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61B WHARF ST - 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-F ily (This Section For Official Use Only) A Building Permit.Number: Date Applied Building Official:✓ ` 9 SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is available) `- r- ��Se !q D N- 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 two rows below Existing Building ErjZpair Alteration ❑ Addition❑ I Demolition ❑ (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 ❑ No I �+ Is an Independent Structural Engineering Peer Review required? Yes ❑ No 1� Brief Description of Proposed Work: e, a C EXjS Ce CeC.1f� ilA!�R (wP , CihV 6 e t^t M nctr 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 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4: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❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ HA❑ H-5❑ I: Institutional 1-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ E S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: „_ •- ._ :SECTION 6:CONSTRUCTION TYPE(Check as applicable)- -' IA ❑ IB ❑ 7 IIA ❑ 1113. ❑ 1 IIIA ❑ IIIB ❑ IV ❑ 1 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: Public Check if outside Flood Zone❑ Indicate municipal ErA trench will of be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required for trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: W Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ " I . SECTION 8: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?: p I ial Stipulations: ��jj rwa, SECTION 9: PROPERTY OWNER AUTHORIZATION Nam and Address of Pro erty Owner e QN�r �ev.�tttie�l�, 9N-p Luwrev)ceRqqA, G(52-1 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Tide Telephone No.(business) Telephone No. (cell) e-mail address If applicable,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 ru ft of enclosed space and/or not under Construction Control then check here O and skip Section 101 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 t - - 51 up) �eF�aG�P1 iN► 4 Company Name p 0 T 1 ,,, Si lvp Name of Person Responsible for Construction License No. and Type if Applicable 19 Rol l(lu� Stt ee f' Groue �ca_nA- �A 0 Street Address City/Town State Zip `�3�`�'�F2�1 ��-i�21-�-3IQ Silu�re�el�tr.IGwr,e+ Telephone No. business Telephone No. cell e-mail a ress SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L,c.152.§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 a building permit. Is a signed Affidavit submitted with this application? Yes❑ No 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)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ , �� (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 a " 1'c true aura1�tint st of my knowledge and understanding. i �-'� Ol�^tP� k6w4_) 1)eR q- 3 Please print and sign name Title Telephone No. ate Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date I i Office of con om—er Attfairs S sines s Rega ah a 0 HOME IMPROVEMENT CONTRACTOR Registration 1139424 Type: Expiration 7/16/2013 DBA Y SI A REMODELING? s f_. ORLANDO SILVA;,mC=- 19 ROLLING ST. GROVELAND,MA 01834=} .;;5 Undersecretary r Massachusetts- Department of Public Safeh Board of Building ReLtilations and Standards Construction Supervisor License 'License: CS 84761 „.dRLANDO J-SILVA + ;,19 ROCLINS ST '� I! 'GROVELAND WA 01834' tAb Expiration: 5N8/2013 Tr#: 16353 N, The Commonwealth of Massachusetts Department of Industrial Accidents E _ 4 Office of Investigations 600 Washington Street av Boston,MA 02111 `t 5� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nam&(-usiness/Organization(Individual): ada� ress:� ,City/State/Zip:`r Phone #: Are-you an employer?'Check the appropriate box: I am a general contractor and I Type of project t(required): 4. 1.❑ I am a employer with ❑ g 6. ❑New construction yees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' insurance. required.] comp' 9. ❑ Building addition workers' comp, insurance required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the time of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a frle up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perju/ryythat the information provided above is true and correct. Signature: /�� i��f/ �— Date: 4 ;Phone#�� — Li _ g / ©�F / i Official use only. Do not write in this area,to be completed by city or town olrciat City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: OP ID:DC a��Ro CERTIFICATE OF LIABILITY INSUR 02124/12ANCE DAT Y1 02/212 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER 978.745-3300 CONTACT John J Walsh Ins Agency,Inc NAME PHONE FAx P O BOX 4407 978-745-9657 M.No Bad, I A/C Nei: Salem,MA 01970-6407 - E-MAIL David C Bruett ADDRESS: PRODUCER gSILVO6 CUSTOMER ID tl: INSURERIS)AFFORDING COVERAGE NAIC k INSURED Silva Remodeling INSURER A:Mountain Valley Orlando Silva 19 Rollins Street INSURERS: Groveland,MA 01834 INSURER C INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DDL UBR POLICY NUMBER MManOP� MMOOY/YEYXYY LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY B20-3169670-01 04129111 04/29/12 PREMISES Ea o=mencen $ 300,00 CLAIMS-MADE I—XI OCCUR MEDEXP(Ar,mmperum) $ 10,00 X Business Owners PERSONAL B ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/CP AGG $ 2,000,00 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY led,acddem) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ q Property 12120J169670-01 04129111 04/29/12 Contents 5,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE David C Bruett ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD CITY OF S,U &N[, NL1SSACHUSETTS 9LLULNG DE►.1RT1t8.\T I_'O W.ISHLNGTON SnMM, 1"FLOOR I'M k978) 143-9595 F.kx(978) 740.984 KOMERI V DUXOLL MAYOR MO.�W ST.PMUA D 1REcrO n O►n nt)c PIIOPII<TY/BI.'II-DLYG co.wilsslo V Elt Can9truction Debris DlSposal Atfidavit (required for all demolition and renovation work) In accordance with the sixth edition atthe State Building Code, 780 CMR section 111.5 Debris, and the provisions of MCL o 40, S 14; Building Permit N is issued with the condition that the debris resulting from this work shell be disposed of in a property licensed waste disposal facility as defined by t ICL c 11 It. S I JOA. The debris will be transported by; i (n4me of haul$() The debris will be disposed of in (name of facdilyj G e or 6? 0 �- 0/833 I�Jdnsr of fird++y) 1 �+ gn�m�ea permrfippliunt� — Cis.. 12 �..._. �+a �3 Page 1 of 1 W. Gerald Hendricks From: "Kathy Chapman" <kchapman@mrrockett.com> To: "'W. Gerald Hendricks"' <j-hend ricks@comcast.net> Sent: Wednesday, February 22, 2012 9:01 AM Subject: RE: Window Replacement Hey Gerry, Your request has been approved I just need you to sign a document before work can begin. I will mail to you today. .Please sign and return. Once received, work can begin. Thank youN Kathy From: W. Gerald Hendricks [mailto:j-hendricks@comcast.net] Sent: Thursday, February 16, 2012 9:31 AM To: Kathy Chapman Subject: Window Replacement Dear Kathy, Per our recent conversation, I am requesting approval to replace the 4 awning windows on the 3rd floor of my unit, 61-B Wharf Street (Privateer Building, Unit B4). I intend to use an Andersen window (from Moynihan Lumber) very close to what is presently there except that the exterior will be white vinyl clad. We also intend to replace the rotted wood trim around the perimeter with Azek. Please let me know ASAP so we can get the project started. Thank you very much for your assistance. Jerry Hendricks 978-887-4187 2/24/2012