2 WINTER ST - BUILDING INSPECTION (2) The Commonwealth of !Massachusetts
Department of Public Safety
\Ia+sathu+vlls Slate lluilding Code(780 C.\IIO
Building Penuit Application forany Building other than a One-or Tsvo-F.nnily Dwelling
(I Ilk tirdi(ln For(lffi, al Use Only)
Iluilding,VermitNumber .. _ __. _-_- Uale:\pplied: __-_ ---..___.._ I Iluildingoffitial:
--- SECIION 1: LUC ANON(Please indicate Black 0 and I.ut p fur locations for which a street address is not available)
f.ViNTC,a- $T SALE ny_ ---_— -70
-
. _....__.....
�Nu.anJ titrc,t CiIY' /fawn Ill, - —.._.. ._
1 Noma fit Building(it ap)r!itahlr)
SI:C`l(ON 2:PROPOSE.)IV(
fdilion of \IA Slab Cade u+ed -. II;\'cw Cunslrut l ion thctI, here❑or ch,tk,111 Ihat apply in the Iwo rows I'duly
laislin!; Building Repair Cl Alteraliuit Addiliun 0 Ucmoluion ❑ (Please till aot,unl submit Appendi.v l)
Change of Use ❑ I ChangeofoctilliallcY ❑ Other ❑ Spe.ify:-yo VgE_ CNArt ..—_ __
:\rcbnildingplansand/ura:nslrudiondrkmucnlsbeingsnpplicdazpartoFlhispcnnitapplicaliun? Yes ❑ --Nu -_--- � - -
Is en Independent Slnutur,d Engineering Peer Review required? Yes ❑ No ❑
Ilrief Destriptiunof Proposed Work:__.Sue r\A „n ,,( A tLtLt:—AREA /NTO
----- --A--WOQi-t ljonrri &4�a A&xlm T
----- Ft
—L----
SECTION 7:CONII'LE'fE THIS SECTION If EXISTING BUILDING UNUfRGO1NG RENOVA'HON,AUDITION,Olt
CHANGE IN USE OR OCCUPANCY
Chetk here it an Existing luilding Inv... '—t(un and Evaluation is enclosed (5ee 78001R.1.1) ❑
Esisling Use Croup(,): _ A N A.-_._ — Proposed Use Gnmp(sp_----_------
SECTION J: BUILDING HEIGHT AND,\REA
ExistingPrupuvrd
Nu. ut flours/Glories(include b,15enlCnt levels),4 Area Per Flour(sq. it.)
N A
Total:\rea(sy. 1'L)and fuhnl Hight(ft.)
SF:C PION 5:USE CROUP(Check as jo licable)
\: ;\ssennbly:\-I ❑ A-20 Nighlclfb ❑ ,\-) ❑ A-a ❑ :\-i❑ B: Busines9
F: Educational CIP: Facto FJ ❑ 1:,❑ I1: Ili h Haznrd 11-1 ❑ 1I-2❑ It-t ❑ 11-J❑ li-i❑
I: institutional I-1 ❑ I-_'❑ I-1❑ I-J❑ -1: Mercantile❑ It: itevident(al R-10 R-'_❑ R-.1❑ R-I❑
S. Sturage 5-1 O S2❑ U: Utility Cl Special Use❑and pleased...rib,below:
5pettal Use
SECTION 6:CONSI-ItUCrION 1'YPF. (Check as a Ilea le)
IA ❑ IB ❑ HA C3 IIB ❑ IIIA ❑ III11 ❑ IV ❑ V:\ ❑ \ 11 0
sl.CTION 7: SITE INFORM,%I ION(refer to 730 C,\lit I ILO for details on each iteuq
Water SupJply: Flood Lane Information: Sewage Uispusil: french Permit Debris Remuvel:
I'ul+lit t C hrtl, itoubidc Flood Lnnc hidi,ele mmllitipal `UJ' Ir if 11 wdl not I,e I I,vowd Piyi'sal pile M
Fm.ua -- fired 1ZS�r Irenth i or+p❑ ��rinJenlilc /.me' oroui +oe Wksr,Iein ❑ 1 riilt..
prrrnnt is rn,Ia+rJ ❑
Railroad riGht-ut-,rp Il.vards to.\ir.\'.le igation: „
( \',•t.Aplh,.iblr l�JJ 1,�lrw tnrr nilhin,frp��rt a!�prn,n h,ir•,'a' hlheir rrvirry nyIrlvJ
,If Cl n neut h� Ito l,I,if,lo,ed ❑ Cl �
SICII S:S:C(1.VIRV-I I!F(l-It I11IC.\IEOf U('CLI'.\NCY
I ;Iilin I l, dr (,r l;rnn( L1 In r ,lln.lru,hf y, ------
I• l u1 ,uu I, .id pcl 11111.r
14v . Ihr b❑ilJnq;,�'nlom.in`•1�iin6ler tin.lrm' `�pru.d•�hpuLnnn.
? 4o qr --0
fit!�4ter �r�9-�- � r
I
SR I ION V: I'ROI'F.R I Y(riVN"t ;\U I II i(moil I IOC
un. .unl .\ddmssof Poop,rh lhv ntr
Z W.11 r6r- 6T $ALfd1.
b(l_O-N-o 0__-MA iF --
Nuuu•(Print)
No and Street.------ - Cn1'i town
I'ra pc rty Owner Caul,l,t I III Wind l ion:
ua nee =. _nnA,.O-- 918
---f--�---- emailaddress
Title relophone No. (business) telephone No. (.ell)
It applicablC, the property owner herebv authorizes
... Name----- ---- ---Street Address ---- City/town ---- State Zip
to act on tilt-properly owner's belt,df, in all utatters rolative to work authorized by this buildin+ +Front a +,lic,ttiort.
SECTION lU:CONS'I'ItUCfION CON-1'RUL(Please fill Out Appendix 2) /
It builJin+is Ics.+than 1i•11 TI ft al endaved s lace and unwt under C'onslruRiun Control then check here®;,red ski +Sraiun lu,I
1().1 Ite+istered Professional Responsible for Construction Control
t"-- -I'cic hone Not. c.tnail address Registration Number
' Mime(RCgistmnt) p
Street Address City/Town State Zip Discipline Expiration Dafe
✓ 10.2 General Contractor
Coln rtny Name G
A
i ti .
Y
Name of Person Responsible for Construction License No. and Type it Applicable
A. sx >-r�t _ r'��t tee --
Street Address Ciry/Town State Zip ---�
r3. ,T Gy�lO+^2 u0 '�Gc/ Ga�6
rcle ,hone No.Jbitsiness rvie,hone No. cell a-mail address
SECfION11 t"r. rr:rir ,yuty.\tµ+� ;ldn;.)� I ,uf1t'r,tli M.G.L.c. 152 25C6
A Workers'Compensation Insurance Affidavit from the CIA Department of Industrial Act:idents must be ttnnplCtcd and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Isla si+ned Affidavit submitted with this a lication? Yes O No,0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor SOG6
Item Estimated
Maturials) total Construction Cost((rum Item 6) 'S___---
I. Building S 5 Ooo Building Permit Fcr'Total Construction Cost s_(Insert here
2. Electrical S $oo - appropriate municipal(actor) 'S
4 Plumbinfl b nuutiei +ality
Note: Minimum fee'5---(contact l )
1. M"llanic•tl (IIVAQ S O
i. Mechanical Other) S 0 unclose check pavable to --.
(I Total Cost y 6000 (nmtact inuni(ip,dih')and write check nuutber byre
SECTION 13:SIGNA PURE OF BUILDING PERMIT APPLICANT
Itv entering nw n.uuc below, I hrrcbv arrest under the peins.tnd penalties A perjury that all of the info rmution ion tuned in Ibis
,ipl,lir•uinn is lrue,utd anur•ne to dte best of my kill.%' lt;e and understanding.
I'lo.1 'nut moll a �.0 _ .... _ _Ilde __ _. _ .. I •Icphonr \0 11e1c
7-
`tr,,t Wdre,s D V �/fi2 %`�" 'P2 =4/ Cot.
\lunii ipal Inspector to fill out this srdiun upon .tpplicatiun appnwal:
9/��//
R & B CUSTOM CARPENTRY
58 WARREN STREET
PEABODY,MA 01915
978-531-3119
DR ARNOLD MALOFF
2 WINTER STREET
SALEM, MA 01970
978-745-6900
Project: Create additional work space approximately 30 Square Feet
We hereby submit our proposal to perform the work described above.All work to
be completed in accordance with Massachusetts building codes.
All material and labor to be furnished at a cost in accordance with the estimate:
All materials and labor will be tracked and billed on a cost basis.
The contract price inclusive of allowances is $5,000.00.
If labor and materials are less than the estimates provided in the outline of
expenses; client will be billed the lesser rate.
Contractor and client agree that delays may occur due to weather, materials,labor,
or client decisions. Contractor accepts no responsibility for such delays.
Payment Schedule:
Contractor will submit bills for work as completed. Client will have right to review
completed work before obligated to make payment. Completed work must be
reviewed within 7 days and payment is due within 21 days from date of invoice.
Any controversy or claim arising out of or relating to work performed shall be
settled by arbitrationmith the Construction Industry Arbitration Rules, and
judgment on the award rendered by the arbitrator may be entered in any court
having jurisdiction there of.
BOB OUELLETTE R& B CUSTOM CARPENTRY
L
Dr ARNOLD MALOYF
Date
dixla.:aasiapnR 098t0 VW'hpogea
aliapanp �agoN
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VS0 n0Z/9Z19 'uogealdx `NN
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a0lo"INOO 1N3VGAO2idLVl 3V1 - -
oogetn3ag ssa tsnu V sne/}v aamnsno,}e aag/o
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T
*= Massachusetts- Depatime•nt of Public Safch -
#' Board of Buildin_ Rc_ulations and Standards
Construction Supervisor License
License: CS 52821
Z
ROBERT F OUELLETTE
58 WARREN ST EXT
PEABODY, MA 01960 -
Expiration: 4/29/2013
('anmi.�iwp•r Tr=: 8730
CITY OF S U_EM, NWSACHUSETTS
� i3u=I\G DEPART\IEJiT
120 WASHNGTON STREET, 3sa FLOOR
TEL (978) 745-9595
FmX(978) 740-9846
KmBERLEY DRISCOLL
MAYOR THoNus ST.Pm%RI3
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\L�IISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Ai nlicant information 00 )`` Please Print��Le ib►v
Va113C(BusitxssOrganizatiorvindividual): e,( tc.r) Od / ,c � A ' ,,'O arlrN 4zv1 J,,^ fl''/
Address: rt' Cti A r i'-'t A f 1 /-1.T
City/StatelZip: &n s. C4,1 : y f d Phone H: T
,\re you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 b. ❑New construction
(full and/or part-time).' have hired the sub-contractor
2M 1 am a sole proprietor or partner- listed on the attached sheet.t 7.T Remodeling
ship and have no employees These sub-contractors have 8. E]Demolition
working for me in any capacity. workers'camp, insurance. 9. 0 Building addition
[No workers comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.[] Plumbing repair or additions
myself.[No workers'comp, C. 152, ¢1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees.[No workers'
camp.inmrance n:quired.j 13.❑Other.
•Any upplicunl Ilur chcckt box AI most alw fill out the seclwa W'Ow showing their worker,'compensation putiey Wo.ation.
'I rl"eOwnt"who suhmil this affidavit indicating They am doing all work and then him outside contractor,most suhmil a new aMdevit indicating such.
:Contrmton that chcYk Ibis box must muchsxt an additiutwl shml showing the nwne of the tub contractom and their workers'comp.policy infommtion.
l um an employer that Is providing workers'compensation insurance for my employees. Below is the policy and Job site
information,
Insurance Company Name:_ f rat I/
Policy 4 or Self--ins. Lic. 0:_7 R J a1? 6 'Z rJ A1 d>f 7 Expiration Date: S'-0 3 `) 3
Job Sift:Addruss: ,l t t. , , 7-- r j City/State/Zip:,f'Lj m, !,r-t A
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to s250.0o a day against the violator. 13e advised that a copy of this statement may be furwarded to the Office of
Investigmiuns ofthe DIA for insurance coverage verification.
l do hereby-certify nr er die puimi nand penultles of per/ary drur the hifunnutlun provided ubuve,is true and correct
Si rmnuro: C9l U' Data:
I'hnne,l• / �� 2 9S�
01liciul use ads. Do nor write in this urea,to be completed by city ur town gjlriuf
City or l'uwn
__ . Permit/i.lcemaeq
Issuing Autltorily(circle one): --
I. Board of 11"llh 2. Building Department J.Citylfown Clerk 4.b.Other Ciectrical Inspector S. Plumbing Inspector
Contact Person: __ ___,_ ,_. Phone B:
CITY OF SAL.EM -'L%IASSACHUSETI'S
BUILDL\G DEPARTNMNT
3 J� 120 WASHNGTON STREET, 3" FLOOR
TEL (978) 745-9595
FAx(978) 740-9946
KIJtBERLEY DRISCOLL
AVLiYOR Twxu ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BCILDNG COJLUISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 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 disposcd of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name oE'hauler) '�
The debris will be disposed of in :
�larl1. S/ �t r . .n
(name of facility)
(address of Facility)
signature of permit applicant
�� ✓mil a-
date
IcbruvCdw