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BPA-18-1105 6 NEW TOWNHS BLDG 4 The Commonwealth of Massy s Department of Public sa ' u" Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling ' (This Section For Official Use Only) Building Permit Number. Date Applied: f Building OfficiaL• SECTION 1:LOCATION No.and Street City/Town Zip Code �fA.sa., sA/ems Name of Building(if applicable) f� o�q�d Assessors Map# Block#and or Lot # SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 6KNo, ❑ Is an Independent Structural Engineering peer Review required? A.;a Yes O No ❑ Brief Description of Proposed Work: dfkiZ( G Naw na�.v .ussd s 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 CMR 34) ❑ Existing Use Group(s): I Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)3 Total Area(sq.ft.)and Total Height(ft.) /p ,f .0 — — .4 eoyk SECTION 5:USE GROUP(Check as livable) A: Assembly A-1❑ A-2❑ Nightclub O A-3 ❑ A-4❑ A-5 Er I B: Business ❑ E Educational ❑ F. Fa F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional 1-1❑ 1-2 D 1-3❑ I4❑ M: Mercantile❑ 1 R: Residential R-1❑ R-2❑ R-3❑ R-4❑ S: Stora S-1❑ S-2❑ U: Utility O 1 Special Use❑and please describe below: Special Use Description: - SECTION ti:CONSTRUCTION TYPE Check as :sable) IA ❑ IB ❑ IIA ❑ ITB ❑ IIIA O IIIB ❑ iV ❑ YA lB--'VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item) Water Supply: Flood Zone Information Sewage Disposal: Trench Permit: Debris Removal:Public IVCheck if outside Flood Zone 13 Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ 7Conse;ntto right-of-wa Hazards to Air Navigation: MA Historic Commission Review Process: pplicable Is Structure within airport aCp ch area? Is their review compl ? [or Build enclosed❑ Yes❑ or No 9 Yes❑ No Er SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: __ Use Group(s): Type of Construction: Does the building contain an Sprinkler System?: Special Stipulations: Design Occupant Load per Floor and Assembly s ce- ! 0 rRN-tj Z�s SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Miga , nJ�uS 9 Sca+k. Name(Print) No.and Street City/Town Tap Property Owner Contact Information: EQ -X62-_3 rlTi a/LoAdecA , Tide Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes: Thtrevoj- nifid.M 4itJi 37 'r¢Y�— Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this buildi t a lication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu,fL of endosed space and/or not under Constx�ion Control then check lucre O. Otherwise provide Mtruction control forms(see section 107 in the code as lo.l Registered Professional Res ible for Construction Control(the essfonal coordiea document submittals Name is t) Telephone No. e-mail address o/q, Registration Number . S'�.. 401— - -/ Street Ad rens City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name "./4'2 A-i Name of Person Respe for Construction License No. and Type if Applicable 977 XAMS M Ave ��Bo�,y .A28 Street Address City/Town State Zip Tele hone No.(business) Tele hone No. cell e-mail address SECTION 11:4vp IDAVIT .GL c.IS2. 6 ts+fdtrial Aoctta must be completed and A Workers'Compensation Insurance Affidavit from the IVIA P submitted with this application. Failure to provide this affidavit will result in the denial of the' uance of the building permit. Is a si rued Affidavit submitted with this application? Yes,1 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Coats:(Labor Total Construction Cost(from Item 6)_ and Materials) 1.Building $ y00 •00 Building Permit Fee a Total Construction Cost x (Insert here Z Electrical $ Cfj appropriate municipal factor) 5___,___-- . 3.Plumbing $ 3 C� Note:Minimum fee $ (contact municipality) 4.Mechanical (HVAC) $ tl/ S.Mechanical Other $ Enclose check payable to 6.Total Cost 4,* . (contact muni ' i )and write check number here SECTION 13:S1bNA11*E OF BUIt3)ING PERMIT APPLICANT entering my name below,I hereby attest under the ` . nd penalties of perjury that all of the information contained in this By application is true and accurate to the best of my knowledge AM nndeershuxi ng. Please print and sign name Tiiie Telephone No. Date fetW Street Address City/Town State Zip Email Address Municipal inspector to fill out this section upon application approval: FF LS�LL Name Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street / Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information L Please Pri� g Print?Leibly Name(Business/organizatioti/lndividual l: It t'�C� �49%rl U r��r/ C_ Address: 30 & i - City/State/Zip: - �''7 Phone#: / 7" 3 Are yo an employer?Check the appropriate box: Type of ct(required): 1 am a em layer with _ a. ❑ 1 am a general contractor and I p _ 6. Nein construction employees(full and/or part-time)." have hired the sub-contractors 2.❑ listed on the attached sheet. 7. ❑ Remodeling 1 am a sole proprietor or partner- ship and have no employees These sub-contractors have g, E] Demolition working for me in any capacity, employees and have workers' q ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]+ c. 152,§1(4)•and we have no employees. [No workers' 13.[:]Other comp. insurance required.] 'Any applicant that checks box#I must also fill out the section beln•a showing their workers'compensation policy information t Homeowners who submit this affidaN ii indicating the}are doing a I I work and then hire outside contractors must submit a new affida%it indicating such Contractors that check this box must attached an additional sheet showing the name of the sub-comractors and state whether or not those entities have employees, It the sub-contractors have employees.they must pro\ide their workers comp.policy number. 1 am an emph ver that is providing workers'compensation insurance for my emphvees. Below is the polis►•and joh site information. Insurance Company Name: _7&XAe Policy#or Self r7 -ins. Lic. :�144&jQ� Expiration Date:_ �i �0A CityiState,iZi 1-Z S 7 Job Site Address:_ P - Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the forret ofa STOP WORK ORDER and a fine of up to 5250.00 a day against the%iolator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance I crage veriticatiun. 1 do hereby ce oder ena ties of perjure'that the information provided ahoy is!r and correct. Si mature: _ �_ _ Date. Phone Official use only. Do not write in this area,to he completed b►'ch),or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: AC40RL?® DATE(MM/DD/YYYY) III CERTIFICATE OF LIABILITY INSURANCE 10/4/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CON I AU I NAME: Michael Mullaney TITAN INSURANCE LLC PHONE 617 500-5053 AIC No Ext: � A/C,No 535 BOYLSTON ST ADDRESS: mmullaney@titaninsured.com 8TH FLOOR INSURER(S)AFFORDING COVERAGE NAIC# BOSTON MA 02116 INSURER A: TRAVELERS 13579 INSURED INSURER B Juniper Point Investment Co.LLC INSURER C: 130 Bay View Ave INSURER D: INSURER E: Salem MA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AUWL POLICY EFF LTRTYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YY t - AIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE FIOCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PPOLICY ❑PRO JECT F—]LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIABOCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONER - ND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100000 A OFFICER/MEMBER EXCLUDED? 7 N/A N 7PJUB-7H80869-8-17 12/09/17 12/09/18 Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 100000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. Inspectional Services AUTHORIZED REPRESENTATIVE 98 Washington St MiCk ,J—ei Salem MA 01970 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Commonwealth of Massachusetts MWDivisionof Professional Licensure Board of Building Regulations and Standards • Const A%dPFrvisor f CS-112501 �> ��ires:07/20/2022 j r. r. THOMAS J 4AR i 37 JACKSON 7�jfE` PEABODY MA 0+,986 *' Commissioner � �a��ion 74 F um es i C��RACTOR OttiCe otHOME MPFtUME IndMd� 071 THOMAS J MA61 MARMI> � dersecretaN THOMAS AVE. Un PJBOKD MA 01960 CITY OF SALEM ROUTING SLIP New Construction 9 S �✓1,s a� S�' Certificate of Occupancy LOCATION p I SCV1j h MaS((" Sl DATE Z /1 Lzols I ASSESSOR DATE Z 7 I t 93 Washington St. CITY CLERKZ---k TE 93 Washington St. PUBLIC SERVICES MADATE dl C 120 Washin o St. o� - Pool- WATER v DATE Z `f 10�� 120 Washington St. � t/V CROSS CONNECTION ATE Z P5 Jefferson Ave 1' �7 LANNING C./ DATE i20 Washington St. rn CONSERVATION V ' ( 'DATE 120 Washington St. ELECTRICAL DATE 48 Lafayette -/(/7 FIRE PREVENTION- _^" - DATE 29 Fort Avenue HEALTH DATE 116 1 � 120 Washington BUILDING INSPECTOR DATE 120 Washington St. ` Initial Construction Control Document . � st To be submitted with the building permit application by a 4 RegisteyADesign Professional for work per the 0'edition of the ,�•� Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Mason Street Condos—L-Shaped Building(Building#4) Date: 09/13/2018 Property Address: 9 South Mason Street, Salem,MA 01970 Project: Check(x)one or both as applicable: (X) New construction Existing Construction Project description: The scope of work will include the construction of a new(6)unit town house style condommim building. I Ryan McShera MA Registration Number: 51025 Expiration date: 8/31/2019,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': X Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge,information, and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review,for conformance to this code and the design concept,shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intro-als appropriate to the stage of constnwtiorr to become generally,familiar with the progress and quality of the work and to determine if the work.is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent comments,in a form acceptable to the building official. Upon completion of the work,I shall submit to the building official a `Final Construction Control Docu ' EDA y ' sy r� Enter in the space to the right a"wet"or .y electronic signature and seal: No. 1 s u) Phone number: (978)595-6764 Email.ryan@redbarnarchitecture.com Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other'is chosen, provide a description.