73 WEATHERLY DR - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use ...
Building Permit Number Date Applied ButldictgOffitzaL'
SECTIONLLOCATION(PIease indicate Block#and tot#&rfacatonsfgrwhrchastreekad otavailable):
3 Jn,V U S.tic.: 10 ► 970
No.and Street (O.Ja J City/Town Zip Code Name of Building(if applicable)
SECTION Z PROPOSED WORI@'
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Q Alteration Q Addition❑ )emofition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ Noic
Is an Independent Structural Engineering Peer Review required? Yes ❑ No!k
Brief Description of Proposed Work �-
J Jn r 00 t>
SECTION 3:COMPLETE THIS SECTION IF MaSTING BUMDING.UNDERGOING RENOVATION,ADDITION;OR
CFIANGEIN USE OR OCCUPANCIF
Check here if an Existing Building Investigation and Evaluation is enclosed(See 78o CUR 34) Q
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHTAND,ARSE!
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(Cheek asa _livable
A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4 Q A-5❑ B. Business Q E. Educational ❑
F: Fact F-1❑ F2❑ H: High hazard H 1❑ H-2❑ H-3 Q H-4 Q H-5❑
I: Institutional I-1 Q I-2 Q I-3❑ I-4 Q 1 M: Mercantile Q R: Residential R-10 R-2 Q R3 Q R-4 Q
S: Storage S-1❑ S-2❑ 1 U: Utility❑ Special Use Q and please describe below:
Special Use:
SECTION&CONSTRUCTION TYPE(Check as Iicable)
IA ❑ IB Q IIA ❑ IIB ❑ MA ❑ IHB D IV Q 1 VA Q VB ❑
SECTION 7:SITE INFORMATION(refer to 78o CMR 12LO for deta Won each item)
Removal:
Water Supply: Flood Zone Information Sewage Disposal: Licen�d Trench Permit: Debris Djs�
Publicly Check if outside Flood Zone Q Indicate municipal� A��will not� Site❑wired❑or trench ors C— Z-
Private❑ or indentify Zone: or on site system Q permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation M. A NstorieCommission Review Pnaess:
Not Applicable�h Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed Q Yes Q or No Yes❑ No Q
Su IION 8:CONTENT OF CERTIFICATE OF( CCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor.
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9r.PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
-13 tea -��� J-•.L 4 5 A" two.. 0197
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
C1�.c.�a 1 arbf�rz Oy /��`>< L b$n (y19� (;hprg u i j 3 P_T•� 1, t
Title Telephone No.(bW111m) Telephone No. (cell) e-maiHddmw
If applicable,the property owner hereby authorizes 40^-t
to1��a,J L.J. �tse Z(�L�r�
Name Street Address City/Town State Zip
to act on theproperty owners behalf,in all matters relative to work authorized b3r this building 't application.
SECTION IOi CONSTRUCTIOPi CONTAOt easefill ouex(PIppendn42)
isi>;ss'tkmn35000ca Ef<of er�2osed". vtnoundetCori"shiaehoa.ContioE t[ien chetiEBaeEFaiid� Sectioi '121
10:1 Registered Professional Responsible for Construction Control
IOD( _
Name((a�egis t) Telephone No. e-mail address Re ' trati N
210 HVMi 51 Marie La e�1 AM A Oi S 9 i
Street Address— City/Town State Zip Discipline ExpifationfDatti
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
`- 1s 14L Md.. &A-
Street Address —� City/Town State Zip
2A-_Z !Oa ! qoL-389 1032? S Fn Scl. LkAj zo�J A
Telephone No. usiness Telephone No. cell e-mail address
. SECTIONn-WORKER.SCOMP4"SATIONINSURANCEAMDAvyr 'G:LC-= ZSf
A workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit
Is a signed Affidavit submitted with this application? Yes No O
SECTIONIZ:CONSTRUCnONCOSMAND.PERMM I%
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$�
1.Building $ Cln Building permit Fee=Total Construction Cost x_(Insert hem
2.Electrical $ LPC7. appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee-$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ JC.D (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
appGcatiq{t is true and a ura to the best of my knowledge and understanding
44J "Cu ChE�ui �ei�a�fz- q�8 _s�Y_ t�i�f �kl 13
Please print a n re �c t � ' C,,,i)WcOi.L Title iTelephoneq No Date
Street Address nn l.P l O)(� City/Town ULState Zip
Municipal Inspector to fill out this section upon application approval /1 3
Name V Date
I
yr
CITY OF S�ULEM2 1LisSACHUSETTS
BL'II.DL\G DEPAR -MNT
�jK6yf 130 \W.ASHCYGTON STREET, 3'D FLOOR
TEL (978) 745-9595
KIMBERLEY DRISCOLL F•1-C(978) 740-9846
tiLkYolt T-10-%W ST.PIERRa
DIRECTOR OF PUBLIC PROPERTY/BCILDWG CONINIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section l l 1.5
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
l 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
_— —(address of facility)—
r'
l
'signature of permit applica t
2 2� l
date
dcbn; ((d.x
i CITY OF SALEN15 ,ANSSACHUSETTS
BL•ILDING DEP\RTM&NT
a ,{f 120 WASHIINGTON STREET, Sae FLOOR
TEL (978)745-9595
FAX(978) 740-9846
K7.,,(gFRT F-Y DRlSCOLL
�J.AYOR It10FL1S ST.PIE.RAB
DIRECTOR OF PUBLIC PROPERTY/BUM.DLNG CONLHISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aimiicant information i ` \ Please Print Leeiblx
Narric(Ousillcsss7�Organiratiorvfndividual):
/ �V�Q fX�O-•� f\ J��O�V'`u't �SJI�
Address: k ykJM P" SY 1
City/State/Zip: Nk� 4 Phone At: g\ (Z3q 1 6O(
Are you an employer?Cheek the appropriate x: Type of project(required):
1.0 I am a employer with 4, am a genet contractor and 1 6. El New construction
employees(fh11 and/or part-time).* have hired the sub-contractors ,�,{_
2.C] I am a sole proprietor air partner. listed on the attached sheet.t ?• remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. workers'comp.Inslrranca. 9. 0 Building addition
(No workers'comp.insurance S. 0 We are a corporation and its
required.)
officers have exercised theft 10.0 Electrical repairs or additions
3.C] I am a homeowner doing all work right of exemption per MOIL 11.0 Plumbing repairs or additions
myself.(No workers'temp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t vmployees.(No workers' 13.0 Other
Gump.insurance required.)
•nay applicant that checks box Of most also fill out Iho action blow showing their waked companudun pocky informarlon.
'I hvneuwnen wha sulunil this aflldavit indicating Ihcy,am doing all work and than him outride eontroetgxa mtal mbmit a new,Md1,,it indicating such.
:Cunlracturs that chick Ibis box most aeachod an additional ghat showing the name of the tuhcdntrtctorr and that,wurkero'wmp.policy infomution.
l um un euployer that is provfding ivorkers'comprwsadan insurance jar my employees. Below is rht polley and fob rll#
injormallon. t-
insurance Company Name:
. ^^GYI'npr7�`y"i
Policy 4 urSelf-hut.n .Lie. 4: ll"CA 1 6061 L7 Expiration Date: 3
Job Site Address: City/Statr/zip: 15,t Okc --•—� CD\q 70
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 2SA of MOIL c. 152 can lead to the imposition of criminal penalties of a
line up to S 1,500.00 and/or one-year imprisonmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. fie advised that a copy of this statement may ba futwardvd to the Office of
Invesligatiutss of the DIA for insurance coverage vcritiealiufl.
ell /I
l do hereby rertljy wader the ns cad pen a u/peflury drat that hiforrnurlan provided above is true and carnal
Daw
UJJIt ial use mdy. Do not virile in t/rls area;to bt cuurpleted by city or town e/Jletal
Cityor'rusrn: Permit/f.lcense#
Issuing Authorily(circle one):
1, llourd of Health 2. Building; Bepurtmcnt 3.Citytrown Clerk 4. Electrical inspector 5. Plumbing Inspector
Contact Person: ..- . .___ ._. Phone I:
02/20/2013 WED 12: 29 FAX 9/8 922 232b Carmen Kirrnaii insurance yNuul,uuz
ACORN CERTIFICATE OF LIABILITY INSURANCE 02/20/2D 3)
PRODUCER (978) 922-0086 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Carmen-Kimball Insurance Agency, Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
48 Beck£ord Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 73
Beverly NA 01915- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A'Technology Insurance CIO
Sheldon Frisch Development Inc. INSURER B'.Essex Insurance CO
PG Box 811 INSURER c
218 Hughey Street INSURER 0:
Marblehead MA 01945- INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR DD'L POLICY EFFECTIVE POLICY EXPIRATION LIMITS
INS 'TYPE OF INSURANCE POLICY NUMBER DATE(MM/ODIW) DATEIIAMU Y)
$ }( GENERAL LIABILITY 3DK8834 04/15/2012 04/15/2013 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES TO
oaou°noe $ 50,000
CLAIMS MADE NI OCCUR / / / / MED EXP(Any one person) $ 5,000
PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN1 AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000
POLICY JECOT LOC
AUTOMOSILELIABILITY / / - / / COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO
ALL OWNED AUTOS / / / / BODILY INJURY $
(Per person)
SCHEDULED AUTOS
HIREDAUTOS / / / / BODILY INJURY $
(Per accident)
NON-OWNED AUTOS
PROPERTY DAMAGE $
(Par cndant) -
GARAGE LIABILITY AUTO ONLY EA ACCIDENT $
ANY AUTO / / / / OTHER THAN EAACC $
AUTO ONLY: ASS $
EXCESSIUMBRELLALIABIUTY / / / EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE / / / / $
RETENTION $ _ $
A WORKERSCOMPENSATIONAND NC990001B 03/31/2012 03/31/2013 X TORYLIMITS ER
EMPLOYERS LIABILITY - E L.EACH ACCIDENT $ 500,000
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE$ 500,000
It yes,describe under 500,000
SPECIAL PROVISIONSISsIow E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATONSAOCATIONS HICLES XCLUSIONS ADDED BY ENDORSEMEWISPECIAL PROVISIONS
Job Site: 73 Weatherly Drive, unit #G,Salem, MA
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS V EN NOTICE TO THE CERTIFICATE HOLDER NAMED TD THE LEFT,BUT
City OP Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Salem MA 01970- ,::.....,. . ..... _.... '1
ACORD 25(2001108) CACORD CORPORATION 1988
Pepe I of
INS025(Dios)os
Massachusetts-Department of Pubic Safety
Board of Building Regulations and Standards
Construction Supersisor
License. CS451135
OFF
H
si�rw '-
s
POBOX811
Air MA 8i
iv
Expiration
Commissioner 07H4/10'14
which
of soy Use�(vo%')of
Una 35,000.
��Space
useM
a current.edrtlan a wo cs�
Future to Pws:w is cause Man.6ov/D�
. Stateetoubre a�
ops icoism Forman°
Office of Consumer Affairs and Business Regulation
10 Park Plaza Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 104546
Type: Private Corporation
Expiration: 7114/2014 Tr# 226592
SHELDON FRISCH DEVELOPMENT INC.
Sheldon Frisch
P.G. BOX 811 ---------
Marblehead, MA 01945
Update Address and return card.dark reason for change.
f Address Renewal Emplovinent Lost Card
--;A t-e j";),r ,Illy License or registration valid for individul use only
Officcof Consumer AffairS&EW112ess Regulation the expiration date. If found return to:
J�JOME IMPROVEMENT CONTRACTOR before
I Office of Consumer Affairs and Business Regulation
Type:
ov"Istraition: 104546 10 Park Plaza-Suite 5170
,� xpimtion: 711412014 Private Corporaticii Boston,MA 02116
SHELDON PRISCH DEVELOPMENT INC- 7r
Sheldon Frisch
218 HUMPHREY STREET
Marblehead, MA 01945 Undersecretary Not valid without signature
132"---- -----
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All dimensions-size designations L4ww1 This is an original design and must Designed: 7/25/2012
given are subject to verification on rFcs o�oales not be released or copied unless Printed: 2/19/2013
job site and adjustment to fit job applicable fee has been paid or job
conditions. f A a C) order placed.
sheldon-weathersly-7-25 Legend Drawing#• I