64 WHARF ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
%1a.-uhusv16 Stale Building Code 1780 C\IR)Seventh Edition
City of Salem
Buildin Permit Application foran Building other than aI-or2•Famil owe ling
(This SnRion Rw Official Use Only)
Building Permit Number. Date Applied: Building Inspector.
SECTION is LOCATION(Pikase indicate Block a and Lot a for locations for which a street address is not available/
r a .. hAyf of ec 11—W Alb 01 970 Arhal l n
.No.slid Street - Citv Town Zip Cede blame of Building(if applicable)
SECTION 21 PROPOSED WORK
if New Construction check here 0 or check all that apply in the two rows bie ow
Extaing Building O Repair Q Alteration O - Addition 13 1 Demolition 0 (Please fill out and submit Appendix 1)
Chniypeof Use O Change ofliccuparicy O I Other 0 Specify:
Are building plans and/or eunstru jinn documents being supplied as part of this permit application? Yes O No lk
is an Independent Structural Engirofermg Peer Review required? Yea 0 No 0
Brief Description of Prulto.ed Work,, Remove raAnr rl ,ph,, -a A1461 E-ep aee
i
with cement
i
SECTION h CONMET'E THIS OCTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANG18 IN USE OR OCCUPANCY _
Check here if an Existing Building 41aluation is enclosed(See 780 CMR 34024) 0
Existing UseCroup(s): Proposed Use Group(s} r
Existing Hazard Index 710CMR 34:1 Proposed Hazard Index 7W CMR 34.
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basemj ent levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height ft)
! SECTION k USE GROUP(Check sea licableI
A: Awembl A•1 O A•2r 0 A• nc0 A-3 0 A-40 A-513 B: Business 0 E: Educational 0
Fr Facto F•1 0 F2 0 H: HI Hazard H-10 H-2 0 H-3 0 H4 0 H-5 0
b Insiftutlonal I-10 1-2D I.3O i1-10 M: Mercantile C) Resident R•IO R-20 R•3 f8 R-40
S: Stun S•1 Cl S-i a Ur Utili'y 0 Special Use 0 and pleaseclestribe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 too ll 13 118 0 1 IIIA Cl HIS O 1 IV 13 1 VA 0 VB 13
SECTION 7:SITE INFORMATION (refer to 760 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information:r�� Sewage Disposal• Tnnch Permit: Debris Removal:
PuNie CR Cluck of nublak%,,f Lune'7S Ind(r,itn munic Fxai� •\Trench well nut br Laen.rd Diyxwal Sitr$)
11neateo OrInd'"ti(v?A or,in jV.,v.trm napimxi❑urtench ur.)xcdc:
! permit r.vnelowd O _
Railroad right-of-way: Hazards to Air Navigation: ♦IA111n1.rw[i•mnu..nm R.vr.e Pnr.
\.a .\pI•hcat�ly❑ I,Siruaure as ohm au)x,rl approach aria' 1,their roe iew oun)detaxl'
or t-,.nvril to Solid rucks-0 Cl 1 a+0 .e Xn❑ Ye,❑ N. ❑
SE BONG:CONTENT OFCERTIFICArEUFOCCUPANCY
E.lawn.•1 Gwiv _�1-wGi a •1: fe poor Clm.lrucnon: 0"urant L.id)4v
I>,w-�tha•l•oildu.g:onuman .rudly�?e•tom e: SjNvialStipulanon.-
T 'd 0026 13CN3SHI dH WdBT :b 1102 LT gad
SECTION9: PROPER•IY OWNER AUTHORIZATION
Namr.wd Address%itPnqurt+•Lhvner N.tmPeW(PrtCntol m rLIC 23 cbnara
(1197f1
Lip
N' and Still City/Tulurn
Pm)x rt+•lavnrc['anent inlormatlun:
Ma m M; hacl n__'_e ( 978 740-6�p�ZFi11 doss-4? mrbckP @rnckPt realty
r
Title
-- Telephone Nu.(bummed Telephone Nu. (cell) r•m vl.tddn•..+ .Coro
li applicable,the pn,pwt%-l ner hereby authunzim AAA _ 01945
_ T_Mi rhael onrl;gi<L � 190 Pl�a aanf St _ M3rblahearl _
titres!Addrmas Lily
State Lip
Name
to act un the ,n, h-.nvnrr behalf,m Al matters relative tal wurk,tutMmzaf by!hide bulldin trtrtt a ,,ideation
SECTION I CONSTRUCTION CONTROL IPkase fill out Appendix 2)
(If N,iW' a k,x�thin]S,tlaf lIt.of Maad VPlrand/urrnn tu,drr C.awructl.nt Cwnrul Use!cheek here O and ski 9wtiun IU.t
lita Registered Professional Res ndb a for Corratrurdan Costaol
114654
T. Michael Rocket--�' f 7RT. LPL-30�n
Tel boor No. e-mail address Registration Nuti r
Name(Registrant) rp 0/8/1 1
190 J23 R4; st M rhl aheara �� -Slate Zip Discipline 13xpimtionRtte
Street Address, City/Town
183 General Contractor
Villa e Constru ti n
Company Name: 1 54710
T M ' chail R9124tial 1
Name of Person Responsible for Cunstruoun Ucenss No. and Type if Ap Ikable
et Marblehead MA _1945
Street Address City/Town State Zip -
__
Telephone No.(business) a hone No. cell email address
SECTION Ili SATION IN (M.G.L.a ISL 1 25(.Y61)
A Workers'Compensation Insuran Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Pail to provide thla affidavit will result In this denial of the issuance of the building pert
Is a started A fill it submitted with thisa ieatbn7 Yes 0 No 0
SECTI N 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Est btta ed Gusts(Labor Tots I Construction Cost(from Item 6)-f 2 5, 0 0-0 -0 0
an Materials)
1.Buildin -f 25 000 .00 Building Permit Fee=Total Construction Cost xl 1 ((nsert here
2.Electrical S - appropriate municipal factor)=f-2 R 0_D 0
3.Flumbl
_ Note:Minimum fee-f r (contact municipality)4.Mechanical (HVAC) f
S.Mechanical (Other) f - Enclose check payable to 17JI-11 of 4a 1 am
6.Total Cult f �'i = (contact munid lit )and write check number here
SECTION'13i SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hrrebv attel under the pains and penilties of perjury that all of the information cintalned in this
applicanun it true and accurate to the best of my kntnvkafgeand under4Linding.
T Michael Rocket! l Manager 11_� - ZZ.
I'Itl print and al name Title U
ialvphune '.,. Date
190 Pleasant St
tit lAtIJ - C iN':Town tit.Ue t
Muni+ipal Inspecturto fill out this srctidn upon application approval:
Name 1 due
i
z d 0026 1317?J3SU-1 dH WdBT :t. 1102 LT l
CITY OF SALEN4 MASSACHUSETTS
ilUWING DEPJUM0 iT
120 WAMWC,CON STUMr,r FLOOR
TtL MS)745.95"
FAX(WS)740A846
KiNwERLEH DRISCOLL
MAYOR TMUASST.PMNM
DtRAMIL OF PUBLIC MWPERTY/DL'II.DQIG 003DUMONER
Workers'Cempelua a insurance Afildawitt BuilderslContrtetorxMeetricfandMumben
AAsuli ent Information Plesaa PrIrR L eai6ly
Vatne(BruktauPOrytiiradmvindlyfdml): Village Construction Co -Inc
Addregs• 190 Pleasant St
Cjty/SIaWZ1jr Marblehead. MA 01945 Pbmc#: ( 7811 639-2171
Are yea as cmployarf Cheek the appropriate bolo •gyp orppject
1.0 1 am a employer with 4. [3 1 am a general cooksom and I ❑I,kor con,nrkuan
amPloyaee(tiro and/or ).• have!droll the
2.❑ 1 an a sole ptapiewwr or !cared an the Rullow shed.I 7. ❑Rmodeling
dap sell have no employees Then wbeoouaaoon have L []DemoVdoa
working tot mein any !'• wor mn'Oomp.insursoo—e 9. ❑Building additkm
(No workers'comp.bumance S.❑ We am a corporation and its
rapdrad) ofileas ban eserc'sod their 10.13 Moeniat repairs or additions
3.❑ 1 am a homeowner doing a0 work right ofameropdon per MOL I Lo Plumbing apain oraadidons
myself[No workers'comp.', c.I5Z j 1(4),and we have no 12.0hoof repairs
insurance required.)t employees.[No workas' 13.❑Oder
amp Insurance required)
•nay dntekaebhmrat raid elw riceaM rbr seatim ta1ovt1 1 chair rarhart•meamadoe peter hahawdoa.
* VAMM a my d5d" eeeetss wah.
'e,dMonm char cesk rh9-hair Wort aax�m dd,ieirl arid a Avft*0 ease @tar wwheo•avny,Paley bhewmaoe.
lartmtatplgyatlrathpmfdLrt;wenterr'tanpenrattoxLrtaroneefor+Kyeatployees. Belsw6dYapelfryaadfabelM
Gt/ormatbm
Inaumnce Company Name- Associated Employers Insurance Co
Policy 4 or Self-ire.Lie.N: W�C 5001342012010 Exphation Date- 3/1 1 /1 1
lobSiaeAddresc 64 Whar4 St City/SlMcaiV Salema MA
Anseb a copy of the worken'eoa#pentntioe policy deduction pap(shmvlAg aim po ft aambw and eaplmdoa dear}
Follow to secure coverage as regWrid uadeu Sectoo 25A of MOL c. 152 can feed to the imposition ofc timioa)peaalda era
fine up to SI,S00.00 and/or one-ya{imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a foe
of up to S250.00 a day against the violator. Be advised that s copy of this datcmem maybe forwarded to the Olroe of
Investigations of dim DtA for insm4ce coverage vedikdiaa
I do AaroBy Avo AwAar ere d pemkkY alpe1/atl Art rAe Iaprawdan provided a8ow barge did e&-rc t
00110 f sae ealy. Do not wrist 1#fhb area,to becompWa by dry or Iowa gBkhi
I
City orTows: ParmldLleewe p
bwAngAathorlty(clrcbone); j
I.Word of llesbb L Balidiag pepartment 3.Cilyfrown Clark 4.Electrical Inspector ! plumMo6 tatpeeter
16 Otber
i
Contact Penn: Phone lie
e •d 002C 13CM71SHI dH WdST :b 1102 Ll qeA
CITY OF SALEN4 NLASSACHUSETTS
• Bt:mmG DEPARTmmgr
t20 W OHINGTON STRE r, 3'PLOOR
TEL (978) 74S-9595
PAX(978)740-9846
ld�ffiERI.EY DRISCOLL
MAYOR IHoMAS ST.P not
DIRECTOR op PI;mx PROPfiRTY/Bt II mG co%mmIONER
I
Construction Debris Disposal Affidavit
(required for all deanolition and renovation work)
I.
In accordance with the sixth edition of the State Building Code,780 CMR section 111.5
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 dispgsed of in a properly licensed waste disposal facility as defined by MGL c
I 11,S 150A j
The debris will be tran+otted by:
i
North Side; Carting
(name of"Wer)
i
The debris will bedispgsed of in :
I
North Side' Carting
(Memo of cility)
Danvers Rd, Salem, MA
(address of 1!acilily)
i
sigoabttc of pertnit applicant
i
date
Jcbrisatrdx i .
b 'd 0026 13rN3SH-1 dH Wd61 :1+ 1102 L1 9a3
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
Burlington, Massachusetts
(800)876-2765 NCCIN040959
POLICY NO. I WCC 5001342012010
ITEM PRIOR NO. I WCC 5001342012009
1. The Insured Village Construction Inc
Mailing Address: Mr Michael Rockett Marblehead MA 01945
190 Pleasant Street
(No. Street Town or City County State Zip Coda
❑ Individual ❑ Partnership ® Corporation ❑ Other FEIN 04-3241709 ,
Other workplaces not shown above:
2. The policy period is frorr{1-T11/2010 to03/11/2011 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 eachaccident
Bodily Injury by Disease $ 500,000 policylimit
Bodily Injury by Disease $ 500,000 eachemployee
C. Other States Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans.
All information required below Is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual 01 Annual
Remuneration Remuneration Premium
INTRA 137531
SEE EXT NSION OF INFORI 4ATION PAGE
Minimum premium$ 500.00 Total Estimated Annual Premium $ 550.00
As indicated,interim adjustments of premium shall be made: Deposit Premium $ 138.00
❑ Annually ❑ Semi Annually ® Quarterly ❑ Monthly
MA Assessment Chg.
$293.00 x�7.2 00 0 00 0//a �1 $0.00
This policy,including all endorsements,is hereby countersigned by C� �"""-'�&-,*a 02/05/2010 I�I
Authorized Signature Date
GOV I GOV I KIND PLACING CLAIM NAME SAFETY
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Boston Insurance Brokerage Inc
MA 15022 123 1505 1 1 1 24 Federal Street 4th Floor
WC 00 00 01 A(11-88) Boston,MA 02110
Includes copyrighted material of the National Council on Compensation Insurance,
used weh as permission.