516 LORING AVE - BUILDING INSPECTION �- The Commonwealth of Massachusetts
.E I, Department of Public Safety
vy.,yf .Ma>sochusells Slate Building Code(780 CMR)Seventh Edition
N 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: Building Inspector:
SECTION 1: LOCATION (Please indicate Block If and Lot K for locations for which a street address is not available)
'5:5 1� 5-r�
..\'o.and Street Cite /Town Zip Code ;Name of Building(if applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition ❑ Demolition Cl (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 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? Yes ❑ No ❑
Brief Description of Proposed Work:
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 ❑ A-4 ❑ 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 1-1 ❑ 1-2 ❑ 1-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 ❑ R-4 ❑ f
S: Storage S I ❑ S-2 ❑ U: Utility❑ Special Use❑ and please describe below:
Special Use:
SECTION b:CONSTRUCTION TYPE (Check as applicable)
IA ❑ 10 13 IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV VA VB [3
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
i Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal:
Public❑ Check it oubide F6nn1 Zone[01Indicate nwmcipal ❑ A trench will not be Licen*ed Disposal Site ❑
required Our trench or*"Ci(v: .
Private ❑ „r umdentdc Zone:._ „r,m .ite�r,tem ❑
permit i*enclnse,i❑
Railroad right-of-wav: Hazards to Air.Navigation: MA I ra,.rirc ...... rc i,"• Pr•„..;
❑ rums rc within all p,rl approach area' I. Ihuir recicrc Cnmlet
, r lm�enl i� ButJ cndu.cd ❑ 7 u, 13 „r .\o❑
lb. ❑ \u ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I:diU, n ,d C ,afc- L,u l,rnuhl•C rm pc if C unntnidion: OCCuI.Jrt Load
I),rot the budding can Lunan Sprinkler!m tem': Special] Stipulations:
`0 �lyl
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name ,wd Address of property Owner
ar6b/� �A tM ,f 6 14 R,V& Ar/C ff f l
Name(Print) No. and Street City/Town Zip
Properh' l)py ner Conlan Infurm.tlit f
r nt _—
Title Telephone No. (business) Telephone No. (cell) r-mail addrrss
It applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the I,ro pert ow nor's behalf, in all matters rela ti%e to work authorized by this bui Id 11`16 permit a pp I ica Gun.
- SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(It building is less than 35,1x)1 Co. tt.of enclosed s pace and/or not under LUnFtrUCtiOn Control then check here O and skip Section 10,1)
10.1 Registered Professional Responsible for Construction Control
dery l`�H 9?k-Sir /36
Name( e&1 IranqYJTelephone N e-mail address Registration Number �O!O
30 1w. T'�ae� d/ 2 U
Street Addre,s City/Town State Zip Discipline Expiration Dale
10.2 General Contractor
Company Name: G is l3
Kr�,,,,: CAt2rt�4,
Name of Person sib tion Construction cense No. and Type if Applicable
741
et ss City/Town State Zip
Telephone No. (business) Telephone No. (cell) - e-mail address
SECTION 11:WORKERS'CONTENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
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
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6) _$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $ - t
Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) $ i) )�H�
5. Mechanical (Other) $ p. Enclose check payable to
6.Tota �
l Cost $ / / o 0 (contact municipality)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 perjure that all of the information contained in this
application is true and accurate to the best of my knot%ledge and understanding.
/ccw �2�
19ca:r print and >ign Milne �ide Tcleph0me \o. I)a to
Ncet :Addre.n Cih;'Town eta e Zip
ill Municipal Inspector to till out this section upon application approval: _
V'ame )ate
vge �`�� s d
`j�Boar o m dmg cgulat ons an tan ar s
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Repistrdlion: 100733 ,
Type: Private Corporation
Expiration: 6/2320/0 Tr# 267195
A. B. CARNES. INC. _
Barry Cames -- —-
30 Arrowhead Farm Rd.
Boxford. MA 01921
Update Address and remm card.Mark reason for change.
Address ❑ Renecral Employment Lost Card
�ngRelptta�?ed. evatx{rded8 #,
_ 8aard of Building Hegolationf erNl Standards
Construction Supervisor License F
is
.w Liconie:. CS 63139 1
r
Expiration- 111 12010 Tr# 12607 ,15
g 1 Rastriction:. 00pRR
KENNETH R CARNES '
s 8 DORIS ST ��c' ✓moi '
GROVELAND.MA 01836 - - s'.
Commisa mr
A(:VKq %+cR 04/07/2009
P IXXIC R 781-324-1809 FAX 781-397-9270 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
New England Heritage Insurance Agency Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
110 Florence Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Malden, HA 02148
INSURERS AFFORDING COVERAGE NAICS
-multm AS "mes,Tnc. __-- - --- ------- -�_ WSURERA: Essex Insurance Co.
30 Arrowhead Farm Rd. INSURERS, Granite State Insurance Company
Boxford, MA 019ZI INSURER C,
INSURER D:
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PORKY 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
__ '---- --— -- ---'-- '----- UNITS—
LTR Rm TM OF INSURANCE POLICY NUmam �� EFFZ{INE �EifPlRATWN
GENERALLUMIL"T 3CZ1799 03/18/2009 03/18/2010 EACH OCCURRENCE _ s 1,000,00
X IJIII
COMMERCIAL GENERAL LIABILITY PREMISES f SO,00(1
CLAIMS MADE [flOCCURMED EXP(ArW person) : S,O
A ParsaaaLaADv wlunr s 1,_000,00
ceERALAGGREGATE- - s 2,000,Om
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMPAP AGG s 1,000,00
POLICY LOC
AUTOMOBILE LJABIJIY ` SINGLE LIMIT
ANY AUTO f
ALL OWNED AUTOS BODILY INJURY --__
(Per Pe'+AA) $
ID
SCHEDULAUT0.5
MRED AUTOS BODILY INJURY
N(XNFOWNm AUTOS
(RN emdem) i
PROPERTY DAMAGE $
(PeramdelR)
GARAGE UABRJTY AUTO ONLY-EA ACCIDENT $
ANYAUTO OTHER THAN EAACC E
AUTO ONLY, AGG E
EXCESS I UMBRELLA UAznJTY EACH OCCURRENCE $
OCCUR F-1 CANS MADE AGGREGATE S
s
DEDUCTIBLE $
RETENTION f E
WORKOISCOMVENATION NC 742-62-18 03/31/2009 03/31/2010
AND ENPLOVERS'LIABILITYTORY KITE fIR
rrN EiEAc.THAccIDENT $ 1,000,
B EDFm
lw�laataY EI DISEASE-FAe�L S 1,000,00C
�
°AlasbeZ=bek E1-DISEASE-POLICY LIMIT $ 1,000,00
oTxIRe
DESCRIPIM OF OPERAIMS I LOCATIONS V6OC-I n I EXCLUSIONS ADDED BY 6®OR89HR J SPECIAL PROVISIONS
ontractor Subject to terms, conditions, endorsements and exclusions on the Policy.
^=: CERTIFICATE HOLDER CANCELLATION
SHOULD ANVOF THE ABOVE DESCRIBED PIXBC64 BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUED(SURER WILL ENDEAVOR TO MALL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SWILL
OM4M NOOBLIGATION OR.LIABILITY OF ANY WIND RIPON THE INSURER.nSAGENTS OR
„PROOF OF INSURANCE COVERAGE ONLY" REPREB 31TATWEIL
SPECIMEN COPY ONLY ADTNDRREDREPRESENFATIVE
William Kell EDA
ACORD u PY009109) ®1989-2009 ACORD CORPORATION. All Tights reserved.
The ACORD name and Logo am nTgkitmmd marks of ACORD
CITY OF S.U.E.Ms NisksSACHL;SETTS
• MILDLNG DEPARTMENT
M 120 WASHLNGTON STREET, )aa FLOOR
TEL 97 745-9595
FAX 97 7304816
(USBEgI EY DRISCOLL
MAYOR THOMAS ST.PIERRS
DIRECTOR OF PIBLIC PROPERTY/BUILDING CO\MSSIONER
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers
Anplicant Information J{ Please Print Leeibly
Name (Business OrWatition Indiv,du J): /TSS 014ayu-'o
Address: 30 L-g- X17 00
City/State/Zip: / Me- Phone All: -29
Are you yer. Ifaek-tbe-appropriate box: T
I. am a employer with 4. El am a general contractor and 1 Type of project(required):
6. C]New construcrion
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet : 7. Q Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for mein any capacity. workers'comp. insurance. 9, Q Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 1 O.Q Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. (No workers' 13.C]other.
comp. insurance required.)
Any applicant dna thaw box jot must also rill out the section below showing their waken'compensation policy information.
'1 Lmwuwrwn who submit this affidavit indicating they are doing all work and then hire outside contractor,most submit a new affidavit indicating such
:C.moosnon that cheek this boa most allwhad an n,lditional Shen showing the name of the sub.conlnctors and Iheir workers'comp,policy intonnatimt.
I um an employer that/s providing workers'compensation insurance for my employees. Below is the policy and Job site
information.
Insurance Company Name:
Policy p or Self-ins. Lie. M 4A'-- 7y�--da?-/2' Expiration Date: 3 _ll �O / 6
Job Sire Address: 3—/6 /V/�Crt)L /Irk City/State/Zip: S C�
,kttach a copy of the workers'compensation policy deciarstion 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 51,500.00 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. Ile advised that a copy of this statement may be forwarded to the Office of
Imesugativas of the DIA for insurance cov- a verification.
I do hereby certify under the par and penafBer of perjury that the information provided above is true and rorrect.
ci�.nI tre6
Uattx
Official use only. Do not write in this area, to he completed by city or town nJjri"i
City or Tuwn: __. __ PrrmiUt.iccme d
Issuing Authority (circle one): _ -
1. Iluard of Health 2. Building Department 3. City/fown Clerk 4. Electrical fnspector 5. Plumbing Impeetor
6. Other _
Contact Person: __ ___ ___ Phone p:
CITY OF SALEM
QPUBLIC PROPRERTY
.
�,, DEPAR'I'�IENT
III
')',S '4; I \'i'M.•J. 'ISJ;,
Construction Debris Disposal Affidavit
(rcyuiicd lur all demolition and renovation work)
In accordance %�itll the sixth edition of the State Building Code, 780 CAIR section 111,5
Dcbris, and the provisions of vIGL c 40, S 54:
Building Permit H is issued with the condition that the debris resulting front
this work shall be disposed of in it properly licensed waste disposal lacility as defined by MGL c
I 11. S 150A.
The debris wvilhbe�trannssported by:
(name tit hauler)
the debris will be disposed of in
' unmr ut facility)
r�:fr sem'
2%
laddres.ul'tac ditvl
ieuatwc n(pennu .yiphcant
dale r