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72 WHARF ST - BUILDING INSPECTION (2) 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 (Tfus9ectionFon.OfficialUse_Only), Building Permit Number.' Date Applied "Buildmg O'fhnal SECTION 1:LOCATION(Please indicate Bfock*and Let#for locations for which a streekaddressis not available)% } UF 57" 5PLEM1tmA 0l9_-�O tA29PL_c-v:) i3LnC,- No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2i PROPOSED WORK Edition of MA State Code used If New Construction check here❑ or check all that apply in the two rows below Existing Buildingf Repair❑ Alteration ❑ . Addition❑ Demolition'❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy R Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes X, No ❑ Is an Independent Structural Engineering Peer Review mire? Yes ❑ No ❑ Brief Description of Proposed Work: ✓ �` y�� r /i r (�r� 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.) MOO 2 000 SECTIONS:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1 ❑ 1-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage 9-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: - Special Use: SECTION 6:CONSTRUCTION-TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ QIB ❑ IV ❑ VA ❑ VB ❑ SECTIONS: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❑ A trench will not be Licensed Disposal Site ❑ Private❑ or indentify Zone: or on site system❑ required is �or trench or specify: permit is enclosed❑ Sfiti"{p Railroad right-of-way: Hazards to Air Navigation: MA Historic t.OnIMISSiOn Review PRecss: Not Applicable`, Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes ❑ or NoX Yes❑ No ❑ 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?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATIQN Nam nd Address of�Pr#erty Owne GU�/q.LF�i9-Gly Name(Print) No.and Street / City/Town Zip Property Owner Contact Information: Title 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(Pleas'e fill out Appendix 2 [f buildiii �s less than 35,000 cd.�Et,of enclosed s 2 ace and'or'not under.Construction Control then ch`eekhere-O`and'ski Section 10.1 , 101Re 'stered'Professional'Reso 6risii�bleforConstructionConhol'. " `•-''' '- �� „ �1gny/t7rib cv yd_ acid,/ i i./f✓I��r. � a�o c9}. Nam (Registrant) Telephone No. �e-mail address Registration Number a c)� r &,f L✓h n 11,4 cr/Y0 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor' d G L Company Name Z�FmhPL \3>9-1u,1L,.,w GS yao�b� Go.ts� su�.�� r�iL Name of Person Responsible for Construction License No. and Type if Applicable �Street Address G Ci /Town State Zip g `!� / 6(7WU_ &Jcl— 11 /%0(1sg 0h,IA9J2'_r7 7- Tele hone No. business Telephone No. cell �c e-mail address SECTION 11:WORKERS'COIMPENSATION INSURANCE AFFIDAVIT T 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 of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION'12:CONSTRUCTION COSTS ANDTERMIT 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 (I-IVAC) $ Note:Minimum fee=$ (contact municipality) S. 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 application is true and accurate to the best of my knowledge and understanding. AStaN Please print and sign nam Titlelephone No. Date �u6 . I Z- � 0/10Z/Street Address Ci /Town , Zip Municipal Inspector to fill out this section upon application approval:_ Name Date CITY OF Siu Em. 1NL1SS:ICHUSETTS 9L:ILDING DEPAXV" I&NT 120 WASHLIIGTON STREET, 3i s FLOOR TFL (978) 745-9595 FAx.(978) 740-9846 KIJtBERI.EY DAISCOLI �Ir\YOR THOStAs ST.p1E.aRe DmcrcR OF PUBLIC PROPERTY/SUI DLNG CONINUSSIONER Workers' Compensation Insurance AMdavit: Builders/Contractorr/Electricians/Ptumbers Amilfcant information // P►eme Print Leeibf Naine(ousiix,s Orpniratiamfndivicival): - h IN 0 Address: 2!2 G U?-t 6p 2a City/State/Zip: 014 Mf. Phone#: —7 0PJ— Are you an employer?Check the appropriate boxt Type of project(required): 1.0 1 am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction employees(flrll and/or part-time).* have hired the suls�eantractors _ - -,-- 2.1 am a sole proprietor or partner• listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have a. (]Demolition Working for me in any capacity. workers'camp.10311ranee. 9, 0 Building addition (No workers comp.insurance 5. 0 We are a corporation and its require).) officers have exercised theft 10.0 Electrical repairs or additions 3.0 1 mil a homcownar doing all work right of exemption per MOL 1 I.0 Plumbing repairs or additions myself. [No workers'comp. C. 152,J(1(4),and we have no 12.❑ Roof repairs insurance required.)t employees.[No workers' camp.insurancerequircd.) lJ.❑Other •Any applicant ilia chcvlis box e f mutt alto all aW the scuiva below abowing choir waken-ommponaolun pulley imomu dots '1 hanauwm"who.ubmit this andavis indicaina thcy am doing nil work and then him outride contractors most submit a rate aminvii indloting such. :Contractors that chat this box mutA attached an additional shear showing the name of the nttromrasnun and their worltan'acmp.policy infomuaoa. - 1 mil en employer that providing workers'cotnpeataden/niurunee for my emplayees'Below la fire pollcy and fah site information. Insurance Company Name: roficy it or Self-its. Lie. 0: Expiration Date: tub Site Address: City/StatrJZip: ,Utach a copy of the workers' compensation policy declaration page(showing the policy nombor and expiration data). Failure to sucura coverage as required under Suction 25A of MOIL a 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonmento as well as civil penalties in the farm of o STOP WORK ORDER and a line of up to S250.00 a day against ilia violator. Ue advised that a copy of this statement may be forwarded to the Office of Invesligutiuts of ilia DIA for insurance coverage wrificafion. /do hereby eerd under r/re pal oaJ perm/alas of per/ury r/cur the Grfurnrudar provided ubuv is true mud correct ,• Bard• � /.3 ' 0111c•ial use unly. Om nuf write in t/ds area, ro be completed by city up town afflc•lat I i i iCity nr'fuwn: PermfoUcceseq -- --___ I.+suing,%ufhur4y(circle one).- 1. Uourd of Iivalth 2. ftuildlntl Uepartutvnt .1.City/rows Clerk 4. Electrical Lupcetor 5. Ploolbing fnspector 6.Other Contact llersow .. phone It: r CITY OF S.V Elt, NLUs.1CHUSETTS BL'tLDLNr, OVARTNONT \� ` 130 WASNLNGTON STREET, 3A°FLOOR % T FIL (978) 745-9595 F.LY(978) 7-W-9346 i<INMERE Y DRISCOLL ibL�Y013 THOSNS ST.PIERAS DIRECTOR OF pLiiLlc pROPERTY/Bt:UZLYG CO.%aliSSIO..NER Construction Debris Disposal Affidavit (required foc all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CNIR section I 11.5 Debris, and the provisions of tbIGL c 40, S 54; Building permit /t 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 PYlGL c l 11, S 150A. The debris will be transported by: °T—I%�L s-kf 5t5i:K /1 (nome of hauler) The debris will be disposed of in Sad vn Tr" (- _ S lLt tio� (name of t'accaity\\) SW �w�co � VN<c (�ddress of tatility) signatu ufperntitapplicant date 72 WHARF STREET 634-13 his#: 11s19 COMMONWEALTH OF MASSACHUSETTS Map 34 d s , i; Block ym CITY OF SALEM Lot: 10408-817 Category: DEMO Pest# 634 13�rw M, BUILDING PERMIT Project#' " °`JS 2013-002055 _4„ Est. Cost: �$50,000 00 Fee Charged: $555.00 Balance Due: $.00 - PERMISSION IS HEREBY GRANTED TO: ConstClass: A Contractor: License: Expires: Use Group: : JOHN JANUARIO Construction Control-CS 42066 Lot Size(sq. ff.): 0 Owner: PICKERING WHARF REALTY TRUST, ROCKETT J HILARY TR Zoning BS Units Gained: �Applicant: JOHN JANUARIO Units Lost: AT: 72 WHARF STREET Dig Safe#: ,i= _: ISSUED ON. 20-Feb-2013 AMENDED ON: EXPIRES ON: 20-Aug-2013 TO PERFORM THE FOLLOWING WORK: DEMOLITION AND ROUGH FRAMING ONLY 2/15/13 SECOND PERMIT TO BE APPLIED FOR ON FINISH OF PLANS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Underground: Underground: Underground: Excavation: Service: Meter: Footings: Rough: Rough: Rough: Foundation: Final: Final: Final: Rough Frame: Fireplace/Chimney: D.P.W. Fire Health Insulation: 'Teter: Oil: Final: House# Smoke: Water: Alarm: Assessor Treasury: Sewer: Sprinklers: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: BUILDMG REC-2013-002235 20-Feb-13 1337 $555.00 fr F i' ISr i; GeoTMS©2013 Des Lauriers Municipal Solutions,Inc.