165 FORT AVENUE - BUILDING JACKET 4� 1 NO. 752 1/3
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EXISTING CONDITIONS
RAYMOND T. GUERTIN
. � .� ;
PEPPY'S PIZZA EXISTING FIRST FLOOR PLAN t �""'r , ' ARCHITECT
LEED AP/BD+C
SALEM WILLOWS ARCADE i -'
165 Fort Avenue, Salem, Massachusetts cxu-366-2 B9 FAR:? 8-356m
i URNPIKE ROAO.SUM 207
IPSWICH,MASSACHOEM 01938 Al
;
f ` ! I 7a:978-3563749 FAx:99ci.c 1409
_ _
x4t Tamutanwalt4 of mttlwar4untb
�. CITY OF SALEM
y` In accordance with the Massachusetts State Building Code, Section 108. 15, this
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eJ
CERTIFICATE OF INSPECTION
is issued to P. GF_ORGOUDIS D/B/{1 K:ING' S PIZZA
7 (Ur itH that I have inspected the premises known as K1W.3' S PIZZA
located at Vi1E.5 FORT AVENUE in the city of Salem
County of Essex Commonwealth of Massachusetts. The means of egress are sufficient for the following
number of persons: ..
BY STORY
Story Cac'iCy6$$$%$ Capacity Story Ca$p�ac$i�+y�$ ft $ $ Capacity
%$$%S%%$%%$$X%$$$%$
BY PLACE OF ASSEMBLY OR STRUCTURE
.Place of Assembly Place of Assembly
or Structure Capacity Location or Structure Capacity Location
RESTAURANT 49 :LST FLOOR A—„
021, 1.?,...-I95d0 0 /' "1/ 1.95.98 4,(:;/17,1 / 11:_39'9
Certificate Number Date Certificate Issued Date Certificate Expires Building Official
l
The building official shall be notified within (10) days of any changes in the above information.
V
7.
CO.' ONWEALTII OF .L�,SSACEIISnTiS -
?�c CITY OF SALE2i
APPLICATION FOR C=IFICATE OF INSPECTION
Date �1( / [ ( '7 Fee Required S VO
( ) No Fee Required
i
In accordance with the provisions of the Massachusetts State Building Code. Sc
108. 15, i hereoy apply for a Certificate of Inspection for the below-owed premise
located at the folloving address: �]
Street 6 Number e+
Name of Premises i n 1 ZZ,
Purpose for which Premises is used
License(s) or Permic(s) required for the premises by ocher Covernrrenral Agencies:
License or Permit Ateencv
o o� / oo� FnI(h
,y tu,z
G7 . � > Ll- Vt vu
N w
CJ,r
Cer.Lf icace to be issued to:
J ti cc o
-- Address:
D7 L. "
_:9vner of Record of Building: LTG eo(t O V O�'
Address- We ma A1^ O ( tt002
Name of Present Bolder of Certificate:
Name of Agent. i_` any. . .
I YH'/71/�n��i]�-moi
Signac re or Person o woom herr-11cate TITLE
is issued or hisiber authorized azenr
Date
IN=UCTIONS: Day time phone /
1- Make check payable cc: The City of Salem
2. Return this application with your check to: Invertor of Buildings. City of Salem
Building Denarrment. One Saler Green. Salem. 1,i4. 01970.
PLEASE NOTE:
1. Application form with required fee muat be submitted for each building or srtacta:
of part thereof to be certified.
2. Application 6 fee moat be received before the cert'-ficate will be issued.
J. The building official shall be notified within ten (10) days of any change in the
above information
.
g
CERTIFICATE 1- 60 7 j - /('O� =I.RATION DATE:
l
PERIODIC INSPECTION REPORT
This form is to be completed each time a Periodic Inspection is made. At the time
a new Certificate of Inspection is issued, a notation indicating that the fee has
been paid will be made to Application Form prior to the new Certificate of Inspection
being issued. Any changes since the last inspection are to be added to the file card
of the premises.
Street S Number F6 5 �%fl
Name of Premises � /- / Z Z /$
Certificate to//be issued
to: �i AJ G / / Z Z /f
Address /b r—, ( tye
Owner of Record of Building % / G e O/' o C.
Address {��� �y�/J
Purpose for which premises are used /SCS 7—e,- 1,1-7,J C
Changes since last Inspection (required on file card also)
1.
2.
3.
4.
5.
Date Order Issued:
Order Issued To: Address
Date Violations Corrected:
REMARKS: {`l/u..�t;,��{l c d E,t % S �y "W ff ,j Cnl r
I have this day inspected the above premises, and the same conforms to the pertinent
requirements of the Massachusetts State Building Code and the rules and regulations
pursuant thereto.
S - //- 99�
Date uildin Offit5ial
Certificate / U `� — �� Date Issued:
Date Expires:
Recommended Neat
Inspection: F _
� - 3
a4r (gommontu alto of tt onrl use#o \"
x o CITY/TOWN OF
In accordance with the Massachusetts State Building Code, Section 108. 15, this
Y y
CERTIFICATE OF INSPECTION
isissued to . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ITertifg that I have inspected the. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .known as. . . . . . . . . . . . . . . . . . . . . . . . . . .
located at. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .in the. . . . . . . . . . . . .of. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
County of. . . . . . . . . . . . . . . . .Commonwealth of Massachusetts. The means of egress are sufficient for the following
number of persons:
BY STORY
Story Capacity Story Capacity Story Capacity Story Capacity
BY PLACE OF ASSEMBLY OR STRUCTURE
Place of Assembly Place of Assembly
or Structure Capacity Location or Structure Capacity Location
4 .3 5 f 51 moor . .
00 Y3 -
Certificate Number Date Certificate Issued Atte Certificate Expires Building Official
The building official shall be notified within (10) days of any changes in the above information.
67 0(P
�0 9a3 - J53 )
141#4"61Ml6t-GE{.*{•94A9 APPROVED 8Y T44E
EAW713EW G
GRANTED
,ip{S,pECIOB PFLOA 7D A P
CITY OF SALEM
oae f z d 6
is Prop"Located In location of
nw Hlawic Maw? Yu_No_ wua�a
is Pmp"Located„
ft Cgwwvagon AIM? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, stall Sid' Construct Deck, Shed, Pool,
RepatdReplace, or._
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Ownsrs Name p i n t{ C6 m b eW
Address S Phone /6- �-
Architects Name G l� p�i7/� l afu�%s,�
Address & Phone Lff c? ��� !�✓p$ G,� �(� ��Z �
Mechanics Name .1
Address & Phone f
whu is on putpow of W? Ls�7
►A.wtd or htrldnp4 lUan�q M a dwwV,ar how many tarn m?
ww b***oodotm to law? Asbwlot7
Eaw"ted cod d� �d ` AY U,,m a 1J aS1W I kmim 0
fl
. t
SIGN UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
l jej LA-C( q �( Vl /-4( .�l �l e,/
_12 6r �Lll�(�n
MAIL PERMIT TO. 7 I M�) CA A)C L� �
h
NO. Zl -62
APPLICATION FOR s
PERW TO
LOCATION
�
PERMIT GRANTED
AP ROVD
INSPECT OF BUILDINGS
1 �
i
What is the current use of the Building?
Material of Building? If dwelling.how many units?
WIN the Building Conform w Law? _ Asbestos?
Architeds Name �I I �� Sal A 1>✓S '�—
Address and Phone
3'l'L M�o�� c,�L
Mechanids Name
Address and Phone
Consbruction Supervisors Lice'nsss o E'� HIC Registration# —
Estimated Cost of Project i— Permit Fee Calculation
Permit Fee t Estimated Cost X$7/$1000 Residential
Estimated Cost X$111$1000 Commsmlai---
An Additional$5.00 Is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
ens of a ury XAULLspecifications. Signed under p Illy P d T
Date J UXJ C
\' N
F• '� .°e G7�b a 3
r' 'D
CITY OF SALEM
a�, �,. :"�1 ,�p�✓ PUBLIC PROPRERTY
DEPARTMENT
:J1111::RI.EY DRISCOLL
\•I.tvott LD WASHING ION SrRELT 4 SALEN1,MAssAC usrrrs 01970
TEL:978-745-9595 •FAX:978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
4pDlicant Information �� Please Print Legibly
NiMe(13uciness/OreanizatioNlndividual): � �r'tv� VtJt�-t>1 �.l-7Ufy-
Address: q C) M t'1`tt'of I gopyi Il Ds
City/Statci/..ip: ��AW � ,v J� "�' Phone i': y �" ✓ v
:arc you an employer'Check the appropriate box: 'Type of project(required):
I.❑ 1 am a employer with 4. ® 'I am a general contractor and 1 6. ® New construction
employees(full and/or part-time).` have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet.: �- Remodeling
ship anti have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions
required.] officers have cxcrcised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers comp. c. 152, y 1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. [No workers' 13.0 Other
comp. insurance required:)
'Any applicant that checks box d] must also lit[out the action Wi uw showing their workers'compensation policy infurnulion.
'homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such.
�Contraetors that check this box mustanachcxl an additional ahect showing the nano of the sub-contmcturs and their workers'comp.policy information.
I run on employer that is providing workers'compensation insurance far my employees. Belo,is the policy old job site
information.
Insurance Company Name:----..--........ __ -------------
I'olicv d or Selr-ins. Lie.�fir:_! _____._�.A_._1.__.__ Expiration Date:
Job Site Address: C�t/�t J�V -1"+ t'"J s ,) City/State/Zip:
e
Attach it 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:viGL 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 fine
of up to S250.00 a day against the violator. lie advised that a copy of this slatcment may be forwarded to the C117ice of
Investigations ul'the DIA for insurance coverage verification.
I do hereby cer i under the nuns na penalties f perji that the inforinurian provid a ) �bov'e is true and)•'o�rrreec,r.
Sienalure: Date: ✓1'`i� V
Phone- 3- bill
Official rise only. Do nor Ivrire fit this area,to be completed by city or rerun ofjicial
City or-Town: _----- Permit/Liccnse#
Issuing Authority(circle one):
1. noard of health 2. Building Department 3.Cityffosvn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone :
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another tinder any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,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 grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL 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, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public 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-contractor(s)name(s), address(es)and phone mmriber(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 date the affidavit. The affidavit should
be retunmed 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 and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the pennitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"lob 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 must be tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
Thu Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\l.\mK 12C7 W.\9 aXG:JNSiREET •SALVM.MAii.Han iLCIi:i9/
CEt:976-745-9595 •F.%X:178.7449846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CMR soction 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 disposed of in a properly licensed waste disposal facility as defined by MGL c
111,S 1.50A. I
(
The debris will be transported by:
6flRv�t, Flw ��tLi,�t dwv.1
cow
(name of hauler)
Hie debris will be disposed of in :
(came of facility)
of t"iiLty)
,:cnlillz ai;p,ica,tt
06/21/2007 09:24 FAX 508 941 0056 ALGAR CONSTRUCTION 0 002/002
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FACSIMILE V R S ET
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T0: ��1lt�nn 1jWLbltu1. CVWAiS )os-- L DATE: J f p��
ATTENTION: ` , T ,r0 FAX N0: Q��.I�Io � G
11P"" TEL. NO:
FROM: �AIA c..'\ Ck.' "14 LAj
REGARDING:
TOTAL NUMBER OF PAGES ( INCLUDING THIS PAGE)
COMMENTS:
40 Meadowbrook Road, Brockton, Massachusetts 02301 Tel: 508.583-6111 Fox: 508.941-0056
300/l00 lz NOIIJNaISNOO 8V91H 8900 l06 809 Xvi 6310 LOOZ/1Z/60
CITY OF - - -
PUBLIC PROPERTY
DEPARTMENT
KISeF U"DUSUYL
.%IAVM 120 Wwurw-sw Srt
SN.k1f,XA3tAdltShll15 01970
TEL 97e-7454M•FAX M7404M0
APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR EA-MY,EA-MY, FOR ANY EXISTING
STRUCTURE OR BUII.DIN .
1.0 SITE INFORMATION
Location Name LA---PA VJ (UOW5 SVlvVAVJIkAtng:
--_- - Property Address:----
Property Is located in a:Conservation Area YIN Historic Dlgrld YIN
2.0 OWNERSHIP INFORMATION
2.1 Owne►of Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN dnATtNr: BMExisting
Addition
Renovation Number of Stories
Change in Use Demolition
Approximate year of Area per floor (SO Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
Mail Permit to: - --