35 PALMER ST - BUILDING INSPECTION r,
�} The Commonwealth of Massachusetts
Department of Public Safety
1 i \Lusachuset State Building Code(780 COIR)So%enth Edition
Od 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 indicate Block# and Lot k for locations for which a street address is not available)
A
No.and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
If New in check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill outand submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specifv:
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: �e.��4 LP w—a �' ao rC� ,0 24 e••r
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 levMg
r Floor(sq. ft.) 3
Total Area (sq. ft)and Total Height(ft.) �} 0 0 O
SECGROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r O A-2nc❑ 4❑ A-5❑ B: Business ❑ E: Educational ❑Facto F-1 ❑ F2❑ zard H-1 ❑ H-2 ❑ H-3 O _ H-4❑ H-5❑nstitutional 1-7 ❑ 1-2 ❑ 1-3❑ 1-4❑ tile❑ R:-Residential R-1❑ R-2 O, R-3 ❑ R-4❑S: Storage SIO S-2 ❑ Special Use O and please describe below:
$pedal Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 118 ❑ 1lIA ❑ (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:
PP Y
Public❑ Check if oubide 1-1uud Zone ❑ Indicate muninpal ❑ A trench will not be Licen.ed Di,pozal Site❑
PI I%,I to❑ or indenlifc Zone•:_ or on .ite,%,tem ❑ required O or trench or.peCIt%:
permit is enclosed ❑ _
Railroad right-of-way: Hazards to Air.Navigation: \I;\ I li,h nr t',•..... om R••.e o l'n ,,..,
Nut :\ppliC.d+lr D I, tit ru Cture�C rthin airport appn aiih arra' I. Theo rrc ic%% C�nnpleted,
, r l nn.cnl to Rudd rndn,rd ❑ lr+ ❑ ur No❑ lr> ❑ Nu ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
C.iiliun ul l-,aic: -_ C,r(;rnupi.l: Fe pe of Cnn1truCtl1)I1: OCCupant Mad per Fluor
1 lnv, the building cuntdm an}prinkle•r tie-,tcm': _ Spraal Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of 1,Ic rty Owner .� A-^e `1 MA� 024 S
Name(Print) No.and Street City/Town ZAP
Property Owner Contact Information: 1 �� •��—
Title Telephone Nu. (business) Telephone:V o. (cel4 e-mail address
If applicable, the properh'o%%nen hereby authorizes
Name Street Address City/Town State Zip
to act un the ,n, erh owner's behalf, in all matters relative to work authorized by this buildm6 permit application.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 350)0 cu. ft.of vndos�d s cava and/or not coder Construction Control then check here O and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
16 /® 39P
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
/�n�/ nr �.�9✓iS
Compo
1 � _ ✓a �
Name of Perso Responsible fur Construction License No. and Type if Applicable
.✓// nN 5 r ` 7¢0- J yH h h-xF} 619 0?-
Street
aStreet Address City/Town -State Zip
Telephone No.(business) Telephone No. (cell) - e-mail address -
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c.152. 25C(61)
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 $ 1, 2-00 Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor) =$
3. Plumbing $
Note: Minimum fee=$—(contact munici a ty�•
4. Mechanical (HVAC) $
5. Mechanical (Other) $ Enclose checky.p.a ible to
6. Total Cost S (contact municipality)endZarite check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained m this
application is true and accurate to the best of my knowledge and understanding.
Plea,e print and >ign name title Telephone No. Date
� reel .Wdren� C`i Tuwn >ta to Zip
Municipal Inspector to fill out this section upon application approval:
b� )v /V (7
CITY OF S.U.Emli NL-�SSACHI;SETTS
BCILDLNG DEPARTMENT
p• 120 WASHINGTON STREET, 3'FLOOR
TEL (978) 745-9595
F.JLX(978) 740-9846
KIN(gFRi FEY DRISCOLL
,MAYORDI THoams ST.Pmm
DIRECTOR OF PLBLIC PROPERTY/BCILDLNG CO\LMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
slams: (Busing Orgjnizstion;Individual): d� vv —k)A.� s S
Address: ( ( G r,,,'t
City/State/Zip: LY,,v. M A O O 2 Phone
Are you an employer?Check the appropriate box: Type of project(required):
I.0 I am a employer with 4. 0 1 am a general contractor and 1 6. 0 New construction
employees(full and/or pan-time).• have hired the subcontractors
2.0 1 atm a sole proprietor or partner- listed on the attached sheet : �• 0 Remodeling
ship and have no employees These subcontractors have S. 0 Demolition
working for me in any capacity, workers'comp. insurance. 9. 0 Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its I O El Electrical repairs or additions
required.] officers have exercised their
3.0 1 am a homeowner doing all work right of exemption per MGL I I.0-Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12,0- Roof repair
insurance required.]t employees. [No workers'
comp. insurance required 13.0 Other
Any applicarn nue chwita boli•1 must also fill oul tha=Jim below sbowing their worker'curnpenation policy infumulim
'I h+mauwnm who tulmut this affidavit indicating they us doing all work and then him omide co a mio s must ohanil a new affidavit indicting such.
:C.mtranan that cheek this box most attached an additional siren showing the name of the arbavntrctors and their wort m'Wisp.policy infurr mart.
I am an employer that Isproviding workers'compensation insurance jar my employees. Below Is the policy and Jab std
information.
Insurance Company Name: W6
Policy N or Self-ins. Lic. N:_ VVC- 679 "? Z ZZ Expiration Date:
Job Site Address: 3s; pal,, S f City/StaLe/Zip: s:., 2 v
Attach a copy of the workers'compensatlos policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 132 can lead to the imposition of criminal penalties of
Fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Invcstlgatiunn ol'Ihe DIA for insurance coverage verification.
I do hereby Terrify ander th pains r peau es ojperJury that the injormadint provided above is true and turret[
riot a I ire' Date.
phonc,Y:
Oficial ase only. Do not write in this area,to be rumpleted by city or town nffe'iaL
City or Tuwn: Permit/I.icemle N
Issuing Aulhority (circle une)t
I. Board of Ileallh 2. Buildinu Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Impeetor
6. Other _
I
Coatact Perron: _ _ _ Phone N:
.1
.1/EB i00�JvlROfuG�eafU�i A � .
Board of Building Regulations and Step nndarita,
HOME IMPROVEMENT CONTRACTOR
ReBiatraUort: 161039
ExPIratibm- 9/22%2010 Trill 275171
Type: DBA
MULLIN'S&DAVI&,-f-j.K<_.,. .3•' .
JOHN DAVIS !'
X111 GRANT ST APT 4
I LYNN MA 01902 - ',dministrator.
AMERICAN
INTERNATIONAL AIU HOLDINGS
GRI OUR
INC. Specialty Workers Compensation Group
INVOICE
Invoice number: 890000064137 Billing Date: 05127/2009
For billing inquiries call: (800)645-2259
Email SWCSupport@AIG.com Page 1 of 1
CUSTOMER NUMBER 1022711080 producer:P0071991
Billed to: 1022711080
01140
CLUETT COMMERCIAL INSURANCE AGENCY INC
JOHN DAVIS 8 PEMBROKE ST
111 GRANT ST.,APT.4 KINGSTON, MA 02364-1109
LYNN,MA 01902-3566
Please contact our roducer for an uestions re amino your policy
w r AMOUNT BILLED ON THIS INVOICE
I'MF�'iE'1`?i'°'ti 4:#0'R`+x ~ -:sq' 'tt1 - {
j iA) 't z^. sic (6) °.�.m'$.. r'a.l?IG) WiID)x >a�#' ,;;s CURRENTLY BiCLED Y a
`.xar<:.,.x`4�.� fr 'at `'af=' `xv' �+t'w= . o s a;'-.,`"'iP TOTAL POLICY h xPREVIOUSLYBIL(EO tt -. H
r� s K "p c $ ��.,`• G) , � r4, (
` ` *""' 7} , q Fl� 'RECEIV Ox?CHAROE t {BO.DATE`, Due Date r- ;Amount ,Due Uae a _ x+�?�ubunt :?
AFTEMS.r ,POLICY- ,�, `"'
06/26/2009 858.00
DOXNNPAY WC 6789222 0.00
AMOUNT DUE 0.001 858.00
Account summary through
Please pay either the amounts in(E)or(1) TOTAL POLICY PREMIUM 7,463.00
Balance(G)must be received by due date shown
or immediately if past due,or your policy will be TOTAL PAYMENT RECEIVED TO DATE 2,250.00
subject to cancellation. TOTAL REFUNDS 0.00
FEES BILLED TO DATE 0.00
CURRENT BALANCE 5,213.00
Protect your msutance`by metlmg each Installment 1n sufficient tell-to errors on or"6etore due date ' :w
. t, �" * x Ma ''�„ a �,, , Thank you So'r Msurirtg wrih Amencan intemaEfonal C Smpanp,
Vit" a tp VJSit www.a7gswc corn tG learn about receiving elactronlc ca/5tas bf invoices and'schetYuiit}g paym_emts online '
RETURN PAYMENT COUPON BELOW WITH YOUR PAYMENT DO NOT SEND A PHOTOCOPY
' ' OICEO �t�' �(a AMOUNT DUE'C7�TAIL�ABOVE� PANIOUNT ENCL03ED
u+..'.., u+"a.rte,zal+.aaraae +.:�-- eros _.,..,'—�•• 858.00
890000064137 1022711080 WC 6789222
CHECK HERE IF YOUR ADDRESS HAS CHANGED AND COMPLETE FORM ON REVERSE SIDE
_ CHECK HERE IF YOUR POLICY IS FINANCED AND ADVISE US IMMEDIATELY
SEND PAYMENT TO: SEND CORRESPONDENCE TO: BILLED TO:
AIU Holdings AIU HOLDINGS JOHN DAVIS
22427 Network Place Specialty Workers Compensation Group '111 GRANT ST.,APT.4
Chicago, IL 60673-1224 PO Box 409 LYNN,MA 01902-0000
Parsippany, NJ 07054-0409
INSUREDS COPY
013 00000000890000064137 06012009 0 00000000085800 7
CITY OF SALEM
;j ys ,
PUBLIC PROPRERTY
1/f
DEPARTMENT
I I I '/•9.'4;_'1 Ii I \C 'i_g 1: ''ilo
Construction Debris Disposal Affidavit
occiiiired fbr all demolition and renovation work)
In accordance \k iilt the sixth edition of the State Building Code, 780 CMR section 1 1 L5
Dcbi is, and the provisions of MGL c 40, S 54;
Building Permit K is issued with the condition that the debris resulting from
this work shall he disposed of in it pruperly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The dchris will be transported by:
�ca.ST �OQ3T �IS P a S'A '
lnamc ul hauler)
the debris will be disposed ot'in
(nalnr ul laclhty)
taJdrc.. nr Iac 11i1v)
Dr, _C5-�
NLIIu1ulc .,t 1):[11111 .11g111ca fit
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