4-6 ATLANTIC STREET - BPA-16-1136 INT/EXT REMODEL The Commonwealth of Massachusetts
Board of Building Regulations and Standards stGi {1 CITY OF
Massachusetts State Building Code, 780 CMR f�� "IQ, L �til M
Building Permit Application To Construct,Repair,Renovate O
Revised Mar 20/l One-or Two-Family Dwelling A 8: 44
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official Print Name ,.„... Signature Date
SECTION l:SITE INFORMATION
L—� 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
t•1` 6 NT1AtuT tC_
1 1.1 a Is this an accepted street?yes no Map Number Parcel Number
V1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 01� Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
M Check if yes❑
/ _ nKD CSINSKl SECTION 2: PROPERTY OWNERSHIP'
J 2.1 Ow er'of Record:
ti ���ttnt:� 1k1��s1' Sakey,% lM po
Name(Print) City,State,ZIP
" -6 A f kntdc Ihre. C&11 ! 1W-0%'4 &tn ,ts cutmor ar+ec I caws
No.and Street Telephone ma A rer
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. Cl Number of Units Other ❑ Specify:
Brief Description of Proposed Work':yafphg5jtU, k7r, r E Y r F R i o t L1or riE PAIR DEC'K C
12FnMmR-I KtICA-IC i .. eFFttiISH ' OniZIN6 i PAVE 'bit I ✓E6AY
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
L Building $ IE* y8 a� 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
000 ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ N 0p0 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ So 000 ❑Paid in Full ❑Outstanding Balance Due:
�v kr-"asEo 9130
Stay r rt, V*tcb NST- 1011`3 it 14
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 10ul�'A-p 12
pb AM 3e\�N License Number Expiation Date
Name of CSL Holder
List CSL Type(see below)
y 0 WAV£RI JE Y Ro
No.and Street Type 'Description
U Unrestricted(Buildings up to 35,000 cu.ft.
U•F1iJDaV6L� Mfg b lfi Lis R Restricted 1&2 Family Dwelling
City frown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
Lt 1 SF Solid Fuel Burning Appliances
��` I19 I S 2 6 /�DAY13R1 C:GCO C7 M N r L,C-Or 1 Insulation
Telephone Email address D He
5.2 Registered Home Improvement Contractor(IHC)
IQ ICo tuloD!% (, n wl BRA=N \bA�12 s�l"I
1 P. HIC Registration Number Expiation Date
HIC Company Name or HIC Registrant Name
41'r %A)-KVCIZ I Qn AIJAnn312tCt)C�hMRt� rn ri
No.and Street Email address
N %w-b.nl,(tT1,— f7tb4S q`D ty�19 IS2A
Ci /Town,State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes .......... ( No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize a 1 -Pe%
to act on my behalf, in all matters relative t k authorized by this building permit application./� I �n
\ fog ECL
1
mt Owner's Name(Ele onic Si ature Date
SECTION 7b OWNEWOR AUTHORIZED AGENT DECLARATION
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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. og_v/oca Information on the Construction Supervisor License can be found atvmy.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halffbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
a
CITY OF S��1I.F.M. 2 L-kSSACHUSETTS
BUILDING DEPARTMENT120 WASHINGTON STREET,Sao FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
1QNfBFRT FY DRISCOLL
MAYOR THOMAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUMDLNG COAL\RSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informationp (1 r Please Print Leeibly
Name (Business:Organintiorvindividual): I3I?IQO r VILDW2
Address: L 4l1 WAYE Q L ev RIS
City/State/Zip: (,,VaA1Z MA bI44 Phone #: 97$ Li79 I r,?6
Are you an employer?Cheek the appropriate box: Type of project(required):
I Z0 am a er em to with 4. ❑ 1 am a general contractor and 1
employer * have hired the sub-contractors 6. ❑New construction
employees(full and/or part-time).
2.❑ I am a sole proprietor or partner- listed on the attached sheet.: 7.�Remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
required.] officers have exercised thew
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§l(4),and wK o 12.❑ Roof repairs
insurance required.]t employees.[No wo13.❑Other
comp. insurance re
-Any applicant that checks box#1 must also fill out the section below showing their worknsarian policy inrormadon
t1 tomeowners who submit this affidavit indicating they art doing all work and then hire outside contractors most submit a new affidavit indicating such
=Commcnon that check this box must attached an additional sheet showing the name of the sub-oontractms and their woken'comp.policy information.
!am an employer that is providing workers'compensation fusuronce for my employees. Below is the policy and Jab site
information. _
Insurance Company Name: tAVELr- rc C
Policy#or Self-ins. Lie. #: -- P _, , SQ-1 It, Expiration Date: L4 ] It I)n
Job Site Address: 4 - 6 A-t 1 lir yy \C, PAVE City/State/Zip: S'A Lf M Iyl�
Attack 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
fine 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby,certify under the pains and penalties of perjury that the information provided above is true and correct
Sianattim Date: 1 t4z I 16
P t , 9 1
Oficial use only. Do not write in this area,to be completed by city or town,official
City or Town: Permit/Lieense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person• Phone#:
Board of Building Regulations and Standards
License: CS-104428
-Construction Supervisor
ADAM J BRIEN
417 WAVERLY ROAD
NORTH ANDOVER MAJ0118146' -
CA—
, �q rsi v
�..nn l.— Expiration:
Commissioner 06/1212018
_ � M fe rpomrixmrrruerr�o C?/G�acfirJe i`�'
'Office df Consumer Affairs&Busin 4s Regulation
' egistr Nion: 'j ENT§,512 CONTRACTOR
egistrenon 168512 - TYPe:
Expiration X3/1/2017 LLC
-
-BRICO BUILDING AND REMODELING LLC
rvj
ADAM BRIEN -
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417 WAVERLY RD rsz-ti,
NORTH ANDOVER MA 01845 Undersecretary•.
�e m.ee•..xn ,+,y
This card acknowledges that the recipient has successfully completed a r
10-hour Occupational Safety and Health Training Course in
Construction Safety and Health
i
Adam Brien
i
Marcus Nerino 1 /19/10
(Trainer name—print or type) (Course end date)
4-6 Atlantic Street Realty Trust �IIASIINI�ul�tllllltlulllllll��
Pg:313
TRUSTEE'S CERTIFICATE SO.ESSEX 1#1131 BWk:35313
Under MGL Chapter 184,section 35 0913012016 02:07 WERT PO 92
1. On August 24,2016, the Donors,Darius Grego0/and Miroslaw Kantorosinski did create 4-6
Atlantic Stredgealty Trust, appointing Darius Gregory and Miroslaw Kantorosinski as
Trustees of said Trust(hereinafter,in their capacity as Trustees of said Trust,together with
their successor(s)in trust,collectively called the"Trustee'.
2. The undersigned is the current and sole trustee(the"Trustee") , of the Trust authorized by the
terms of the Trust to give this Certificate and make,execute and deliver all documents
necessary to implement the action(s)referenced in item no. 5 below; see Resignation of
Darius Gregory as Trustee attached hereto.
3. As of the date hereof,said Trust has not been amended, altered,revoked or terminated,and is
in full force and effect.
4. The Trustee of the Trust have authority to act with respect to real estate owned by the Trust,
and have full and absolute power under said Trust to purchase an interest in real estate and
improvements thereon held in said Trust and no purchaser or third party shall be bound to
inquire whether the trustees have said power or are properly exercising said power or to see to
the application of any trust asset paid to the Trustees for a purchase thereof.
5. The undersigned have been empowered, directed and authorized by the holders of one
hundred(100%)percent of the beneficial interest in the Trust,to purchase property located in
Salem,Massachusetts commonly known as 4-6 Atlantic Street, and to take any and all other
actions that the Trustee, in his sole discretion,deem necessary or appropriate to effect the
foregoing; and
6. There are no facts concerning the trust which constitute conditions precedent to acts by the
Trustees or which are in any other manner germane to affairs of the Trust.
[Rest of Page Intentionally Left Blank]
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EXISTING 8x8 POSTS UP/DN TO
BE VERIFIED AND REPLACED w/
4x4 PSL POSTS AS REQUIRED
STRUCTURAL NOTES: CENTRAL BEAM TO BE —
1. Contractor shall verify all dimensions REINFORCED w/(1)1.75x9.25 LVL CENTRAL BEAM TO BE
2. All loads and loading conditions are per IBC 2009(6th edition of the REINFORCED wl(1)1.75x9.25 LVL
Massachusetts building code)
3. All lumber shall be construction grade or better.
4. All LVL Fb=3100 psi.
5. All combined LVL plies shall be connected per manufacturers
specifications for side loaded assemblies.
6. Toe nail all existing joists to new LVCs.
SISTER EXISTING co
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- DATE ISSUE
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SCALE:3/16"=1'-0"
S- 103