94 WHARF ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Department of Public Safety
,.•f \Lls.adua.etin?Late 0ud.bng Cl-de 1780 LAIR)S%-%vnIh EdiI tors
City of Salem
—Building Permit Application for any Building other than a 1- or2-Fimily Dwelling
t rhls 1a tmn For Ofhctal L;'m On IV) i
Building Penult.\umbrr Date Applied: Building Impector
SECTION I: LOCH TION (Please indicate Black a and Lot s for locations for which a street address is not available) '
X qSt S \ II
\o. and Street Cnc /row,it Gp Cade .Name ut Building Ott appbcablr)
SECTION 2:PROPOSED WORK
It New Construction.heck here❑car check all that apply to the two rows below
- _ "Eso-ting"Bullding - -Repair-❑---Altrmliun --AddithmQ -Demolition-0-(-Rlmtsr-fill.+ul-and-submit-Append4x-1}---"—_ __
Change of Use M Change of Occupancy b I Other ❑ Speedy:
Are building plans and/car cunstruction documents being supplied as part of this permit applicalwn? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Descnpliun of ProyOxd Work:
�r----ypp b rNr-
C+
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaivatlon is enclosed(See 780 CMR 3402.0) O '
Existing Use Gmup(s): Proposed Use Group(s): - p
Existing Hazard Index 780CMR 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(sal. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A•1 ❑ A•2r ❑ A-2nc❑ A-3 ❑ AA❑ A-5❑ 1 8: Business ❑ E: Educational ❑
F. Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institu Honal I-I O I-2 ❑ I.3❑ I.4❑ M: Mercantile❑ R- Residential R-I❑ R•2❑ R-3❑ R-4 ❑
S: Stora a S.1 ❑ S-2❑ U: Utility❑ Special Use❑and leave describe below:
Special U .
-
II SECTION C CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ If8 ❑ IIIA ❑ 1111110 IV ❑ VA ❑ ve ❑
SECTION 7:SITE INFORMATION(refer fo 780 CSIR I11.0 for details on each item)
I
Water Supply: Flood Zone Information: Sewage Disposal: french Pennil: Debris Removal:
I'uhlri ❑ Check tl nd.tJe F11.0 Znnv❑ Indicate munrcrp,ll❑ �\ Irrrieh wdl nut he [_Teemed Ur.L, .,+I`.Iv❑
I"',atv❑ or mdenblt Zone. _ nr.m.sir•v.trm ❑ re.I We ❑car trench „r .l,cah
I'rrmn t.enaln`ral ❑
Itailruad right.uf-way: Hazards to Air Navigation: , ,,,,,
\,•t \I.1•h..dde❑ Lslru.11uv.. th"I,nrl•„rt.1ppil Ich Irv.l' Lthcn rcl i.... . nnl•IrI,J'
L •e.l❑ 1c.❑ ,-r\u❑
SEC'r10.N 8:CONTENT OF CFRTIFIC.\rE OF OCCUPANCY "—�
I .till, n„I ( J,
_ L ......-e l
— t"`a _ .I'c• 11 . 0•I Rr.Ih gal l4i ultuo I u.hl ice 11 „„
I t.r. rhr I•u d.In,q. nl.tin.111 ter s.item' `(•Treat`npul.a b, n. - _ - .
� Y
SECTION 9: PROPERTY OWNER AUTHORIZATION Jni
\'.rnx•.ur.1 .\ddn•a., I I'm rl•a•rty Owner G/
//2k Ts�/LANDTJfiN 9y WN/�R� � ��'rv' M-
\.i me Wrint) .No. .u,d Navel k ih , amen "P �
X' I'nr)4•rlcll,u,rrCor,lactlnfurmattug � 7/ Lys&fir 6/7-6�°'7Jy/ CoM
Gdr rvlary,honr No. (busmes>) Telephone No. (cell) .• merl ed.l n•..
It ippltc.ible. the properic r,aa ner hrrrbv authorizes
j V `
Name street Addrras cth•i Town State Zip
` to act on the ro •ert% ,n.ner',behalf, in.ell rnalters Malt%v to work .m,thirtzed by thts bud,hn • permit a + phc.rlum.
SECTION 10:CONSTRUCTION CONTROL 1Please fill out Appendix 2)
111 building is los than 1 mucu. it.ul .nckrvJ ,ace and/or nut under c.,,tructrun Cunu,rl then cheek here O-told -kit,\•.sun 141 II
10.1 Re istered Professional Responsible for Construction Control
•V-:rmvfR-i• iYrm r rp one u. r-m.0 0-tress egutralion Number - -- --
Strut Address - City/Town State Lip Discipline Expiration Date
10.2 General Contractor l
Company Name: /'? S 4C(b qr)l
J\ Name of Permm Res)xmsiblr for Constr
u
ction ``. ` 1 JLicr;sr No. and Type it ApplicabletR�S -
\ r-��LA
Street Address City/Town State Zip
Tele hone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS' ANC AFFIDAVIT(M.G.L.c.152.9 25C(Q)
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 si ned Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(labor
and Materials) Total Construction Cost(from item 6) f
1. Building f C5 �- Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical f appropriate municipal factor)=f
7. Plumbing f
a. Mechanical (HVAC) f dote:Minimum fee f (contact municipality)
5. Mechanical (Other) f Enclose check payable to
X6. Total Cust f (o es a� lamtact munici alit )and write check number here
SECTION 12:SIGNATURE OF BUILDING PERMIT APPLICANT
Hv cmrnng my name below, I herebv.l t t"l under t pMs p d penalties of perjury that.dl of the information c,ml ned m this
epphc,un,n rs true.end accur.ur to the b Hof my I�•Ird and undrrstanahng. !
�7i2K ZsB/ZAi^l�rr6�� s!ir i . l��r �771ri Or.IJ /i
i I'Ir.,v molt .,n.l .q;n n.n a• ride fcicph,
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Municipal Inspector to till out this section upon application approval:
\ern Il,:e
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CITY OF S.U.&M, NL-kss.A CHUSETTS
BD 1:L LYG DEPARTMENT
120 WASHLNGTON STREET, Y4 FLOOR
` TM (978) 74S-9595
FAX(978) 740-9846
(gSBERLEY DRISCOLL
MAYOR THO.stm ST.Pulman
DIRECTOR OF PUBLIC PROPERTY/BUII.DLNG CONNISSIOYER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
_Debris,.and the.provisions of MGL c-40j-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
111, S 150A.
The debris will be transported by: s
Nd/E.YNS/DE Cfi�7'iNG
(name of hauler)
The debris will be disposed ofin
Spvw /icA�Urh� �IAr/o/�
(name of facility)
Sw)awrpS'L /P �/ l slM
(address of facility)
signs re of permit applicant
date
Jcbnvtf J.w
s
CITY OF SALEM
PUBLIC PROPRERTY
" o DEPARTMENT
-
N Yt'a 12CWASHI.NG IUs S1aELT • au F.M.MAS1xCill it I Is 0197^
lla.:978•;15.9595 • Fvx.979-741C"9846
1Vorkers' Compensation Insurance Affidavit: Builders/Contracturs/Electricians/Plumbers
nnlicant Information y
�� 11 ( Please Print Leeibl
VaIDC(BuutxssiQr�anirmionlindtvnduul) j
l \.6Wi0.•S kJ t//" - '7 e-r k aA, -U�
Address: ( � 'n c'!x O.i� L.--A4 anG `
cily'starcizipjA -Vit-k. - A(\ 01g4S Phone J:-Ta1 (��C� 4 C) IiS
:%re you an employer!Check the appropriate box: 'Type of project(required):
4. ❑ I am a general coutractor and
I.IL1 I :un a employer with�_ G. ❑ New conxtructiun
employees(full and/or part-time).` have hire)the sub-contractors
2.0 1 um a sole propricuw or partner-
listed on the attached sheet. �• ❑ Remodeling
- ,hip and have no employees Theo subcontractors have 8. ❑ Demolition
working for me in any capacity. %workers' comp. insurance. 9. ❑ Building addition
i No workers'comp. insurance S. ❑ We are a corporation and its
required.]
oBiccrs have exercised their 10.❑ Electrical repairs or additions
right of on exem Li per MGL 11.❑ Plumbing repairs or additions
3.❑ I um a homeowner doing all work S P P' I
myself.tNo workers' comp, c. 152,g 1(4),and we have no 12.❑ Roof repairs -
insurance required.) t employees. LNo workers' 13.❑Other
comp. insurance required.l
-any.1flicun that checks box ill must also till uut are section wow showing Ihuir w•ockui cumpemaliwr pulicy informaiioa
' I lumvownen who submit this affidavit indicating They ire doing all work and then hire outside cuturxlon must submit a new amdavil indi"ing inch..
"fonwwt,rx that check this box mean anachcd an addilimal wheel•hawing 16e"ante of the sub�ontrxturs and their svorken'comp.policy informative,
l tun ul employer thus lr pruvidits4 workers'compensation insurance jar my employees. Below is the policy and job silo
iuj✓rnmri✓n.
Inxlrance Company NameT(-Qs 7 - Px�'S..
Policy 4 or Sclf-ins.cL�ia 0.-1 P AVI `7Z t3 1J(` (r._I� Expiration Date:,,gl— L
Job Site : ddress: 4 W6r"C � \ C'i1y;51ate/"Lip:<SG- "Z ^ mP
Altuch it copy of[lie workers' compensation policy declaralion page(showing;the.policy number and expiration date).
Failure to secure coverage as required under Section 25A of}IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year intprisoninum, ua well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to i250.00 is Jay against file violator. Ile advvu:4 that a copy of this statement may be forwarded to the Oflice ut
Invcsti-au-ros ufthe DIA for insurm:cc coverage scrilication.
h da hereby certify trader the p iijIS l otd pejuddes ujperjury thus the infwmrAion provided above is true and correct.
,ie:runre' Jffl d'-eNecr-�- I Data
O.1iciul use wily. no nni write in this area, to he completed by city or lawn o/jiriul.
(Jly or'fosvn: Permit/License d_
Issuing Authorily(circle one): i
I. Board of licalth 2. Building, Departtucnl 3. Cilyr'fo%n Clerk 4. Electrical Inspector i• Plumbing; Inspector
6.Other
0,111acll'cnoil: _ _ Phone.-I:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
- Pursuant to this stature,an empfuree is defined as"...every person in the service of another under any contract of hire,
cypress or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
d the toregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or(rus(ee VI .ul individual,partnership.association or ocher legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152. §25C(6) also states that "every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally. MGL chapter 152. §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of(his chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)namc(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
I ndustriul Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Sclf-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. in addition,an applicant
that must submit multiple pennitilicense applications in any given year,need only submit one affidavit indicating current
policy information (if necessary)and tinder"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit(hat has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where :%home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dog license or permit to bum leaves etc.)said person is NOT required to complete this.affidavit.
1'he t)l lice of Investigations would like to thank you in advance for your cooperation and should you have:any questions,
please du not hesitate to give us a call.
The Dcparnncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OIQce of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or I-877-MASSAFE
Fax M 617-727-7749
itccixd ;-_'G-Us
www.mass.gov/dia
-Apr 07 2011 2:22PM HP Fax - - page 2
VDAC
TRA~ELEI s WORKERS COMPENSATION
pAND
0 EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 Ot ( A)
POLICY NUMBER: (7PJUB-77SX651 -1-10)
RENEWAL OF (71DJUB-778X651-1-09)
INSURER: TRAY LERS PROPERTY CASUALTY COMPANY OF AMERICA
t, NCCI CO CODE: 13579
INSURED: _PRODUCER
GERLAND, THOMAS W. BA JOE GREENE I'NS AGCY
THOMAS W. GER( ND CJNSTRUCTION 121 PLEASANT ST. , P.O. BOX 12
11 MANATAUG TR IL MARBLEHEAD ',MA 01945
MARBLEHEAD MAIIII945
Insured IS AN NDI IDUAL
I
Other work pl es ar d.lderrtiflcatlon numbere are shown in the schedule(s)attached.
2. The policy peril d is f m 08-06-1 o to pg o6-1 1 12:01 A.M. at the insured's mailing address.
3. A. WORKER: CO PENSATION INSURANCE. Part One of the policy applies to the Workers
Compens#on U w of the state(s) listed h re:
MA
E
B. EMPLOYE IS LIABILITY INSURANCE: Dart Two of the policy applies to work in each state listed in
Item 3.A. I he Ilmls of our liability under art Two are:
Bod y Injury by Accident: $ 100000 Each Accident
Boe ly Injury by Disease: g 500000 policy Llmlt
Bock y lnjuy by Disease: $ 100000 Each Employee
C. OTHER S TES INSURANCE: Part Three of the policy applies to the states. If any, listed here:
COVERAGE REPL CED BY ENDORSEMENii WC 20 03 06A -
JOErPEENE(NSIIRA InFINC.
an
D. This policy ndud s these endorsements end schedules: ---
y SEE LISTING 0 ENDORSEMENTS - EXTENSION OF INFO PAGE �`+apvr�6.�
l%44RBLEHEAt?,flMA
4. The premium k r this olicy will be determines by our Manuals of Rules, cassificatlons,.Rates and Rating
S Plans. All required inl Drmation Is subject to varMeatlon and change by audit to be made ANNUALLY.
DATE
OF ISSUE: I -
U 7 2 110 WC ST ASSIGN: MA
OFFICE: IRE ASSIGNMENT 701
PRODUCER: OE EENE INS AGCY 22T2G
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Apr 07 2011 2:22PM HP Fax - page 1
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Joe re me Insurance Agency, Inc.
122. , as gton Street
P. O.' Box 2
Marti' hea , MA 01945
Telep one 781-631-5000
Fax: 1 781-631-3993
Em ` : la ydolib r e eenea enc .com
Dat' : 1 7 26 I
Nu�4-lbei of pages, including cover page 3
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MASSACHUSETTS ASSIGNED RISK POOL
REQUEST FOR CERTIFICATE OF INSURANCE
Use this form to rec uest a Certificate of Insurance from an Assigned Risk Pool Carrier.
Please provide all t the i equested information, including the facsimile number(s)of the person or persons to whom the
Certificate of Insuq nce sh Duld be issued. If this forrh is fully and accurately completed,the Certificate of Insurance will be
issued and distrbu d by f csimile to each fax number provided below,within two(2)business days of the carrier's receipt.
This Form may be ir iailed or faxed to the Assigned Risk Pool Carrier. To obtain each carrier's contact information refer to the
Certificates of Insu nce se Son located in the Producer Community section of the Bureau's website,(www.wcribma.oro).
t. Name, addres , fete hone number and facsimile number of the INSURED:
Name: Alt ut Qfq
Mailing Addre L. MA 61gy-g-
i
Physical Address: N
Phone: CD 0 Fax:
2. Name, addres , telef hone number and facsimile number of the CERTIFICATE HOLDER:
Name: C $v iIu rtl
Mailing Addre ' : 12 S# 1JE T %r ai- M d) 70
Physical Addr s: LZO ASN IIJ O Ta
Phone: Fax:q'7$-7 qQ-q%L1 G
3. Name, addre , con cf person, telephone number and facsimile number of the PRODUCER:
Name: 5 +EFA1S u 1.1c N =rjc
Mailing Addres : a PYh4 i'Y) O
Contact Person L
Phone: l- dC Fax: ZS 1- 63I- F47t7. 3
i
4. Policy Numbe,i,Polle y Effective Date and Policy Expiration Date
If a Certifle to of It isuranoe is needed for more than one policy term,provide the Policy Number,
Effective D, to anc Expiration Date for each policy tern.
If the policy has not yet been issued,you must attach a copy of the Notice of Assignment. r.
Policy Number. 7 - I - 10
Effective Date: O 0 6 116 Expiration Date: 69166111
5. List any specs it req sts for optional coverages/endorsements(see Page 2 for listing of coverages available
in the pool ant I thee inditions of availability)or additional information(including changes in exposure not yet
reported to tht carrif )that will assist the carrier in the issuance of the Certificate of insurance.
NOTE: An ad itiona insured(s) shall not be listed on any Certificate of insurance unless such additional
insured(s)is a name insured on the policy.
i