2 WINTER ST - BUILDING INSPECTION v ,
-\ CITY OF SALE,,M
'� i PUBLIC PROPI R"l'Y
Rr �� ICI PARTNf1 N"1'
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APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT: Applicants must complete all items on this page SITE INFORMATION
Location Name 2 5-7 Building 0A A,CNdo/J /1N�n��
Property Address S,a�-c irk /04 0/9yc) -
Located in: ,vo Conservation Area Y46 4/0 Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes R3 IN
Residential (3 or more Units) R2_
Type of improvement Residential (hotel/motel) RI _
(check one) Assembly (Theaters) Al _
New Building_ Assembly(restaurants & clubs) A2r_A2ne
Addition Assembly (churches) At _
Alteration _ Business CB)_
Repan/Replacement_ Educational E
Demolition Factory (moderate hazard) FI _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard 11_
Accessory Building Institutional (residential care) 11 _
Institutional (incapacitated) 12_
-
Institutional (restrained) 13
Mercantile M_
Storage S1 _Moderate Hazard
Storage S2 _Low ILtzeutl
OWNERS1111- INFORMATION(Please type or Print Clearlv)
OWNER Name QA XYQNU c-, 0A LOE /-
Address z t.011y7EYL 6f,
Telephone —Pio —8 //
Signature _ .------- ---->�_oe n �o
DESCRIPTION OF%$ORK TO BE PERFORMED
e9W s of
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✓1Jdl�+ 5� �.64T/ Tiper/s �r/L�w ,�7d1>i2, il/1��y is;Gao}Zl/t✓6 S —C
FST MATED CONSTRUCTION Cost A-r2,nz
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CONTRACTOR INFORMATION
Name 22,W;�,OcIC- ,4u,�L.i P16 OL "l el:,�
Address -/r 61 q v /
Telephone ,tii �k-3-7(f67
Construction Supervisor's Lic # G3CJG G
Home Improvement Contractor#
,%itcnrrECT/E'N(;1NEER INFORNIA'rION
Name I-ZIA)C 4 S/e oV �s�c�✓�T� s
Address /o N/tfiV T WZO, ct0 Y1A dy)-SS
Telephone 7NI 3 S3—0YO O
Mass. Registration #
PERMIT FEE CALCULATION
Estimated Cost x $I1/$1,000 + $5.00= yy- `v
CONIMENI'S
The undersigned applicant does hereby attest that all information stated above is trite to the best of my knowledge
under the penalties of perjury
Signed (owner) (aocnt)
APPROVEDBY : )
DATE APPROVED: 1 ' D
� e
1 CITY OF SALEM
PUBLIC PROPRERTY
' "a ^ DEPARTMENT
Wn,ru�a:r.r�SCICtif • SAU-sx,Mn».t..lu
1b.t. V8.715.95'15 • 1:tx 9711-74"'Ix16
Workers' Compensation Insurance %fridavit: Builders/Contracturs/Electricians/Plumbers
\ 1 flicant Inforfnalion Please Print Legibly
V tltnl: ilia.nle,y t�rganv:Uion,lndn uluol l:_ ✓J720C/Z— f7l(ZlLQ11V!' rrin/S UL T7-A N?S
,lddrcss: / 5 e-A 00 -r ,S r
City,State.Zip' 1/mil- t1 — I'hune '!: e�,7—d)d-7967
Are%I :un a employer with uu an employer? Check the appropriate b Type of project(required):
1.❑
i 4. 1 am a general coil 6. ❑lractor and 1 New construction
en pto)ces(full antL'ur part-time).' have hired the zuh-convectors 7. - Rtmodeling
2.❑ 1 aot a sole proprietor or partner- listed on the ntract r shave
ship and have no employees These sub-contractors have S. ❑ Demolition
working ror me in any capacity. workers' comp. insurance. 9. ❑ Building addition
5, ❑ We area corporation and its
[No workers'comp. insurance 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL I I.❑ Plumbing repairs or additions
3.❑ I ant homeowner doing all swat c�152, ¢1(4),and we have no 12.❑ Rtwf repairs
myseif. INo workers' comp.
insurance required.) employers. LNo workers' 13.❑ Other
comp. insurance required.]
-nit. .q,phcalu Ibat<Cucks box Ill nlYll Asa IIII W,I the 5e'cl,011 IKtuw ihuwnttt their wo,kCU cumpenvaiwt to licy u,liurtusitnu
' I lumeuwrx:n who submit this affidavit indiwJntt they am duiny all,vork asul then hire outside cwurxlon muss•uhmil anew al'11 vil indiwong,ugh.
4'omracum that check flits box must jilwhW an addisimal.hues,Ifo-mv Ilse nano of this sub<omrxWn and their tsurkars'comp.policy mrurmatiun.
/am un employer that is providing rvurkers I compensation insurance jar ttty employees. Befoly is the pu/it y and job site
btjornratiom
Insurance Company .Name:
I'olicv is or Self-ire. Lie. ExpiratlonDate: O's
Job Site -\ddress: .5( Cny;StataZlp: _%—A4ZAj, A" O/9;*7
Altach a copy of the workers'compensation policy declarafion page (showing the policy nunnber and expiration date).
Failure to.secure cuvemge as required under Section 25A uf>IGL c. 152 can lead to the imposition of criminal penalties of a
Arc up to.S1.5110.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 it day •Igainsl the violator. lie advised that a copy of this statement may be lurwarded to the Office of
Im.>nt(a eons ul the DL\ for u»urarce cascr.Iye Nei iticanun.
/do hereby certify urt,ier the poinr mtd pena/ticv of perjury(hut the ia/orinui/on provided above is true and correct.
:I k!'ial
I'h .re
()/ficial use urdy. Oo not write in Mix area, to he ruurp/rlyd by airy ur to lvn a/Jiriu/.
('itv or town: Permi0l.ieense g.
Issuing AWhurily (circle one):
I. iii,arJ of Ilydth 2. Itudding Mparuneut .1. (-Sly.-lotto Clerk 4. L•'Iextrical Inspecror ;. Plumbing lutpectar
6. Other _
Carmel Pcnurtt .. _. Phone t!:
I
Information and Instructions
%I;i 9&icliusctts Gcneral Laws chapter I i2 inquircs all employers to provide workers' compensation for their entployces.
Purmu:mt to this statute, an empluree is dclined as"_.ev-ery person in'thc service of another under any cuntrachf hire,"
.%press Or implied. Oral or Written." _
An empluyer is defined as "an Individual, partnership, association, corporation or other legal entity, or any two or inure
,d the loreeoing engaged in a Joint enterprise. and including the legal representatives of a deceased empluyer,or the
reeciver Or trustee ul .ui individual, paitncrahip, association or other 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.rounds or building appurtenant thereto shall nor because of such employment be deemed to be an employer."
>IGL 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. NIGL chapter 152, 4. 25C(7)states "Neither the commonwealth nut any of its political subdivisions shall
enter into any contract for the performance ufpubiic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants -
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) name(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 dale the affidavit. The affidavit should
Lie returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial 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. Self-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 :md printed legibly. The Department has provided a space at the buttum
of the affidavit fur 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 pennit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple penniu'license applications in any given year, need only submit one affidavit indicating current
policy inl'mmation(if necessary)and under"Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that 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❑lust be filled Out each
Year. Where a hone owner or citizen is obtaining a license or perinit not related to any business or commercial venture
(i.e. a dug license or permit to burn leaves cte.)said person is NOT required to complete this affidavit
1)1 f cc of lliv'estl.atiunl \Wuld like to thank y'ou in adYailcc fur your cooperation and should you have any questions,
please du nut hesitate to give us a call.
The Uepa«merit's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Olflce of Investigations
600 Washington Street
Boston, MA 02111
Tel. q 617-7274900 ext 406 or 1-877-MASSAFE
Fax q 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC. PROPRERTY
:4
`- DEPARTMENT
��" ---
-------------
construction Debris Disposal Affidavit
(rryuircd for all demolition and rcnocat un work)
In accurdance ith the sixth edition of the State Building Code, 7S0 ChIR section 1 1 1 .5
Dcbris, and the provisions of 1v1GL c 40, S 54:
is issued with the condition thatr
the debt resulting from
Building Permit #
(his work shall he disposed of in a properly licensed waste disposal Iacility as defined by MGL c
111. S 150A.
The debris \%'ill be transported by:
64s4 T�
I name nC hauler)
I he debris will be disposed of in
V
t name ul L ohlY,
t367OV
I,nldre.. of I�nliicl
acnatu,c of prnom .wphi 'it
JJ 3W6Q
,Imc
CONSTRUCTION CONTROL
PROJECT NAME: Renovations to Endodontics, Inc.
PROJECT OWNER: ' Dr. Arnold Maloff
PROJECT LOCATION: 2 Winter Street — 1st Floor
ARCHITECT: DAVID A FARMER OF KING DESIGN ASSOC.,INC..10 HIGH ST.,MEDFORD,MA
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSEITS STATE BUILDING CODE,
SEVENTH EDITION,I, DAVID &FARMER REGISTRATION NO. 8333
BEING A REGISTERED PROFESSIONAL ARCHITECT HEREBY CERTIFY THAT I HAVE PREPARED
OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS,COMPUTATIONS AND
SPECIFICATIONS CONCERNING:
ENTIREPROJECT XXXARCHITECTURAL STRUCI'URALMECHANICAL
FIRE PROTECTION ELECTRICAL OTHER(Specify)
FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF KNOWLEDGE,SUCH PLANS,
COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSEITS STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRACTICES AND
APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER
CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT
ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE
WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING
PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.22:
1. Review,for conformance to the design concept,shop drawings,samples and other submittals which are
submitted by the contractor in accordance with the requirements of the construction documents.
2. Review and approval of the quality control procedures for all code-required controlled material.
3. Be present at intervals appropriate to the stage of construction to become,generally familiar with the progress
and quality of the work and to determine,in general,if the work is being performed in a manner consistent
with the construction documents.
PURSUANT TO SECTION 116.4.,I SHALL SUBMIT PERIODICALLY A PROGRESS REPORT TOGETHER
WITH PERTINENT COMMENTS TO THE Salem BUILDING COMMISSIONER.
UPON COMPLETION OF THE WORK,I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY
COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY.
�EFtED qqC,
�kPF
a
No.8333
o
+,SP
DAVID A.FARMER PERSONALLY APPEARED BEFORE ME AND
SUBSCRIBED AND SWORN TO BEFORE METHIS 30th DAYOF October, 2008
1 rd07 ARY A:�v ous�lc
a�„Y :? GO rxh� W' tl'i{CanSSRCtIUSETTS
My Cor,m.-F_appre�Mar:8,2013
Bedrock Building Consultants
145 Cabot Street
Beverly, MA 01915
Contractors List: for 2 Winter Street: Salem, MA 01970
The following contractors will be working at 2 Winter Street (All have workers Comp)
Plumbing: Al Corelle: A Corelle & Son 978-922-4410
Electrical: Gil Fontaine: Fontaine Electric 781-953-0050
Carpentry: Bob Ouilette: R& B Construction 978-265-6033
Paul Ritchie: Paul Ritchie Floor Covering 978-927-3256
t