C6
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 is�uance of the building permit.
Is a signed Affidavit submitted with this application? Yes;P No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor p0
and Materials) Total Construction Cost(from Item 6)
I. Building $ O _ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical appropriate municipal factor)=S
3. Plumbing 5
J. Niexhunical (HVAC) S o Note: Niinimun,fee=S (contact municipality)
5. Mechanical Other S Inclose check payable to
6.Total Cost 5 �� QOD" (contact municipal itr')and write eck number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Ilv entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application 's IMe,n,d ICCurale to the best Of my know let]ge.md understanding.
PIe,;se prin�tfMill sisi}n 11 line/ Tidtle/ Telephone N Pa
titrccl Address City/rown ( Slate Zip `
�municipal Inspector to fill out this section upon application appruvaI-
_ Name Pate
CITY OF 5ALEtiI
* PUBLIC PRUPRERTY
n:I Ysar.r, r DEPARTMENT
\It1,nt
I�� \erA,f 11.\,;I11,\i I Nel•1' • i.11 t'N, lit 'I I IN
'sYurkcn' Compensation Insurunca 110Jurit: du lders/Contractors/E►ectriclam/P►umbers
� 1 )Ilcant In urmafio
PI ' s rinf Le 'hl
.�(;IITC IILiu„cvi,)r;lanvarinmindrv�duull: /1/C /}�� �/O/�/'/�,��
Address: y (3 L cr 1
Ciry.Statc.%ip• /�///'P%f/' d�Q _iJMaa
Phone oil!—Oz
' .t re 1 nu an vinployar'.1 Check the appruprlute box;
I ❑ I ant a emp(uyer wish 4wrP . ❑ 1 ;nn a gencn)couaaelor and 1 13Pe u(prrt)eet(requlred):
,,a, 1s(Tull antl/urpart•time).' hove hired the.vuh•euntracwn h' ❑Now cunstructiun
3 ►•Can sole prnprictor or partner• listed on the anached.vhece f
} .vhip and have no em lu ces 1. ❑ Remotlelin�
P Y Thee tub-cOnrracton have
aarkind fin mu in any capacity, workers'camp. Insturunce. a' Demolition
I Not workvn'cutup, insurance 3. ❑ We are a cnrpontion and its 9' ❑alliwing addiliun
required.) ofl'lcers have ewreistd their 10.0 Electrical repairs Car additions
3.❑ 1 :Can a holm owner doling all work right ofexemption per MCIL 11.0 Plumbing npuirs or additinry
myself.h'o t,ark,:n'cutup• C. 131,¢I(s),and wt hnw no
insurunce required.)Is .mpluyce,l.(Ko warkers' 12•0 Ruul'rapairs
cmnp, ilisuranco required.) 1 3 C Other.4 nr„�,phrwa tliW ahnrb Osa Al marl alw tilt uW tM wcuuu 41uY awwm i
Ilu,ry,nrwn.11to" mlil this arT,yvil indl- lin i a brit wwYW'cunlyenwlluY(IWicy inliullWli„Ie'C•.nlnwltwr ihN Ihrra nor hot,ntrr allahwl•�n aeeiryl.lA„W e1n,r a loess�ynM of rN rru►eanlr'a
Tars n+wt.utwrir a nw aln,Yvh indlaYina,Tree,
/tun Can elnpleyer Out Itprurl/fnr warArrs'rumprnra/lon Gr.rurtlnee/Lr/ny errx+,ua,and thew uarkere'ea y,r"dKy,nrbrn sn W
ill/unn pl J Yax i9durY/J Mr pu/l4y 1,8016.til6
Inaurant;cv Company Vmnt���
Policy All Car Sulf•ins. Lic.m! IL y� -
Job 5i Eapiratwn Sits: dddress: %J CrJi4l�attach n cosy of the workere'eumpeniat(nn ppo,ll_cy Jeclarullun puce h howlnpt rhetpollcy nwnbur and vxp at�p Qat
ra,lurro w\deuro.uaeruge L required uuJer Scctiun'dA ul'NIQL c. 132 Call lead to Ill*imposition ofthininal penaltie of
fin¢till m SL 5141)(1 antJ/ur uaie•year 6npri.m,tit,ncnr, ar we11 Car civil Ixnalucs in IhY l'unn ol'a STOP 1VURK URGER and a fine
ai up rn i130 M)a Jay igailul Il,d v6rlanir. Ile aJvrlcJ thus a ropy of lhty dulcmem may be turT'll"W w the RDE Cal'
Im...l,guu�ms ul',hu UTA :or nr�uranca:n� 'rr•.
� a� :I llic alum. -
/Ju berrAy 1.rri/y mr�/.y t y,rin �rnJperrnlllie u
/' /prr/nry rhYr the in/bnnullan PNrr'1/er/Y0111'I it!rues 1111d ivarre'er.
rr„ Old
7 — —
7')1114
only. 1)u nnr wiry in 1141 un•u ru ArlrltJ by Tits Car ro wn a//hie[
t rr: _ s
hnrily (circle ouv):
I(v.11111 1lerkJ. l'IvcHir,lllu, lrvNr :.
I Phi,nbind hi pcclar
it 1' u.rcl I't nun: _
information and Instructions
rson m the service of another under Any coNnct of hire,
�lu,soclmsctis\+tntuw, Jn rmplarrr iY Jcivqul as allevelry m rs to provide workers' compeni+uan ror (heir ct o hire.
I'ttfsu.ufr to tilts
.press or unphed, oral or wntten." or anyIwo or mors
lit ,.r or the
�n.onpluprr Is detineJ u"an individual.partnership.JYsueuaoa.carporauon or other Icg,al rnnry.
t the lot at
engu�cJ m a Iwnt enterynse, lid including{thetheol gal%: entatcros to a^e�m plo)caI. Howcvcr the
gin not more than three Jpartmenu and who resides therein.or the occupant of
ecetver or uuatee u1'.m uIn 4 J ual, pesmershtp,Assoewuoa or other
legal
entry, P y the
owner of a Jwelling house having to s lions to ee n4inIdnunce,cuastruction or repair work on such dwelling house
.hvcllrnv house of Another who a ploy% thereto shall lot because of such employment be diegaid w be an employer."
or ,,n the grounds or building{Jpp
�IGL chapter 152. 41SC(6) also states that•'every state or local licensing
bu dings I shag e withhold the Issuance or
Uaacs wltb the Insurance covsrago required.'
renewal of a license or perntlt to operate a Auslness ar to eoostruet buildings In the commaaweultY or any
rene ealis aho has not produced acceptable avid@a' of sump Oilu political subdivisions shall
\JJitionulty,MGL dwpur 1 S=, a:SCl7g Mates"Neither the conunonwcJldt nor any
inter into any:untracs Ylu the parfomta^ievan eJbo the conuiradi g amhorticyy'�ace ofeonlpli urea with the insurance
requinmenis of this chapter have been p'
APPltca^ts checking the boxes that apply to your situation slid'if
ensation a111davit completely. M nwuber(0)along with their certificuteU)u!
111111 sus the worker' comp ad eel and p s LLP with no employc�te other than the
necrosa 7 supply sub contractor(s)nama(s), free have
workers' compensation insurance. (tea LL�rolmant of IInndustrial
insurance, Limited Liability Companies(LLC)or Limited Liability Partnership
netnba 2 or partners,are not I L 13 a al to carry be submitted to the Dep
employees,a policy is requited 9e advised that this affidavit s mayIL aAmant of
\Iw be sots to silt act
ditto the uenadvnol 11e�pda"shoo
ucidenu for confirmation of insurance c Itcation for the permit Ix li"nae is being) ret
ha rcntmed to the city or town that the npp
Industrial�\ccidenu. Should you have any quasttotss regarding rho low below.
you are required to obtain a workers
cotnpenItalian policy,pies"call the Depurtrstent at the number listed below. Self-insured. companies should enter then
.cif-insurance license number on the a ro tiara line.
('Icy or'rows omelala cat the a licant
plc;,.w he.ore that the i� il natsin�he avrd and errt dt.silt a loth Investigations has ha+r to corrgonent al ct you regardinprovided u g at thpp buttons
cam
Of III*alfiduvit for
y
I't:usa )a sure to till in the puneitilicatw nutnbar which will be used as a referenceonly submit number. Ia aJd^wn, is Jpp ur ur
that must submit multiple Penn'tol'aI t4 J rpl)ebions in any liven a"'"cadt hould G unll lu u�iiunta in uJ w OY lit
PP
policy information(if necessary) ,,J or marked by he city or town tnay be p
potu%licy i \copy )(III*ullldavit that has been oftic"'e to(futurey sump
apvm).'* I as proof a home at a vA l cindeI'lir is obtaining on rung a lense ur permit not related to any bur nesstur commerc I .alied nut ctor
yml
.lug{licence or permil w burn Icava etc.)said persmt is NOT required
to complete this alflda usha,a.my yuesuons,
I h: (P O" u1 Investigatiumt,wulJ hie w dank you in advance 1'ur your:ouperatiun and should y
please Jo nut hesilara to give us A all.
fhc U.p•utmenl Y adJrets, t¢Icphuna aTh Commonwealth of Munchusetu
Departtt►ent of Industrial Accidents
() Rcs of Isvesdgadons
600 WaWnBtoin Street
90310n, MA 02111
rel. q 617.727F� 617 7
00Cxt 02 Of 1.9'7-MASSAFE
,,• ..J < �I,.�Is www.mast.i{ov/tin
1
CITY OF SM.&M, AAss.ICHL'SETI'S
BLAWNG DEP.1RT%LLN-r
120 W.LSHOIGTON STAFBT, Ye FLOOR
hL (978) 745-9595
KIINMERLEY DRISCOLL FAX(978) 140.9846
N(AYOX I}to.+w ST.PtRf�.
DIRFCTOt{OPpl'nL[CPROPERTY/1't: DCgGCO-WUSSIONER
Construction Debris Disposal AftIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State
Buil
Debris, and the provisions of MGL c 40, S 54; dmg Code, 780 CMR section 1 I L 5
Building Permit N 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
I 11, S 150A.
The debris will be transported by:
(narno of hauler)
The debris will be disposed of in :
Iildrae of Faoility)
� L � L lLlli
eignamre of permit applicant
I.hn vd.b�
Board of Buildinau, Regulations and Standards
Construction Supervisor License
License: CS 21273
RICHARD C WALLACE
4 BRAMAN ST
DANVERS, MA 01923
Expiration: 10/31/2013
('„mmi..iner Tr-: 4426
CITY CiF SAS n
_ a BUILDING LICENSE
i This is fo certify That ' •"}'� 5
RICHARD C. WATAACE 't y
4 BRAMAN i ST. DANVERS ST., ♦Mass.,' r1
Has been granted a license by }he. Building InspeeTor,as 6 ` g
-- G7?fdt?ReT. (` a yg f
�' - Attest:
5/12/93
( ) _ Building InapecTor,
fiC airs&B
Office of ConsumerAffairs&B sines Regulx600 i,
HOME IMPROVEMENT CONTRACTOR-
TLJCE
Registration .7a104777 Type:
Expiration: 7/15t2012 DBA
CONSTRACT@IG 1;74
Richard Wallace
1
4 Braman Street
Danvers MA 01923 / —�—
Undersecretary