119 WEBB ST - BUILDING INSPECTION �. 4�j7 OD ,r9D 99
The Commonwealth of Massachusetts
Department of Public Safety
\Lv x.rchu.ells State Building Code(780 C\IR)Seventh Edition
lt� r City of Salem
Building Permit Application for any Building other than a I. or 2-Family Ilin
(This Section For Official Use Oniv) Inaluji
BUddingTermit Number: - Date Applied: Building Inspector..
SECTION l: LOCATION (Please indicate Block 0 and Lot M for locations for which a street address is not a r le)
/i' ot, 1 .
X Nu.and Street Cily /Torun Zip Crate Name of Building applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition ❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
GhangeufUsr ❑ Change of Occupancy ❑ Other ❑ Specify:
A r'r. building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No ❑
h.rn Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
X �N77�F�lQ
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY '
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): P
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No. of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area (sq. ft.)and Total Height(ft.)
SECTIONS:USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 8. Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ T H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H4 ❑ H-5❑
I- Institutional 1-1 ❑ 1.2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R:. Residential --R-10 - R-2 O- R-3❑ Ri
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and lease 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:
1 ublic ❑ Check If outside Flood Zone❑ hrdicele municipal ❑ A trench will not be Licensed Disla,s.tl Site❑❑ur trench or. . .-
Private Cl ur mdcntiiv Zune: or on site system❑ required I ecliv:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: %In I Ito.-r r t-,non,b.u.n 14.•,i,,. 1'r,•
..\ot Apphcebie Cl 1,Structure mlhm airport aF+i+roach area.' Is their re%ie,c completed.'
a l'„n.cnt w Budd voclo,ed ❑ 1 1'vs❑ or.No,O 1 Yes❑ No, ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
L:,c(.narplsr: rr peof C,m.tnlcuon: Occupant Load per I lnoe
I),n•. the buildup o,nlainan Sprinkler wstvin Special Stipulations:
F
SECTION 9: PROPERTY OWNER AUTHORIZATION t
Na e and Address of Pn+pvrty Ownr
ame(Print) No.and Street Ci N/Town Zip
N �J7n
Prop e ly( enry(s• )t�ar—t I�orm�a/t/iu r :
22g7 0
99f) lh427J
Title
Telephone No. Ibu.inrs) Telephone No. (cell) e-mail address
If applicable the prok�prrty owner hereby authorizes
-,��pIJ off fo2l HII RV6' 3r=�1 /KIr b191 J
Name - Street Address City/Town State Lip
to act on the +n+per1% owner's behalf, in all millers relative to work authorized by this buildin • permit a p lication.
SECTION t0:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is ktis than 35,00i)cu.tt.of encluxd space and/ur nut under Construction Control then check hen❑and ski Sechun IU.11
10.1 Registered Professional Responsible for Construction Control
N
Name(Registrant) Telephone No. - e-mail address Registration Number
Street Address City/Town State - Zip Discipline Expiration Date
1
10.2 General Contractor
Company Name�, p < .' •'Y
X �� >, t i v - Cs j i 3S 1(op (g
Name of Person Responsible for Construction License No. and Type if Applicable
f'Z C'CCxLSE+�) �iti t�� `� mti, Y719tJ
Street Address City/Town State Zip
CM- - 9_Z�
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.fi 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 D
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical - $ appropriate municipal factor)_$
X3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=E (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ 1u;00 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Bv entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is t - and accurate to the best of my knowledge and understanding.
1'Ica.e + i t and .gn name ride relephone No. Uale-
( Y c k PQ5 ST —4:k ru D
:,str'ret :\ddres - Cit. i To,cn St at Zip
>funicipal Inspector to fill out this section upon application approval: ' v�
N34n a 11ete
.4
APR-15-2010 02:09P FROM: TO:9787409371 P.1
ACORD CERTIFICATE OF LIABILITY INSURANCE DATis/201Y)
EIMM
oa 2olo
PRODUCER (978) 922-6600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Sterling Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
306 Cabot Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Sox 493
Beverly, MA 01915- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A.Cornmerce Insurance Co.
G. Faust and CO. INSURER B'.
Glenn Faust DHA INSURER C'
62 Cogswell Avenue INSURER O
BeverlyMA 01915- 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 CONTRACTOR OTHER DOCUMENT MATH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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.
INSRADO'L POLICY EFFECTIVE POLICY EXPIRATION
LM I SAID TYPEOFINSURANCE POUCYNUMBER DATE SMIDDIYY DATE MWDOIYY LIMITS
A GENERAL LIABILITY TBI 03/31/2010 03/31/2011 EACH OCCURRENCE S 1,000,000
X COMMERCIAL GENERAL LIABILITY PRA MISES Eeorenw $ 50,000
_ CLAIMS MADE FRI OCCUR / / / / MEO EXP(Any one mean $ 5,000
PERSONAL S ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
C ENLAGGREGATE LIMITAPPUES PER: PRODUCTS-COMPIOP AGG $ 1,000,000
POLICY JECT LOC
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT S
ANY AUTO (Ea accident)
ALLOWNEDAUTOS / / / / BODILY INJURY S
SCHEOULEDAUTOS (Per pmaon)
HIRED AUTO$ / / / / BODILY INJURY $
NON-OMMED AUTOS (Per accident)
PROPERTY DAMAGE S
(Par accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT It
ANY AUTO / / / / OTHERTHAN EA ACC 8
AUTOONLY: AGG $
EXCESSNMBRELLA LIABILITY / / / / EACH OCCURRENCE $
OCCUR �CWMS MADE AGGREGATE $
S
DEDUCTIBLE
RETENTION $ 3 $
WORKERS COMPENSATION AND
EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERIEXECUTNE EL.EACH ACCIDENT E
OFFICERIMEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE
If yes,describe Under
SPECIAL PROVISIONS W. EA DISEASE-POLICY LIMIT S
` OTHER
DESCRIPTION OFOPERATONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
(97B) 740-9371 FAX ( ) — SHOULD ANY OF THE ABOVE! DESCRIBED POLICIES BE CANCELLED BEFORE THE
Attn: Matt EXPIRATION DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
Hayden Lock FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON WE
119 Webb Street INSURER ITS AGENTS OR REPRIMMENRATIV6111.
AUTHORIZED REPRESENTVft
Salem MA 01970-
ACORD 25(2001108) CA D CORPORATION 1988
�n INS025(0108).0E ELECTRONIC LASER FORMS.INC,-(800)327-05A5 Pepe I all
c CITY OF S.U.E.`I, UxSSACHL:SETTS
BLODLVG DEPAaTT1E`iT
120 W.\SNCNGTON ST%M. Yet FLOOR
T1nL (978)745-9599
Rut(97I) 74&961f
Kl\BEJA EY DRJSCOl1, h{OkW ST.POt!<Ri
MAYOR DiREAcrca OP PL OLR:PROPERTY/al'ILDL%G Co.L%OSSIOV ER
Workers' Compensation Insurance Affldevit: builders/ContracfarwElectrlclrn%iPlumbers
t,nellcant Informallots Please Print L.eniblfc
Vairla 19uane+aOrtaeuanenlndrvtdrdall: C-�t�l� I�Ru51 I
Addresr. .o2
cily/statelzip: �Y EQ W /Yl, p1917 Phone N 3`19 SP 7290
F
ployer!Check the appropriate beat Type ref project(requke*
t. Q 1 am a contractor ad 1pbya►wits p^� e. QN Cd.bWctiaa
"(fWl and/or pan-time).• have hired the sub.eormsesore
l*proprietoror pwuwz- listed an the attached shove.2 have no cmpioyees Thee sulrcoeareemrs haw e. Q t?.molition
rot me in any capacity. workers•Comp.inwsooa. 9. Q Duildug adlditio.
in'comp insurance S. Q We am a ceepon lms and is
rcquined.l ol'fk td ers haw aamels their 11 10.0.Eloctrical repairs ro epa or st"tio
1.❑ 1 am a homaowrior doing ail work rigbt of eaamptiotr po►MGL I I.Q Plttmbinill repain or additions
myself.(No worker'comp. c- 152.L 1(41 and we haw no 12.0 Roof repair
insurance requird.l! .mpkgreae.LNe workers'
comp insurance required.) -l,Q Other
•nny appaow AM duties bm et Motion Am no wa the rots below a•swip talk weekw'dagwdw 6m yafky inananlae.
'I6wendwtrw who mawtr n is sf lemb indlwap they aw dahy ell week awe On hie riaHa aroees"nwar PA"ti now,afndsea 4wif odes sus►
l.+ertwe dao dew.ton[r tndar aeeetr.r rt.dwrl.hr,dhwtty the ors erohe wt►aowdtrrtw eV thdr+odors'sntp ydky inarwttYei
/tri.eon rrwpfsys rbet aPrarll/wP oeerboro'rowPewmd../nr.rrwtn fir aq tar'I.yeet adtr a Me p./feP ew/p1 r/r
infe►twdnrloia
Insurance Company Name—
Policy t or Self•iou. Lie.p: Expiration Daw.
Job Site Addlnae: - Cityisfntsizip:
\nacb a-copy of the worken'compensation policy dmlaratleapop(sbewing rho pelky number and aspiration dab)6
Failure to stun coverap as required under Sectice 23A of MOL c. I52 can lead to the imposition oft:riminal pensltie s of
fine up to S 1.500.00 and/or one-year imprisonment,as well.s civil penalties in the form of a STOP WORK ORDER and a ftos
.df up to S250.00 a day against the violator. lie advidal that a copy of this statement maybe forwarded to the 001ce of
I nv cart gaoiuns of dow MA for insurance covcraso vuiitcation.
/de hereby c•rrrify under the point end peno/Nrr a/oer/ary rhos rob infwwedow provided/ubow is dew and warred
: cn.ttutec �qI 6i�e1��""'�' Uat.: �/�• �J -
Franc
OJJ7aid ua ran/y: Oo n W wrin in Chia free.n M.mwp/ird by riry or ratve a/f&•idd
City or ruivn: Prrmie/Lltenrl__.
Icduing .\uthtnly Icirct.unel:
I_ Iluard of Ileallk 2. nodding Deparltnvnf J. Citytrowe Clerk t. Flectriul Impector 5. Plumbing Ingpeetor
6. 01 her -
i L,,otacf rcnon: _ .. Phone t:
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CITY OF SALEM
PUBLIC PROPRERTY
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DEPARTMENT
1'.11: MI11 ''Mlv r'll
51 atri •)•\II
I'n: v:11.704 AI t 1 \!i:H7/•:JS'1!1111
Construction Debris Disposal Atlidavit
(required fur all demolition;utd renovatiun work)
In accordance with the sixth edition of the State Building Code, 730 CMR section I I I.S
Debris, and the provisions of MGL c 40. S 54;
Building Permit At . _ is issued with the condition that the debris resulting from
in a properly licensed waste disposal facility as defined by MGL e
this work shall he disposed of
I 11. S 130A.
The debris will be transported by:
mama of hauler)
The debris will be disposed or in
/� {nart,t ut ui Ily
pldJreaa ul IxJuyl - .
aynature of Iwrnut,Ipphcant
,late