37 WINTER ISLAND RD - BUILDING INSPECTION (6) t �
The Commonwealth of Massachusetts
Department of Public Safety
/(�� J ;tiro f,.; t.ldsti,trhusrtls til,uc Building Curia(7R11 CTIR)
`I Building Permit Application for any Building other than a One-or Two-Fancily Dwelling
(phis Section For Official Use Onh')
Building,Permit Number: Date Applied: - Building Official: -
SECTION 1:\LOCATION 1(Please indicate Block#`a�n�d Lot#for locations for which a street address is not available)
3^ c
_ ( "N N')� 9-r lS 1C.3� T wU\I t n� _l't-t.+•`.t-�c. {�r„�.E.-�v,= .d-
Nu,and Street Cih /Mown Zip Code Name of Buildinl;(it aPplicabla)
SECHON 2:PROPOSED WORK
Edition of NIA Slate Code used If New Construction chock here❑or check all that apply in the two rows below
laisting Building❑ Repair L9G Alteration ❑ Addition❑ 1 Demoliliun ❑ (Plodse fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:—
Are building planS and/ur construction documents being supplied as part of this permit application? Yes ❑ No ❑ ,
Is do'Independent Structural Engineering Peer Review required? Yes ❑' No ❑
Brief Descrikitiun of Proposed %Vurk:_Re &-N, �N?Ate!5�'x¢ 1 Ge�e�e W ��� t �o y�i o
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 CNIR,34) O
Existing Use Group(s): I Proposed Use Gruup(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)ik Area Per Floor(sq. ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-I ❑ A-_2❑ Nightclub ❑ A-3 ❑ A4 ❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Factory F-I O F2❑ H: Hi h Hazard H-1 ❑ H-2❑ 11-3 ❑ fl-�4❑ H-i❑
1: Institutional 1-1 ❑ 1-2❑ I-3❑ 1 4❑ M: Mercantile❑ - Ri Residential R-10 R-2❑ R-3❑ R4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA Ili ❑ IIA ❑ FIB ❑ II(A ❑ 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 Rentuc if;
Public❑ Chock if outside Flood 7_uno❑ Ind iCdta numiripal ❑
:\ trench will not be Liconsod Disposal Site❑
required ❑or trench orspecify:____._.___
Private❑ or indentily Zunr: or on site s'slam ❑ permit is vnclosed❑
Railroad right-of-way: Ilazards to Air Navigation: �I �i�Lir .,,, n •,..�� -__„i'
'\ Nut Applirdblr❑ F
rurtu«,within airport app«mch area? Is(heir«•view iomplclod'
or Consent to Build enclosed ❑ Scs❑ Or NO❑ Y.v❑ No ❑
SFC'I'ION B:CON'IEN'r OF CI'.It'rIFICA'rE OF OCCUPANCY
Edition Ot Code: Coo Gruop(s): ._ I\po of Construction:_--_._ Clieupant Load per floor.
Uucs the huilJinl;remain an Sprinkler,
.S1v111?. ____—_ __Special
1
(�'� ���
�e��
/ U
��
�,
If T
SECI'ION 9: PROPFRI'Y OWNER AU'1'IIORIZA-I[ON
Nome aml Addioss of Property Otrner \ 1
1__l'- J 1 -eae•^ _—�L _LO ,
Name(Prin l) No.and Street City/Town Zip
Property Owner Contact Information: -
Title ---- Telephone No. (business) Telephone No. (cull) a-mail address
If applicable, the property owner hereby authorizes
Name Street Address - —City/Town State Zip
to act on the pro terly owner's behalf,in all matters relative to work authorized by this bu ild Ing permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill.out Appendix 2)
If building is less then 35,0W cu.ft.of enclosed space and/or not under Constmction Control then check here O and skip Section 10.1
10.1 Re istered Professional Responsible for Construction Control p.
_ YC- 2Mx.w Rel�� roI ) _ ,S O\4 rc-�(� CFgJVZZ1h 6Ie....n tey. L��U 11
Nance(RegistranQ Telephlm No. e-mail address Registration Nwnber
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
:?rQt__ " R2�.�-cam \ wl'VeSV Pne>`^1,
Company Nance\
1J0� C,` r TO ��OIJ CS
Nance of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State �Zip
�
Telephone No. business Telephone No. cell a-mail address
SECTION 11: tyt n:t,itic: t i.rnn,r\SA rn)k I AI I WAM 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 pennit.
Is a signed Affidavit submitted with this application? Yes O No Cl
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building b Building Permit Fee-Total Construction Cost x (Insert here
?. Electrical S p appropriate municipal factor)-S
- 1, Plunnbing S '
4. \1cchanical (HVAC) $ Note: hlininmm fee=S (coutachmunnicipality)
5. Mechanical Other S Enclose check payable to z�-4b
h.Total Cost $ I S66 Q (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT j
I entering any name below, I hereby attest under the pains and penalties of perjun that,all of the information contained in this
application is true and accurate to the best of no, knowledge and understanding,
Ca��r �,a_ Sz�/y2��ta 4� er..ey �eJl \tJ3lS, GO SOS- 7�
Please print and sign name Title -- felepltune o 1,ale -
Street Addicss ///''''''��� - - -
City/Iowa /�u Slalc "zip
Municipal Inspector to fill out this section upon application approval: -__ "' `"'�'J _ -
Name
, Y'S
�b CITY OF S'U.Eai, LLNL-kSSACHUSETI'S
BI:IM0413 DEPARTMENT
120 W.vHLNGTON STREET, 3 "FLOOR
I-EL (97I1) 745-959S
FAX(978) 740.9846
ICI.% BERLEY DRISCOLL
MAYOR Tio..%W ST.P[ERRS
DIREcroz OF PCBIIC PROPERTY/BCanNG COMMISSIONER
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 40, S 54;
Building Permit p 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 transpo
rted by: yy��
n/Wt� l2Cc ra
(name of hauler)
Q The debris will be disposed of in
-AY
(name of facility)
S o (r.o�a�� S, C'c b-C ^^�
(address of facility)
signature of permit applicant
data
�a bf1.41��K
CITY OF SALEM
„ ;.1' PUBLIC PROPRERTY
DEPARTMENT
r UC. nl I Y:IA IN e.I I
\l Itt el
12:\dA1/11Al:l U.�ilaeYi'• SaI I•.Nr Mn�\.u.w V I n J17):
I'cl. •�74•'ri ri'ri • F tx v711•NG ISM
Workers' Cumptnaatlon Insurunce alRduvit: guilders/Cuntracturs/E)ectrieluns/Plumbers
1 )Ileanr fair itnnuHo
PI Print Le ibl
V:1111CIIlual,kayt)ryyivaiinrvinJlv�Juu11: r f C(�\Q,�- 11 \
Vlllre.im: co r r� -
cay,.5tarc•%ip• Ifiuna l' 6� S� L4 7 0 b b
it:
I .Pre)nu an emplayer'!Cheek the apprtlPrlom boa:
I,❑ I am a empluyer with e. I)M o/pnl/list(rvqulrrd):❑ I:un+general contractor and 1
�•enlIsla)Vex(full gndfur pirminte).• "lives hirl:al the rub-cuntracturs rl• ❑New construction
i,un i tole prnpricuw or partner listed on the anached sheet % 7• ❑ Retnodelinj
chip and hava no cmpluyceli These sub-contractors have
aorkiny for irtu in any capacily. evorkem' comp. Insurance. a' fkmolirion
1 No workers'sump. insurance J. ❑ We am a col q• ❑ Ouildind addition
required./ pomtinn and its
ot)kers have unamiscd their 10.0 Electrical repair,or additions
3.0 Visit a hrmva»vncr Joins all work righf of exemption par MOL 11.0 IflumbinY repairs or iddilinrus
myself. INo ev,orkem'comp• C. 132,f l(4),and tvie Is IV no
insurance required.) t .mPloyees. INo work/rs' 1=•Q Roof mpairs
clnnp. inrursncxt mquinvl J I3•Q Oiller
'Jill.rpphcaln tlIW vhcYs eel AI mgW also IIM ow the Welton Wave dewule Iheir wastes,casilPelllWlw leliey mriulrlWiwY
'I Inrlwntwreers whe"Anvil this AZIl inJiueina Ihery an Jeins WI wort fIW Ihna hoe gwiiae easprtlilps Inwl.ulenil a nee a1RJsri1 itwliasine wwt.
'r rMlryahMn IhW ahaxh,his boll T,W Jllwhee.In]llJillgtlel+hell Jlnwina the rinse of this Iga•eelerfrleya fad the.wYAM'
f Af
hors tlr1 C/II/Ilty////!Yr/r p/uYldfnX IY41ANJ'CY/npHrfnr/an/nreranee/a/Iny//nplWy/p,R B/IatY/e/l) PII I y Y/I pI f
iulurnrWbl/R y
Insurance C'umpany Vame: a ? " r�� S, ,� S V r-c,\N_
Ihdicy 4 ur Sdf•ins. Lic.H: L-(�c*,r� �
� G.t vM-\� Espirauun tj
;tie:
/ol)Site Address: ni I
�1`•�hl.-Qr� ``II c'
httaeA is cn
Py of the workers'cumpematloa pulley declar'allon page(showing the Polley number and expiration date).
Ibilure to rich eoveraye as required undur Suctiun_'Sr\u1',\IGL c. 152 eau lead to the imposition of eriminal
up nt S 1.5110,01)endlur line-year imprixomncnt. as well gs civil penalties of a penahla in the 1'unn ol'a STOP WORK ORDER and a first
i up fit i!50.00°Jay Igaivat the viol-itar. Ile advi.+cd thus a copy of Ihih stuhmem may be IurwurdeJ to the Ullica ul'
Iit1'�.\tl�,rllgllf uI :Ile III,\ IOr Ili.uracce ;e;v;r��c ��l ilie.�nun,
/du hereby l rrri/Y ar the poine r/nd p/nn/iia•x u/prr/ury/but the in�ur/nur/ow pruviJaJ ubuve is true and correrA
i a;;- wl _
I).trc Q vj
1116
L
IIy. /)a to,n•rite ire thlr grew to Ae runry/eled Ay city ur rmen illhimA
l•II eYn: permit/l.levme a
uthorily (circlennc);
t(Ilc.rhh ) Ihuldin•. )
. I vpartvne ). aClerk J. L•'Icctric.d fugiccrur i, prulllpinyyceror
'a nuu: i
�—.. � I'Aunv 7r �
i
i
Information and Instructions
every ron tit the jeo,ce of another oodar any cunlmct of hire, .
�Lus.uhuieus t.icncral Laws chayoer I52 tc4ulres all etnPlo)ers to Proviso workers cOmpensauun fix their enlP ogees.
I`ur.u.uu to tills .tatuta, in r01,14Fro ix dctined as"-.e ry i"`i
♦Preis of IRt Plied. Jral of wflllen." , or anytwo or snore
lip,axioctatlJa.corporation or other legal entity'
ernplu et or the
1n cln 'JU)•er 1+defined as"an individual. Partner)" ti i^ ce loyea• However the
% the I:Iceguln{engagcd,n a Imnf enterprise'
and including the legal rcpre+muadves of a deceased "s. Y
I CGG1ver Jr ttualee ut ,u1 IIIdlvtduall paamenhlp, ax,oetapar of other legal a resides
therein.
Y { ' P
Jwner of a dwelling house having not more than three apartments anJ who resides repair or the occupant of the
urenant thereto shall tot because of wch em loymcni be deemed w be an employer."
,hvclhng huu;a of another who employs per+one ro do maintenance,cunitructiPn or repair work
on to b dwelling employer.
or on the grounds or building aPD
�tGL chapler 152. fj25C(6) also slates that"every sfsu or local licensing b{dings I shall withhold the Issuance for as or
Uaaee with the Insurance coverage required.'
renevvsl of a license or permit to operate•business or tq construct buildings la the commoowaulgh or any
+ +SC 7t rates"Neither the commonwealth not any of ill poligiul subdivisions+hall
;lppliredenicunt Nlto has not produced aceaptable erldence of comp
\ddiuunally, r1GL chapter t S_, i- l
enter into any contract for the Parfomlan centedbo the conuract g alulhorityvidence of cumPlitulce with the msuranc
requirements of this chapler have been p'
Applicants the boxes that apply to your situation and. if
compensation afndavit completely,by checking with chair cariAcam(s)of
PIJ:1:ut till Jut the worker,' comp ea and horse nu111ber(s)along Ixs ocher than the
necc+airy,supply subeontractomp n ies .L , •address( to P Partnerships(LLP)with no employ
workae compensation insurance. it an LLC or LLP does hava
insurance. Limited Liability Companies(LLC)or Limited Liability
ustrial
members or partners, are not required to carrybmittlad to the
enlployess,u policy is required. Bt advised that t4 Also be inure to sign and date the rt'lidav�lt.ntnu of io tip i should
hcation for the permit or license is being requested, not the Department of
\ccidenta for confirmation of insurance covorege the low or if you are required to obtain s workers'
has rcttlnled to the city or town that
have 4�,nons regarding panics should enter their
Indusrial Accidents. Should Y Ilranent it the number listed below. Self-insured com
cotnpansation policy. Please call the Dep
self•insurance license number on the a ro note lino.
City or Town Officials
The Department has provided u sputa at tho boom
P1ra..c he .ura that the affidavit is complete turd printed logtbly.
the app
Of III* affidavit fur you to till out in the event the 0111ce of Investigations has to contact you regarding
lieations in any given year, need only submit one atvatila t indicating current
I'I:uw be wre to till in the t>,;rmitllicmtse n"sltbi°r which will ba uicd as a reference numbltr, in addition, is applicant
that moat submit mulliple Panniu and law app be provided to the
Policy ilttormati,if the necca' it that has hoer Officially >vmrpJJ ur m�tkledtbyi tile city oretown nay he
p o (city of
tuwn)."I\copyPermits or licenses. A now alltduvit must be filled out each
applicant as Proof That a valid affidavit is an file for figure 53 of d;r.,t �rc care ur Permit tor citizen is burn leavese.)obtaining d Perxoon is otts*or NOTtrequired o relatedt not mplete thH atfidnvitm111ercia venture
I he )1llce ul I11ve.tigattuns ,vould like tJ thank you in advances fur your couperation and should you ha%u.my 4uesuons,
plea,e du nut hesitate to give us a call.
flit Ucparunent'x addfa+s, telcphuna and fax number'
The Commonwealth,of Massachusetts
Department of Industrial Accidents
Of&e of Invesdgedons
600 Washington Street
Boston, MA 02111
'rel. q 617-727-4900 eat 406 or 1.977-MASSAFE
Fsa M 617-727-7749
d 4.111.115 www,mass.govldia
:y
Massachusetts - Department of Public S;deh
Board u1' Buildim., Re ulations anti Standards
Construction Supervisor License
License: CS 26W --
Restricted to: 00
DONALD E JORDAN
15 RIVER PL
METHUEN, MA 01844
Expiration: 2123QO12
('anmi.rioncr Trp: 18890