73-75 CONGRESS STREET - BUILDING JACKET
Certificate No:
Commonwealth of Massachusetts
City of Salem
Building Electrical Mechanical Permits
This is to Certify that the Mixed Use located at
Dwelling Type
0073 CONGRESS STREETin the CITY OF SALEM
-------------------------------------------------------------------- ----- -
Address Town/Gity Name
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF
OCCUPANCY
6 residential Units & 1 Commercial Unit
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires _ _ _ _ _ _ unless sooner suspended or r oked.
Expiration Date
Issued On: Thu Nov 13,2008 Alt
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\: V
GeoTMSOO 2008 Des Lauriers Municipal Solutions,Inc. ------'-------- - -- '-------------------'---"-----"-""-"-'-'---"
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Certificate No:
Commonwealth of Massachusetts
City of Salem
Building Electrical Mechanical Permits
This is to Certify that the Mixed Use located at
Dwelling Type
0073 CONGRESS STREET in the CITY OF SALEM
Address Town/City Name
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF
OCCUPANCY
6 residential Units & 1 Commercial Unit
This permit is granted in conformity with the Statutes and ordinances re 'sting thereto, and
expiresunless sooner sXspended
Expiration Date
Issued On: Thu Nov 13,2008 - - -
GeeTMS®2008 Des Lauriers Municipal Solutions,Inc. -----------------------�--------------------------------------
---------------
The Commonwealth of Massachusetts
Department of Public Safety
%lassachuselts State Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: t1jiAL09 I Building Inspector:
SEC�TIOON�lam:/LOCATION (Please indicate
Block N and Lot 0 for locations for which a street address is not available)
No. and Street Cih• /Town Zip Code Name of Building(if applicable)
k SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ Alteration Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? 1 Yes ❑ No ❑
Brief Description of Proposed Work: .Qev
U I < Lek of w/Aze ryw.
7�
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ `
Existing Use Group(s): Proposed Use Group(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5 ❑
I: Institutional I-1 ❑ 1.2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential - R-10 R-2 R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable
IA ❑ IB ❑ IIA ❑ 1100 ILIA ❑ 1118 ❑ 1 IV ❑ I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: =Sewagesposal: Trench Permit: Debris Removal:
PP Y�Public ❑ Check if outside Flood Zone ❑ icipal ❑ A trench will not be Licensed Disposal Site❑
Private ❑ or mdenlil)' Zune: stem ❑ required ❑or trench or specifv:
permit is enclosed ❑.
Railroad right-of-way: Hazards to Air Navigation: \I,\ Ilieloric l , ntmis.im Itvoir+. Pn,
..\nl :\pplicably❑ Is Sl nic(ure �c�lhut airport appru,tch area.'. Is their rewcry completed.'
,n ( nn1Cnl to Rudd endo,ed ❑ Y"❑ or No❑ )es❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Fdal,-n of C,de L.e Giouplsl: it peot Construction: (.)ccupant Lnad per Ioor:
Uoe. the bu1111log contain-in Sprinkler Spslem.': SpoCial Stipulations: .
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Properly Owner A��d`},�L //� ^^
e t c Q 6�P, ` l X
Name(Print) No.and;beet Sy2 City/Town Zip
Properly 0%wner Contact Information:
q?s- yes- S,3 R z ---
J Title Telephone No. (business) Telephone No. (cell) r-mail address
If applicable, the property owner herebv authorizes
Name Street Address Citv/Town Stale Zip
to act on the ro per1v owner's behalf, in all matters relative to work authorized by this buildin • permit a t,lien ion.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is Iew than 35,(XR)cup ft.of enclose[s+acc and/or not under Construction Contrut then check here O and skie Sectiun I0.0
10.1 Registered Professional Responsible for Construction Control
UK/4Y) eoho: 97�- 85z_ tR67 C IOb�R
Trle hone N .
, e-mail address Registration Number
Name(RrgistmnU ' F � 4 � .� �.Z i)
r
Rez7 2 —
17 � d
Street Address City/Town State Zip Discipline Ex imlion Date
10.2 General Contractor
Cu pa, t
ny Nme:
� �,- a �acl�e5 0�15�7b
N.me of Person Responsible for Construction f1� I k License No. and Type if Applicable
abl 1gq ,5
IR Re-zzW Rd
Street Address -CityTown State Zip
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT 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 $ 2 X6TJ appropriate municipal factor)=$
3. Plumbing $
Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) $
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact munici ality)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.
Please pinta npt R I ^JriU �1 Title �t Telephone No. I), to
-Z Ul M/1 I s
titreet Address Citt i Iot%n eta Lip
Municipal Inspector to fill out this section upon application approval:
Name Date
"F CITY OF S.UX.`I, ,*LkSSACHL;SEM
BuLDLNG DEPARTSIErT
120 W.►smcYGTON STREET. 3sa FZ.00R
T L (978) 745-9595
F.Vc(978) 740-98"
pXCDE EYDRISCOLL 'MOMUST.MR2ts
IAYOR
DIRECTOR or Pt:gttC PROPERTY/et:ttDaG couartssto.N Eat
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrfclans/Plumbers
a s Ilcant Information 1Print/
VaInd tBusin1eq Orrymraiioirin.kveduall: � 1CA/VI .� ct l , QS7 AI/I'I� l,U l'1�`"�"UC��oh
city/state/zip. � �lu /'�� �1 � I5 phone 0. �7� 8Sz `1q� 7
7e you ea employs?Cheeh the appropriate boa: Type of project(required):
I am s employer with 3 e. 0 1 am a general contraeeor and 1
employees(full and/or pan-time)."' have hired the atbcauraeoora 6. ❑New construction
2.0 1 am a sole proprietor or partner- listed an the attached sh"L : 7• 8 Remodeling
ship and have no employees Thee sub-contractors have a. 0 Demolition
working for me in any capacity. workm'comp.insurance 9 [iuiWing addition
(No workers'tomµ insurance S. 0 We are a corporation sn .d its 0 Electrical repairs a additions
mquired.) of 1CM have exaciaed their 10.
3.0 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.INo workers'comp. c. 152,410),and we have no 12.0 Roof repsira
insurance required)t employees. LNG workers' 13.❑Other
tomµ insurance required.)
-Any appliC=d the ahaita boa el MUM air rs tar tM fovea•.lest attswiag tba4 warkao•cadtpwdeeatr paltry iafitrntal
'I I.edruwnefa who subadr dhk aMdvir indiorng dwy rA Joins ell work aa/thus hie dw4ih Counk sew~snbek a weave a1RJwir ittdidity auk
:C.maaton thew rkeck this sea rnua attfehea as alsitwttd sere shswity Ilre err of the wr►cwesbn sae their wa ore .taxes.Pricy inannoxon,
/out an employs that Ir proridlnd worRers'res ihmurs bm/nsrramee jot my rmployrest •Nora Ar/ha pN►ap aad Jot slur
injortmwbta
Insurance Company Name: A 7 �J
Policy a or Self•ins. Lie. M _ U h -!I-le Expiration Data.
Job Sire Address: - 3 HC,,LC, 1 7�( City/StatNZip: 56u" I-W
attach a copy of the workers'compensation pogcy declsratioa pap(showing tbn polky number and expiration data)6
Failure to secure coverage as required under Section 23A of`tOL a 152 can lead to the imposition of criminal penalties of a
Pne up to S 1.500.00 and/or one-year imprisonment,as well a3 civil penalties in the form of a STOP WORK ORDER and a tine
of up to 5250.00 J day against the violator. Ile advivsl chats Own of this statemunt may be furwurdled to the orace or
Invcangariodu.d'the n1A for insurance coverage v wilicatdoe
/Jo hereby Certify under the pain ram/Pena/Nles ojpa/ary that the in/braradom providad above is true and correct
` _u.uure_ (� p -"7�•t'`�/ - 1)ufo: I? �Z l) 1
O/Jlcia/we an/n Don of write in thin area,to be wtap/etd by city or rows n/j/a•/at
City or rutvn: _ . _ Yermit/Llcense M__.
hsuing.Wfhurily (circle une): j
I. Ituard of Ilrulth 2. Rudeling Department 3. City/town Clerk J. Electrical Inspector 5. Plumbing Inspector
6. 1)Iher
l„nuct Person: _ _ __ __. Phone a•
CITY OF SALEM
%�.s \ PUBLIC PROPRERTY
,, % DEPARTMENT
'Il I_'<)\Y'.\it II\t i I(,N S rN EL-T $5.\I I']t, St.\+i.\t
1 rl:108-74;-7595 . 1:\x:978.740-9846
Constru
ction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5
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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
17111fn^ uJb�'W-�
(name of hauler)
'I'Ine debris will be disposed of in
(name ut acl my)
(address u(I'acility)
.ignature of Permit applicant
(late
Ic1v i. tl Loa