15 1/2 PALMER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
*fir Department of Public Safety
Mass,uhusett,titate Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION(Please ' dicate Block#and Lot# for locations for whil a street address is not available)
'i o o p
No.and Street Citv /Town Zip Code Name of Building (if applicable)
SECTION 2:PROPOSED WORK
If New Con ntction check here❑or check all that apply in the two rows below
Existing Building ❑ Repair Alteration ❑ Addition❑ Demolition ❑ (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:
v.�
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): S
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: Hi h Hazard H-1 ❑ H-2 13H-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 ❑
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 ❑ IIB ❑ IIIA ❑ [IIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
FP y. Licensed Disposal Site❑
Public❑ Check if outside Floud Zone ❑ Indicate municipal ❑ A trench will not be
required ❑or trench or specity:
III ca to ❑ or indentify Zone: or on site sm'stem ❑- permit is enclosed Cl
Railroad right-of-way: Hazar Ids to Air Navigation: MA I li,h.rie Cninmi+.iim t2ecirrc Prnro..:
.Nut Applicable EI 1,Stricture N, thin.iiipnrt approach area:' Is their rev iemv completed?
or Cln senLtu`Build Fnelosad ❑ J " Yes ❑ or No ❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
[dation of Code: Use Group(s): T%PC of Construction: Occupant Load per Fluor:
Does the building corn_tainan Sprinkler System?: Special Stipulations:'
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
ell
O �
Name(Print) Nu.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town Stale Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit a plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is less than 35,11110 Co.ft.of enclosed space and/or not raider Construction Control then check here 0 and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
ill ry ��- X93 , 330
Name(Registrant) Telephone No. e-mail address Registration Number
!tea ofQ c ,/a �- 5,2X 0—
ozi� s o
Street Address City/Town State Zi Discipline Expiration Date
10.2 Ge raI Contractor
Name of Person Responsible for Construction ` Sy s/ License oand Type if Ap, li(able
/�Cy/!ps •..62//
Street Address CitO(own State Zip
,6�Z->e!y— 6f93 3—re 2—
Telephone
Tele hone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COIvII'ENSATION 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 ❑ No ❑
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 $ appropriate municipal factor)=$
3. Plumbing $
Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVAC) $
5. Mechanical (Other) $ / Enclosecheck payable to
6. Total Cost $ �b�� (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 perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
Please print a/nd0 sign no ne Ti le Telephone No. Date
/�2 O lir 1 Cmc✓ ! �nG'. tr 2/2-
tilreet Address City/Toren 77 State Zip
Municipal Inspector to fill out this section upon application approval: ^�
Name Date
CITY OF SALEM
a r PUBLIC PROPRERTY
DEPARTMENT
;'I ,,,,:
I1I: 9'N"Yi.9}4Ji ♦ 1 \Y: 'i'N-'4_954,.
Construction Debris Disposal Affidavit
(requiied for all demolition and renovation work)
In accordance \\ith the sixth edition of the State Building Code, 7S0 CMR section 1 1 l.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit H 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
I 11. S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in
;_W_ t__ .
+_ _�' lJZiJ�
(name ut 1 L itv)
laddres ul'facility)
�i�naturc of prnnit applicant
,late '
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1.111. 14 1 ) INS,(,91
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Workers' Compensation Insurance Issffidnvit: Builders/Contractors/Electricians/Pfumbers
issimucant Information Please Print Le ihfv
Name lual l:/
ddress:
Cily'srare'zip 'rorti'/2 Dec m2/27 Thune
.arc)uu ,I employer:'Check the appropriate box: I')pe or project(required):
1. 0 1 am a employer with 4. 0 I am a general contractor and 1 0. New construction
cng+lu)ccs(full and,Ur part-tune).• have hired the soh-contractors
y. 0 I am a soic prnprictor or partner- listed on the attached sheet. t 7 Rtmodeling
ship and have no employees These tub-contractors have g. Demolirioo
Lurking Im Inc in any capacity. /workers' comp. Insurance. q, Building addition
No workers' cum insurance 5. We are a corporation and its 11
I P' 10. Electrical repairs or additions
I required.] officers have exercised their
J. 0 I um is homeowner doing all work right of exemption per NIOL 11. Plumbing repairs or additions
myself.tNo workers' Lump. C. 152, j 11(4),and we have no 12. Rauf repaink, / I
insurance required.] + employees. (No worktrs' 13.0 Utter � �L
comp. insurance required.)
•\n. .ygthcmll(tut checks boa 01 muel:Jan fill wn Ihv•:cello(Iwluw,howina then wurkco'cumpena ion IwIwy nlwrn ,iun.
' I lomuownen.vhu ,Wtud this a17Wavit imlicatina Ihcy J6 doing till work a,N amn him uutvlde ewur.wt,r*muN.uh+nio a new atrdavit ini"ma.uch.
d'.,mcwom
that whv,k this box MIMI Jrtwhcd..n aedlliunal nlwel.hi-ms;raw n:mN)of tk tub•contracton and their Lurken•comp.policy Infurrnantin
lit," un empfuyer that is prtmiditg Ivurkers'cumpenwuion insurance jar u+y rurpluyeer. Below is the policy and job..ire
b1foruatlon.
Insurance Company Name: --'.----
Polity a or Sclf-inn. Lic. R: G-z • 3 /5 — t [9 � .. -- Expiration Date.
Job Site Address: � Z S City;Slateizip:en 7 D
Attach it copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
I;JIIurc a)secure cuwerage as required uudcr Scctiun 25:\ til>IGL c. 152 can lead to(fie imposition oferiminal penalties of a
rine up to.11.500.00 and'ur une-year imprisonincnt, as Loll as eo it pcnalhcs in the furan of a STOP WORK ORDER and a fine
of up to S250.00 it Jay against She violator. lie adv lscd that a copy of dos sialcinmat may be Iorwarded to the Oltice of
In\ ul ,he DIA :br al,m ❑ Ce wet 111LJLun.
/do hereby lcruw unr r the/mn mrd prnl,hirc ufyrrjury that the iu/unnu/won provided above is true and correct.
F11,,ardollIvAill
dy. D: _ Permit/l.lecnse prily (circle nue):
c.tltlt t. Nuddin:; Dcparuncnt 1. Ciel.tofuC•ierk J. Electriod luspcctor 5. Plumbing Inwpcctor
Information and Instructions
�1.1�sal flu.+eta licneral Laws diapter 152 requires ill employers to provide workers'.compensation for their employees.
I'unu.ult to this statute, an emplurre is dclined as" .ewer) pctson in the service of another under any contract of hire,
.press or unplwd, oral or written...
.\n employer is defined as "an individual, partnership, .tssocianou, corporation or other legal entity, or any two or snore
.r the foregoing engaged it a joint cnterpn>c, and including the Icgal representatives of a deceased employer, or the
re�elwer or trustee ul all nldlvtdual, paitnershlp, association or other legal curtly,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
.Iwellmg Iwuse of another who employs persons to do maintenance,construction or repair work on such dwelling house
01, oti the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.1.IGL chapter 152. §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or pentlit to operate a business or to construct buildings in the comtrlunwealih.for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
lddiuunully. MGL chapter 152, as--5C(7)Mates "Neither the commonwealth nor any of its political subdivisions,hall
anter into anylontract for the performance of public work until acceptable evidence ul cumpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contructor(s) name(s), address(es)and phone number(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 foe confirnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
Ile teemed 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 Omclals
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of[Ile affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
I'I,:asc be sure to fill in the pennallicense number which will be used as a reference. number. In addition, an applicant
that must submit multiple Penn io'liccuse applications in any given year,need only submit one :iffclavit indicating current
policy intormation(if necessary) and under"Job Site Address"the applicant should write "all locations in Icily 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 filled out each
year:,Wherc 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 but leaves etc.)said person is NOT required to complew this atficlavit`. ..
iicc,,l Inwesttgatluns would like to think )ou in advallcc fur your cooperation and should yuu have,any questions,
please do not hesitate to give us a call.
ncc U.paruncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of lovestigatlons
600 Washington Street
Boston, MA 02111
Tel. 4 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.mas3.gov/dia
�y z WINDOWS CORP. J
1335 Main Street
Worcester, MA 01603
)98 Toll Free: 1-800-388-7998
0�S - gS-13 CO 268-6996 Tel: 508-792-1480 Fax: 508-792-1481
07 �: Job Order #: 6z�3
- — Telephone.
,;.ail e _ _ Fax:
Expected date of installation: '
_ Unit ` Total
Unit Size Price * e Cojor Price
b1 ' i Hpyo( fly% /Ag,-
)f�4aw
Tot Unit
a���" Tax .3V-ra
Wobd Molding ( ) Total 8 O
Cappingy� ess Deposit
Steel Caseinen[ ("" " I �
Night lock ( i Remaining Balance a� J
49
Brick to Brick " ( i * Includes screen and installation
* Invoices are to be paid within thirty days o1i issue. All amounts overdue will be
assessed finance charge of 1 1/zoo per month or 18% per annum. Customer agrees
to pay all legal fees and expenses associated with the collection of overdue invoices.
* The company has the right to withhold 5% of the contract price from the deposit
if the order is cancelled within 3 days after this contract is signed. No refund will be
returned to customer after the three- y period is over. (Screen warranty only i days)
CustomLer signature:`_ Company Authorized Agent
r dW /
Date., %"° Date: 5;Z - a
;{/�c-�nvrxrmm�nwall� a`�✓f�anan���neCQ -
g"A of iNldle4 ReBnlAtI0" a Standards - -
4 jkry„y- I HOME IMPROVEMENT CONTRACTOR{N...; -
i{ (� Reglatratlon: 13: ,
tlon: 51!!2009 . TA tiZ8J20435-
ExPira
Type: PartriMNP
" SUNSHINE WINDOW CORP. _
SENDAI CHEN '
145 EAST BERKLEY ST.
BOSTON,MA 02118 Ad1°lWnW
�Ia..achu.clr. - UCp:u-tmcnl of Public Safe,%
Board rn1 Buildim_ Rc�ydation, :rnd Standards
Construction Supervisor Specialty License
License: CS SL 99431
Restricted to: WS
SEN CHEN
1 ST GEORGE STREET APT-2B
BOSTON, MA 02118
�-� �•hJE Expiration: 10/4!2011
1 •.nnui..i.nmr Tr4' 99431
j 0 R
CITY OF SALEM
BUILDING LICENSE #2217
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