23 WEATHERLY DR - BUILDING INSPECTION L { I
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`--The'Commonwealth of MasJAM&S SERVICES
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Department of Public Safety
Massachusetts Stale BuildingCode 780 �j 8 - �
Building Permit Application for any Building other than a-0r oA'Cw'FamilyRvelling
(This Section For Official Use Only)
Building Permit Number: Date Applied; Building Official:
SECTION 1:LOCATION(Please indicate Block k and Lot fi for locations for which a street address is not available)
t1� '54IY-nA['IPr al��
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the nvo rows below
Existing Building Repair Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 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 EngineeringtVeer Review requ. •I? 1 Yes ❑ No ❑
Brief Description of Pmposeal Work: .0(l ltr n C�'."� C10A :F CAL.
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) ❑
Existing Use Group(s): I Proposed Use Group(s):
SECTION4: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 applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ II: High Hazard H-t❑ H-2❑ 11-3 ❑ 1-1 4❑ H-5❑
1: Institutional I-t ❑ 1-2❑ 1-3❑ 1-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use . -
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB Cl IIA ❑ 111) ❑ I11A ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ IndiC,ue municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indenlify Zone: or on site system❑ required ❑or trench or specify:permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \I;\I I ii Gnnnu ci n I ro I r yrs:
Not Applicable❑ Is Structure within airport approach area? Is their review Completed?
or Consent to Build enclosed❑ Yes Cl or No❑ Yes❑ No ❑
SECTION 6:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: _ Occupant Load per Floor:
Does the building Contain an Sprinkler System?: _ Special Stipulations:
SIS7 552 S, Iz1
11K10 = ilo
SECTION 9: PROPERTY OWNER AUT'IiORIZA'FION
1
Nam•and Address g,fA n�gerty Owner rr f`
Q .. (�C( CK1/\
II cr.0 '5—, � + �1 F} OC�i rIC
Name(Print)- No.and Street City/'town`- Zip
Property Owl, G ontact fnfornaelion,
GUl1 VtYi_
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
toad on the property owner's behalf, in all matters relative to work authorized by this buildmg permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here and skip Section 10.1
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
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
'relc hone No. business Telephone No. cell a-mail address
SECTION 11:4VOpKI,iKS'COAII'6NSA'I'ION INSU1R;\N(T \1:FII \VI I' M.C.L.c.152.9 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 O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Itcnr and Materials) TotalConstruction Cost(from Item 6)
1. Building S Q'O'�' Building Permit Fee-Total Construction Cost x_(bisert here
2. Electrical - $ I OG 4' appropriate municipal factor)=$
3. Plumbing S gG' G
=4. Mechanical (HVAC) S Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check Y payable able to
6.Total Cost $ 10, dU (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.
Plc e runt and sign name 'title Telephone No. Date
Street Address City/Town State Zip
i
Municipal Inspector to fill out this section upon application approval: r Z-
Name Date
n44ti,�,,
CI'I•Y OE S.�L.E�I, l�L1SS.ICHL'SETTS
BUILDING DEPARTMENT
�vx.o-' 120 WASHLNGTON STREET, 3aa FLOOR
, T EL (978) 745-9595
FAr(978) 740.9846
K1MBERLF_Y DRISCOLL
,kAYOR T Ho&w ST.PiERRE
DmECZ•OR OF PUBLIC PROPERTY/BuiLDIVG CO%L\IISSIONER
liVorkers' Compensation Insurance Affidavit: Builders/Contractorv/Electricians/Plumbers
,Alilicant Information Please Print Leriibl
Naine IFluainassprganicatiaro'individual l:
y Address: S
City/State/Zip:'27 ( f(I'2 LIB— Phone M .
Are you on employer'Check (he appropriate box: FRemcdeling
ect(required): -.
I.❑ 1 a employer with 4. ❑ I am a general contractor and 1mislruclion
nipinyces(full and/or part-time),• have hired the sub-contractors
2- I ran a sole proprietor or pannur• listed on the attached shcet. i delingship and have no employees These sub-contractors have litionworking fsr me in any capacity, workers'comp. insurance. g addition1No worker•'comp. insurance 5. ❑ We are a corporation mid its
required.) officers have exercised their cal repairs or additions
3.❑ 1 ani a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself. (,so workers'sump. C. 152, §1(4),and we have no 12.❑ Raof repairs
insurance required.) t employees. tNo workers'
comp. insurance required.) (3,❑ Other
•Any all plieura nut checks bux 91 must also rill out the%cc lion below showing their winters'compensation pulicy inanmattun.
'I Iomeowtwn oho suhnnit this alTI(Inuit indicating they arc doing all work and then hire outsido canlmctara miul suhmit a new alfldaviI indicating such
l'Immcrors thin ch(rk this box mint inaahal in addoiuml shut showing file n:une of the"b•conlrsctun and their workers'camp.Policy inromatiun.
/out an eutployer that is providing ivorilers'compensation hi-furaace for my employees. 21e101y is the policy and fob site
iufrarma!lnn.
Insurance Company Name: 4 _ 'ter'' J
Policy d or Self-np. L10.II: I 4 //I /� Expiration
tub Site Address: (✓ -( City/State/Zip•
{ Atlach avopy,of the workers,compensatio pulley declaration page(showing the policy number and expiration date).
1, h'aihire to secure coverage as required under Section 2JA of NIGL c. 152 can lead to the imposition of criminal penalties of a ,
fine up to S000,06 and/or one-year imprisnnmen4 as well as civil penalties in the farts ufa STOP WORK ORDER and a tine
nFup to S250.00 d day against rht violator. Ile advised that a copy of this Ntilement may be forwarded to the 011ice of '•�
Investigalions oil [Ile OIA for insurance coverage verification.
/do herrby cerlify a tder t/ ain en f perjury that the infurrnution provided ubuve is true and correct.
Si•m t c Date:
I'hunc t
Ofliciul use only. Da nor write in this area, or be completed by city or Iowa officiu2
' � I
City nr ruts n: Permitt'Llccnxc 4 I i
Issuing,lulhurily (circle one): -�_ --- ----
L Board of 11ea11h 2. Building Dupartmeut .1.cayawNi,Clerk d. Electrical luipectur S. Plumbing luspecror
6.Olio
Contact I'c stun: Phone 3:
CITY OF SALEM, MASSACHUSETTS
K Sj� S� BUILDING DEPARTMENT
120 WASHNGTON STREET,3" FLOOR
'ILL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR TrIOMAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
//-.5
Date
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Marcia Kirkpatrick
From: Thomas St. Pierre
Sent: Wednesday, August 13, 2014 12:22 PM
To: Marcia Kirkpatrick
Subject: FW: 23 Weatherly Drive, Salem MA Arlene Germain
From: CyndyAnselmo [mailto:cyndyCcbecpllc.net]
Sent: Tuesday, August 12, 2014 9:28 PM
To: Thomas St. Pierre
Subject: 23 Weatherly Drive, Salem MA Arlene Germain
Hi Tom,
Arlene Germain is a new unit owner at 23 Weatherly Drive, Salem, and she is doing remodeling work in her unit that has
been approved by the Board of Trustees. She is having new kitchen cabinets installed and other work in the
condominium including replacement of toilets,vanities, medicine cabinets, electrical fixtures, new appliances.
Thank you.
Cyndy
Cyndy Anselmo
East Coast Properties, LLC
Real Estate and Property Management
400 Highland Avenue Suite 11
Salem,MA 01970
P: 978-741-2003
F: 978-745-9684
cvndv(O"'ccpllc.net
1
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _
I Sm egistration 132449 Type: Office of Consumer Affairs and Business Regulation
xpirabon 2O/2075 _ Individual 10 Park Plaza-Suite 5170 -
-- ._ Boston,MA 02116
CHARLES E. KNIGHT JRs,;''__
CHARLES KNIGHT
5 EAST COLLINS ST -
SALEM, MA Ot 970 Undersecretary Not valid without signature
Massachusetts -Department of Public Safety
Board of Building-Reg ulations-and.Standards
Construction Supervisor i
License: CS-070760
```1\:I I c „,
CHARLES E NM AIT
5 EAST COLLINS S
SALEM MA 01970
Expiration
Commissioner 08/19/2015