3 PLACEEASANT ST - BUILDING INSPECTION (3) �- The Commonwealth of Massachusetts
f
Department of Public Safety
'w-,..✓ MaSSJCh115C111 State Building Code(780 CMR)Seventh Edition
City of Salem
y'
Building Permit Application for any Building other than a 1- or 2-Family Dwelling
yIJ (This Section For Official Use Only)
Building Permit Number: Date Applied: O Building Inspector:
SECTION 1: LOCATION (Please indicate Block p and Lot If for locations for which a street address is not available)
.No. and Street City /Town Zip Code Name of Building (it applicable)
SECTION 2:PROPOSED WORK
• If New Construction check here❑or check all that apply in the two rows below
Existing Buildin Repair❑ Alterations Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use Change of Occupancy ❑ Other ❑ Specify:
Are building flans 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:
K�NW MID G p
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Checkhere if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) [3Existing Use Group(s): Proposed Use Group(s): g
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
-
NExisting Proposed
No. of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sI eft.)and Total Height(ft.)
4 SECTION 5:USE GROUP(Check as applicable)
A: Assembly(A-1 ❑ " A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5 O B: Business E: Educational ❑
_F: Facto F-1 ❑ F2 13H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1:'Instltut*onal 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 ❑ 118 ❑ IIIA ❑_ IIIB ❑ IV ❑ VA ❑ VB
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: information;Flood Zone Infoation: Sewage Disposal: Trench Permit: Debris Removal:
Public ❑ Check if uuL ide 1-1nud Zane❑ Indicate muniCipal El trench will not be Licensed Di.posal Site ❑
I'rI male❑ ur umdentifc Zone: ur un .ite,%stem ❑ rrt•quired ❑or trench Ir.puafm-
permit i*cnd0led ❑ _
Railroad right-of-way: Hazards to Air Navigation: �I:( I li>h m,t nuni..nm Iv circ Pry
N..t \hplic.dde I.tifruCfure lhm aoput approaCh are,l' I. Theo rem-lumc cnmplvtud'
• r l um"nt I.. Build untlu"Cd ❑ 1"c. ❑ t,r No 0 1'c. ❑ \u ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
L.iWnnid ( ,dv: ---- L.v(.ruupl.l: Cm �C of Con,tniction: )
. F l ciupant Lund per Iluur-
1), the building cnntaom an }prinkler Scaem.': >puaal Stipula Guns
UGU �M'I'i �lwvov7� S
r
SECTION 9: PROPERTY OWNER\AUTHORIZATION
iy
I Ind Addre.. a Pntpertt• Owner ��� /)r ' \OJ Le M 1
7e. �.e^ I WUV�
Street Cih'4Tuwn Lip
.1�antr(Print) � 10.and :beet J 1
11(y,rhlAvnerContactInformatmrl.�j /�a �.-. d� Sj �j CSV .\ Q–e—g4f✓�l �,a)��1/1
Title Telephone No. (business) Telephone No. (cell) e-mail address
If ap ,liiablr, the tpya�t\ owner hereby authorizes
C h � r r Q n a, y�,�M�� 5 1 rn+l m,- o�9ys
1
Name Street Address City/Town State Zip
to act on the prorem owner's behalf, in all matters relaliye to work authorized by this building permit a >plication.
SECTION 10: CONSTRUCTION CONTROL (Please fill out Appendix 2) - "i -
(If building is less than 35,1MO eu, fl.of endured s pace and/or nut under Construction Control then check here O and k,,Section Ill.l)
10.1 Registered Professional Responsible for Construction Controls ^�/ f
�JL-Ot- 37� S•�l� �JSe A)
a7(Rr•o�nt! < � IT^e^41 one No. e-mail address, Registration Number
Street Address City/Town State Zip Discipline ' ! - Expiration Date
10.2 Generall Contractor
CCLJct /`�V^SkW
C s
C}�mp�a ny Na me: I C� / 3� t.
Cc�nPS� �.� ``tJ\Ann
Name of Person Responsible�>rrConstruction M�6P-Q.,
'p�L�nse No. and Type if Applicable C���
o`Z.'7 V1nd MJkv F1
5StreetAddre7TZ _ - � City/Towna1State zip
Cot -
re � � -@P41,.,r
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11: WORKERS'COMPENSATION 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 emit,
Is a signed Affidavit submitted with this application? Yes❑ No ❑ _
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6) _$�o Q5,
1. Building $ 10 Building Permit Fee=Total Construction Cost x ) (insert�he�r�e I;k (
2. Electrical $' a^. - Q�d appropriate municipal factor)_$ OVQ l
3. Plumbing $ ocU QOd
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipalit �^
S. Mechanical (Other) $ Enclose checkY'P'i ible to tJ
6.Total Cost $ a S QC)0 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Bv enteringmy e below, 1 hereb • test der the pains and penalties of perjury that all of the information contained in this
a. Mica tion is t ie an 1 Accu rate tto lh e. t o v knowledge and understanding.
�o V/? �n 0�h�Y 7%� �3
I'Ica.e +nnt and .ign lame � �1 itlr � Tcln�one \o � Date
Ktrrcl :\.1.irc.. Cite;Totcn ;tate (ziip
Municipal Inspector to fill out this section upon application approval:
\time I ate
a
CITY OF SALLM
J
;t• ..,: PUBLIC PROPRERTY
DEPAIZT�IENT
Construction Debris Disposal Affidavit
(required Ibr all demolition and renovation work)
In accordance \\ith the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit It 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 150A.
The debris will be transported by:
t
I name of hauler)
The debris will be disposed of in
v r��.L4
(name W racilny)
So"1e-W, MASS
laddres. ul Iacllilvl
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>las.achuset.ts- Dcp:troften I of Public Sareq. `.
9 Bnitrd ul' Builtlin_ Rculations.and Standards
=�'�: ConstructionSupervisor License - --
License: CS 49371 „„ i
Restricted to: 00
ROBERT P SULLIVAN JR
27 NORMAN ST
MARBLEHEAD, MA 01945
Expiration: 6/5/2010
t „nn;i..inrr Tri 28193
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Board
anvnwnmea o�✓lfaa,¢�/auk
- -\ Board of Building Regalatiooa and Standards
HOME IMPROVEMENT CONTRACTOR 'i,]
a Registration: 139971 .)
Expixpiration: 9/8/2009 Tr# 261842
Type: DBA'
SULLIVAN CONSTRUCTION
ROBERT SULLIVAN -
27 NORMAN ST.
MARBLEHEAD,MA 01945 Administrator
4
CITY OF Sa71.1.1Yi, %LkSSACHUSETTS
BULDING DEP.kim E iiT
\ tae 120 WASHIAIGTON STREET, 3'o FLOOR
'ISL (978) 745-9595
FAX(978) 740-9846
KI,IgFRi FEY DRISCOLL
T
MAYORDR Hosw ST.PtEm
DIRECTOR OF Pl BLIC PROPERTY/St;MDLNG CONMSSIONER
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers
Anpllcant Information atse {A,\ Pleals[e"Print Legibly
Nalne tnusinc�&Organizalion,Individual): a AMoose ! h(-,)
Address: a —7Ko r r^Arc\. r4
City/State/Zip: MAC'h"f-A+ - rAA Phone #: 7kl I!�3 t 37&7
Are you an employer?Cheek the appropriate box: Type of project(required):
1.W1 I am a employer with-#- - 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).• have hired the sub-contractors
2.❑ 1 atm a sole proprietor or partner- listed on the attached sheet : 7• ❑ Remodeling
ship and have no cmploycea These sub-contractors have g. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑Building addition
(No workers'comp. insurance S. We are a corporation and its 10. Electrical repairs required.] officers have exercised their ❑ pairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. C. 132,§1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. LNo workers' 13 ❑Other
comp. insurance required.1
'Any applicant[him checks bon sl must also rill out the sistuao below showing their woroco'compm cion pulley infumstion.
I I hvneuwnen who submit this aRldsvit indicting they are doing all work and then hiss outside con oin must submit a new affidavit indicting such.
4%,m anon thal check this bol[must anachod an additional shsel showing the name of the sub mnoam and their wariness' ,ump.policy information.
I um an employer that b providing workers'compensadon Insurance jar my employees, Below is file policy and Job rile
information. -�
Insurance Company Name: 6L-)0,T-(A- 7-ii scio(AC"it,
Policy N or Self-ins. Lie, d: �-j+`�'`� y4 ( 7 Expiration Date: 3/t d �r
Job Site Address: �1 '.�5�n City/stake/Zip: 5 A,Itis- MA, of q I a
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration tate).
Failure to secure coverage u required under Section 25A of MGL c. 132 can lead to the imposition of criminal penalties of a
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 5250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations ul'thc DIA for insurance coverage verification.
I do hereby certify wider the�Vithits�/I dd pem/der ujperJury that the in/armatlan provided above is true and correct.
Phone A:
Oficial use mdy. Do not write in rho area, to be cuntpleed by city or town official
City or Tuwn: Permit/Llcense M
-- - - - — —
� Issuing.\uthurily (circleunc):
I. Board of Health 2, RuildinL Department 3. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Persoo: _, -_ _ __. _ Phone#:
, From:RSC Insurance Brokerage 781 863 4420 06/15/2009 09:32 #363 P.001/001
AC-M. CERTIFICATE OF LIABILITY INSURANCE DAY 4 2'° E°200
PRODUCER (781)986-4400 FAX: (781)963-4420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
aes Com ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Risk Strategies Company HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
15 Pacella Park Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Suite 240
Randolph 14A 02368 INSURERS AFFORDING COVERAGE MAIC t
INSURED INSURERANGPS Insurance COmpan
Gashouse Ino, DHA: Sullivan Construction INew1EmWorGaard Insurance Cc
27 Norman Street INSURERQ _
Marblehead MA 01945 INSURER e
THOLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY 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.
- I MITE;EtHom Mhy SEE 4 REDUCED BY PAID CLAIMS CY POUCYE7WR11TION
INBR AOWL TYPE OF HISURAMOS POUCY URBER D LIMITSj=IBM .
GENERAL LMEUTY 1,000,000
% UIL GWBN lury - 10�N1® N 500,000
A CUUNs MADE OCcUR W093105 10/9/2008 10/9/2009 B 10,000
1,000 00GENE AGOREGATE 0
2,000,000
GEN1 A6OREIM7E APPLIES PER 2,000,000
LIAT
T Mint
AUTOMOBILE UA®.T' COMSINEOSINGLE MIT S
(Fa wncVO
ANY AUTO.
uyONMEO AUTOS 1300ILY09AIRY S
IPE Pews
SGNEDULEDAUTOS
HIRED AUTOS - (PW SO L1�INA� S.
NON )VOIFDAUTOS .
PROPERTY DAMAGE S
(Pareails�O -
OARAOB LIABILITY AUTO ONLY.EAACCIDENT S
ANYAUTO OTHER THAN
AUTO ONLY: AGO
BYOES&%M WULIA LIASNJTY
OCCUR MClAM1 MADE AGGREGAM
S -
OEDUCTMLE
DTH
$
WORRIERS GOISENMTON AND Bob Sullivan, President
auqxwaw LIABILITY ANYPROPRIETORVARTNEtIE�CUTNE Included in CNrvera9e H C 500,00
OFPICERRAEMSER EXCLUDED? SUVCD19174 12/3/2000 12/3/2009 E S 500 000
NymdwwvlbePNw S 500,000
onIIOT
018DEPRON OF oPSRAMONSROGTIONW HMLEWEICLUWJMM ADDED BY ENDDPBEN nWECULL PROVISWNs
Ianced as evidenda Of in9=800a
CERTIFICATE HOLDER CANCELLATION
SNOFO.O ANY OF THE ARM DBBmemD POLNNBS BE OANCEU.iD OMM THE
EVIDENCE OF INSURANCE MMPAIMM OATS THEREOF, THE WHRNIM INSURER WILL ENDEAVOR TO MNL
10 DAYS wFurnm NOTICE TO THE CERTIFICATE NOUM NAMED TO THE LET.BUT
FA&URE 10 OO so SHMLL eFc=No OSUGATNNN OR UA131UTY OF ANY FOND UPON THE
INRURM ITS AGENTS OR RBPMMMT VM&
AUTHOR®RBPRESSNTATM
Michael Christian/SNS
ACORD 28(2001108) ®ACORD CORPORATION 1988
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