270 WASHINGTON ST - BUILDING INSPECTION (2) qyf� � I
The Commonwealth of Massachusetts
h I` Department of Public Safit
\Lusdch usclls`,lane Building Code ,11 \IR)
0uilding Permit Application for any Building other tha. ne-or'1-wo-Family Dwelling
(Phis Section For()(ft,Lit Use Onlv)
Iirlildiug Permit Nmnbee Date Applied: .---.--...--- Ouildi I: _
SECT-ION l:LOG\'i[ON(Please indicate Gluck R and Lut N for locations or s ich a street address i of available)
No. rind Street Cily/fuwlt - /ip Code Nantc•of Building(if applicable)
SEC PION 2:PROPOSFD WORK
Edition ul NIA State Curie used ----- If New ConstrllCtilnt check here❑orcheck all Ilim apply in the Inv runs below
Fxisting Building❑ Repair❑ :\Iteration ❑ :\JJitiun❑ Dennlition ❑ (Please till out and submit:\ppendis 1)
Change of Use ❑ Change of Occup,mcY ❑ Other ❑ Specify:---___-- _
Are building plans mid/or construction ilk Wit ntcn1.4[Icing suppl jet[,es part of this permit applictlion? Yes ❑ No ❑------
IS In Indcpcndcnt Structural Engineering Peer Review ret uired??,� Yes ❑ Nu
Brief Description tat Proposed Work: ® �
SECTION 3:CONIPLETE rills SECI-IOI4 IF tAlbI-ING BUILDING UNDERGOING RENOVATION,ADDITION,Olt
CHANGE IN USE OR OCCUPANCY
Check here ifan Existing 0uilding Investigation and Evaluation is enclosed (See 791)CNIR 34) ❑
Existing Use Gnrmp(s): .___--- _ Proposed Use Group(s):___
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)h Area Per Fluor Isy. (t.)
Total :\rim(sq. ft.)and Tutai Height(ft.)
SK-11ON 1 USE GROUP(Check as a livable)
V Assembly:\-I.❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-3❑ 0: Business ❑ E: Educational ❑
F: Facto F-I ❑ 1:2❑ H: tli h hazard 11-1 ❑ 1-1-2❑ l ht ❑ li-T❑ I.1-5❑
I: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ NI: Mercantile❑ It: Residential R-10 R-2❑ R-t❑ R-4❑
S: Storage SI ❑ S-]❑ U:.Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONS'I RUCHON T-YPF. (Check as ap livable)
IA ❑ 100 I1,\ ❑ 110 ❑ IIh\ ❑ Ill0 ❑ IV ❑ VA ❑ \'ISO
5l:'CTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Uispusa is Trench Permit Debris Iteuurval: ---
Public Cl Check it outside Flo...I Lunn❑ Indicutn nnmicip,tl ❑ .1 trench will[till be I.icensed Dispnsal Site❑
I'm Ilk'❑ or indenlity Line' ar,ni,]Ie Ss sleet❑ reyu ired ❑or Ironch or sped(%:
Railroad right-of-Way: I1.1LdRIS 111.\Ir \aPlgJtltlll: r ,i ,. ,, .
\, t l'I'llcal'le❑ Is 1;Irm lure l+ilhin 111-1...it.lpproakit area! Is lhur rrvirw,umhlaloJ'
or l nmeiit to lhuld an lu`+'+I❑ l rs❑ or No O l rs❑ \o ❑
--- SPCI ION 9:CONYITiNT()F CFR I'IFICA'11:OI'
Itdunm,d iode'. lsr Vnmp(sl. \pe of Cvnlnu u,nr tL,up.inl l,�aJ par ll,sr —
It,a-. that+ui diiq;,, main.in sprinkler tit,Irm` tiI"k I'd�l it'll l,tlion.
- SF( IIUN 9: I'ROPh:ltTY UIVNFR AUTII(HiILA'I[ON
u
\ o u \d c nl . dm ut'O•ss ul Prop+rwe r v T
Ctt Town Zip
N,unc (Print) No. and treet
Properly Owner Cuntar:t lufonnation:
I isle ---"-------- --- Folk-phone No. (business) Telephone No. (cell) - --c-mail address
If applicable, the property owner hereby aulhoriics
Name Street Address City/town State Zip
to act on the property owner's behalf, in all matters relative h+work authorized by this building permit a +,lication.
SECTION to:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if build in+is less than 35,001)cu.ft.of enclimsi space and or not under Cc,n.str lction Control then check here❑and ski p Sec Iion I0A
10.1 Registered Professional Responsible for Construction Control �V
N,une(Registrant) L Telephone No. '-i tail eddres Registration Number
Street Address City Tuwn --� Stale Zip Discipline Expiration DateDate
10.2 General Contractor
Company�N. uc
N.1flte of Person Responsible for Constructs n License No. and Type if Applicable
CA&d / G In Ir �� G�— lL��Z 1p
Street Address City/Tuwn State Zip
Trie+hone No business Telephone No. Cell o-mail address
SECTION 11:to v:f.IK,}_,'aireVO I1y 1\_i.\"l <.\.\I"r.tl i ll''�)'.I I M.G.L.c. 152.A 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of industrial Accidents must be completed,out
su
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 13
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item Estimated
\iatcriale) Total Construction Cost(from Item 6) 5__
1. Buildlog S Building Permit Fee-Total Construction Cost x—(Insert here
2. Electrical S appropriate municipal factor) .5_
t. Plumbing $
Note: Minimum fee=S_--(innla't m It ipalily)
;. Mechanical (HVAQ 5
3, \IcclnaniCal Other) 'S Enclose check payahle to —__-
1" Total Cost 5 (contact municipality')and write cheCk number here -__-- - --
SECTION 13:SIGNAIUREOF BUILDING PERMIT APPLICANT
Its rnlerint; nw n•une below. I hereby a(tcet under the pains,utd powltics of perjun that all of the information amtaincd in this
apphcothnt is Inn and IeCurate to tale best of uy kuom ledge anid,u/}nderstanding.
Please print and 'Ign n,1111k, Illle 1.1cphonc No. ,p p,Ua�lc MI6
i
�Irvrl .\ddres�..GAj1jAL Jli City; I'i,wn �N%K—
i
\lunicipal Inspector to fill out this section upon application approval:
.Kann• I n.ue
Cra UP SALEM, NWSACHUSETTS
' BUILDING DtP.kWrNlV-\T
120 WASNLNGTON STREET, 3-FLOOK
TEL 1918 745.9595
Rut:(975) 1$0.9844
!Cl\i B E RL-EY D R)SCO L L
Akyo Z Ttionits ST.PIUAR
DIRECTUit OF PL9LIC PRO PERTY/BI:RDI\G CO>LOIISStONEa
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrici•rnUPlumbers
lipolleant Information Please Print Leaihly
..Nellie liluaitw,ulyrgtm»linnlndividu.lt)�Li VIA" J 66kfE� Z[hi C'
Address: I GA ftna
City/Static/Zip: {� I �SS Phone hl:
Are you employer!Check the appropriate bass Type of project(required):
1, am a amploycr with _ 4. ❑ I am a general contractor and 1 6. ❑Now construction
elnployens(hill and/or part-Lima).• have hired the sub-contractors
2.❑ lama sole proprietor or partner. listed on the uuuhed sheet.2 �• ❑ Remodeling
ship and have no employees These subcontractors have g. ❑Demolition
working liar me in any capacity. workers'camp.insurance. 9, ❑ Building addition
(No workers'.camp.insurance 1. ❑ We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
).❑ 1 am a homeowner doing all work right urc tdmpliun per MGL 11.0 Plumbing repairs or addition&
myself.(\o workers'Gump. c. 152,91(4),and we have no 12.❑Roof repairs
insumnce required.)l ampluyees.(No workers'
cump,insurance required.) 0.0 Other
•Any applic:ue dw ehcuks bat rl mwt also rill uu1 the seerioo balaw showing their,raram'<ompnudun pulley mdamaaon.
'i hwnvuwiav whs.uhmit this rMdavil Indicating they aro doing all,vork and then hiro uuside cantnetsxt must inhnit a now allidavil indiming such.
:V.,mmmun it al chwk this buts mttil reached an.IddiduNd.hs1%hawing IW nwne or Its sult-canbtclan and shalt waken'crop.pulley infixmadoe.
fain an employer that h prgyfJGrX Below/s Ju po t icy and job site
inlunrrudon, �JJ-- n/�n y� C /
I a Hl natlCe Company Namellg h �..... Z&12 �Y•G �� J , 170 .
Policy J ur Scif-ins. Liu. 0:/4lize L/A /7/ ��2 s'C3 IP�c---T7 Expiration Date:
Iva Site Address: —2�C/G Cily/stattizip:-,5A09et&
\lhch a copy of the workers'compensation polity declaration page(showing the polity number and expiration data).
Failure to secure cuveraga as required under.Section 11A of MGL C. 152 can lead to the imposition of criminal penalties of a
rine tip to S 1,500.00 und/ur one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and d Imis
of up to S'_50.00 a Jay against the viobanr. Ile advised that a copy of this..tatement may ba turwdrdcd to ilia 0 lica of
lo%cvligutians of the DIA for insurance coveraga vcriaeaiian.
l Flu hereby reify/r der du in ry/but the inil'tirOlullon presided above its true wii���d correct.
Ul/icia!nee Holy, Da unr wrNr in rlriv ureo, ru hr curuylned by my car sown n//7riu!
Ciry or l•uvn:.V_. .. ._, I'crmili l.lccmei
\Wburily (circla Ana):
I. Uuard of lilvlth !. Iluildln;I)cp.li lutcul I. ('ilyi fown Clark I. lilectric it bi,pertor i. Plunlbinp Inspector I
CITY of S.u.E.Ni, AkSS.ICHL'SETTS
JL'tLOLYC OEP.1A-nLLNr
I _0 lff-wimms STXW, 1'4 accit
I'M k973) 745.9595
1skX(973) 7 t0.9844
Kl1®t RLBY OUXOLL
MAMA MawfS7.pr�
OfREGTOR OP M OUG PROPItiTY/9t:MnC CS cosaifssro.'EA
Construction Debris 013pos21 Affidavit
(required for aU demolition and rcnavation work)
In accordance with the sixth edition otthe State Building Cade, 190 CUR section 111.1
Debris, and the provisions of UGL a 40, S 34;
Building Permit At 1 1 is issued with the condition that th' debris resulting from
l 1, S 110A.1 work shall be dispos ed of in a properly licensed waste disposal facility as defined by NICL e
The debris will be transported by:
�'E'VYlii� <Y�l\K � � ��
(name of haulvr)
-- The debris will be disposed of in : 2 w�
vcl2ELL
(clams of r uilay)
(�ddrrtl ot'fruih�y)
urnamra u(permitrpphcant
!Ji7
Issa ell azelt.s- De'partInCnt of Public S:
Ra dcty
ted of Ruildin Regulations and Standard `
`- Construction Supervisor Specialty License
License: CS St. 99378
Restricted to: RF
INICHAEL=BRADLEY' `
3.CANAL STREET
r »
LYNN, MA 61905 C^
N"
j� Expiration: 6/20/2013
f nnmuissimrp Tr#: 3903
(Ake of Consumer Affairs&Business Regulation
irlr_ Fffl ;isA;: IMPROVEMENTS CONTRACTOR
Registration a 123834 Type:
r;<piration 411412013 Public Gotliojstio
'., J r'.SConaLuction Idcr
=yl
Jan-, rsr i4aV:, a. 4di't 1
s
3 CA!1F,L ST
1
Ll n MAP 05 Undersecremry
Y"
05/16/2012 12: 11 FAX 7815982423 f�001/001
' �at'ofzo®
CERTIFICATE OF LIABILITY INSURANCE DATE,MMODYYYY,
FBELf
CERTIFICATE I$ ISSUED qS A MATTER OF INFORMATION ONLY AND CONFER$ NO RIGHTS UPON THE CERTIFICATE HOLDER.1THI$
FICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE
W. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THH IISSUINGFNSURER(S), AUTHORIZEDSENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.TANT: R the Certificate holder la an ADDITIONAL INSURED,the pollty(le6)must he endorsed- If SUBROGAON IS WAIVED,subJect to
ms and conditions of the policy,Certain policiesate holder In lieu of such endorsements maY require an endorsement. IA Statement on this certificate deer nOt confer rights eO the
Woodward & Higgs TAC Jim Higgs
156 49 Insurance Inc. N E:
(781)g9B-3o40 PA aBr*ad
202 $t, PRONE
Suite 2D2 E-M (1811890-2429
Lynn MA D1901 INSURE 6 AFFORDING COVERAGE
INSURED HBO RA:Atlantic Charter NAICR
J & M H Construction Inc, INSURER e:
3 Canal Street INS OURC,
INS PER 0:
LY= MA 019D5 IN HER
COVERAGES CERTIFICATENUMBER:Cr-1 S:t60669s u1P
THIS IS TO CERTIFY THAT THE POLICIES( INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY REVISION NUMBER:
EC
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORD CONTRACT OR OTHER DOCUMENT WITH
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SryOWN MAY HAVEED B REDUCED BY P HE I DE SCRIBED HEREIN IS SUBJEGTPTO ATo THEI TERMS,
INS LMMS.
TYPE OF INSURANCE
GENERALLIABILITY Y BE POLI TEFE POLICY EXP
LIMITS
COMMERCIAL GENERAL LIABILITY FACN OCCURRENCE S
CLAIMS-MADE ❑OCCUR AMA N
a
MED EI(P An vre sail {
PERSONAL&ADV INJURY a
GEN'L AGGREGATE LIMIT APPLIES PER: GENFAAL AGGREGATE S
POLICY PRO.
LGC PRODUCTS•COMP/DP AGO S
AUTOMOBILE LIABILITY
8
ANY AUTO COMBIN INGLE LI
ALL GNNED SCNEOULED I
AUTOS AUTOS BODILY INJURY(pq,,ganl S
HIRED AUTOS AVT$MED BODILY INJURY(Pw gcfidpnll S
PROPS I TY DAMAGE
a
UMBRELLA DAa OCCUR {
EXCESS LIAR CLAIMS1dgDE EACH OCCURRENCE
$
D ET 1, AGGREGATE S
A WONERS O ER&LI BILIT
AND EMPLDYERe'YAB14TY t
ANY PROPRIETCWU NERIEXECIJ IVE YIN VYC STATIF OTH-
OFFCERAIEM ED7 BEREXCLUD ❑ NIA
Mar( gdary In NRI E L.EACH ACCmENT S
D BCP u TON FOrPERATI SDeknv E L.DISEASE-EAEMPLOYE {
E L,DISEASE•POUCY LIMB a
DESCRIPTIONOFDPGRATIONSILOCATIONS( HICLE3(Aaarh ACORD101,AddlllenAl Ramar{a ScBaduh,XmOn apAcvhraqulrvd)
A request has been Submitted directly to Insurance CarrSer t
corkersvers ortleasatipn for the Commonwealth of o issue a certificate of insurance as regards
cover shortly. Maeaachueetta. This certificate will follow under separate
CERTIFICATE HOLDER
(970)740-98a$ CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Salem
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Building Department
AU RI REP ESENTA IVE
26(2010J06) Christine Higgs/Cwls
ACORD
IN9025(20100s).01 The gCORD name and I O are (01SEIB-2010 ACORD CORPORATION. All rights reserved.
G9 registered marks of All