The URL can be used to link to this page

1-36 SETTLERS WAY - BUILDING INSPECTION 451°° c� c�go The Commonwealth of Massach,>�I fy- Department of Public Safety t E �fj e Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a A� "Fa it D ening (This Section For Official Use Only) Building Permit Number: Date Applied: BuildingOfficial: © lho —"' SECTION 1:LOCATION (Please indicate Block#and Lot#for locations for which a street addres not available) n 1`30 S�Iffl.QIS Gbh 5e,� r:iSS OlY6G (L�l s CdKi �+claw�.t�t✓wl Vt No.and Street City/Town Zip Code Name of Building (if applicable) SECTION 2:PROPOSED WORK Edition of NIA State Code used If New Construction check here❑ or check all that apply in the two rows below Existing Building❑ Repair j$' 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 requ+�i}re�d? \ II Yes ❑ No Brief Description of Proposed Work: `y-e_ I LW� G'vc fi ¢Y �J' ✓c. — -e d e la to\o" v�S SECTION 3: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): 77roposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(inehIde 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-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Factor F-1 ❑ F2❑ 1H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ I-2❑ 1-3❑ I-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 ❑ 1 IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information:�.,r Sewage Disposal: Trench Permit: Debris Removal: Public K Check if outside Flood Zone W Indicate municipal-K A trench will not be Licensed Disposal Site-' Private❑ or indentify Zone: or on site system ❑ required l(or trench or s�ecify: k/N& permit is enclosed ❑ �!S e ya� Railroad right-of-way: Hazards to Air Navigation: A9A Historic Commis_i.nn_R�_v_lcwPrgross: Not Applicable- Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed ❑ Yes ❑ or No 2C Yes ❑ No SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY - Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: 1 Z SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 6-Atot (ove, �i.. AaAt t�,&o 1-37 jz-*Lus j/1y-Ss" 19ZVdd Name(Print) No.and Street City/Town Zip Property Owner Contact Information: n In� So?- ZsY 1 y7 Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes / t awas rJlw �S �Qi11/L 0LJe_ Ve✓ ll Ma$ 01 ?15 Name Street Address City/T wn State Zip to act on the 2ro2erty owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu. ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section"10.1 10.1 Registered Professional Responsible for Construction Control `✓ lJ;� YStiC5--07T60p Name(Re ist ,nt) Telephone No. e-mail address Registration Number S'J/Uf.✓J-Gfn-F WW nPn�ciOl.( NM� r?U0 GS I� Street Address�� City/Town State Zip Discipline Expi ationDate 10.2 General Contractor Company Name �L!!HL S /mar✓�L2� Name of Person Responsible for Construction License No. and Type if Applicable StreetAddressCity/Tow/n� // � I/ �� //State �Zip -6,52- ?,Sd 1 - -� rutvrc.P&✓U&- 4007 Tx-� A 'telephone No. business Telephone No. cell e-inA address SECTION 11: lV0RKERS'COMPENSATION INSURANCE.A('PIDAVIT M.G.L.c.152.§ 25C(6)) A VVorkers'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 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ 11 W .Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ ,1. Mechanical (H'VAC) $ Note: Minimum fee=$ (contact mud ipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ S/J �4��_dv (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 and sign name Title "Telephone No. at j3 f i✓c✓rL J:c(, I eirf D15LS- Street Address Cit /Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date Collins Cove Condominum Association To: City of Salem Massachusetts From: Board of Trustees Collins Cove Condominums Re: Berube Construction Date: Sepetember 30, 2016 The Board of Trustees has authorized Berube Construction of Beverly Massachuetts to work on the buildings belonging to the Association located at Settlers Way in Salem Massachuetts. John J Finnegan President Collins Cove Board of Trustees 4 Settlers Way Salem, Ma 01970 508 294 1727 Finnegan.John@hotmail.com 07Y OF SALFJK MASSWASM BLEAliDAMXDA 1r 12D OA�XrRDM 711L�7S9995. ' g r Fes A"M MAIM DnasSUMM Dixecrna oF>taucr/ava� Construction Debris Disposo►/Aff tdhk* (required forall demolition andrrenovatfon work) In acc0rdma wah the skM edtthm of the Stift eumbg Caft 780 tf,Secow 11LS Allo and the provlstom 0f MGL 040,S 54;tag Penplt it tstssuedwsh the oundMon throbs debris res dit from this worhsha6 be dkposed of in a pnoperiy Amwed wasoedePwft facWtyas deMW by MGL c ill,S 15an. The debris will be transported by: DI 103°1/ (name of h84 The debris will be disposed of in: (name offacifity) MCSS (adof facility) Signature of applicant 2.94� 2916 Date \ The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: -77", UJ er-LI 1),.L, CC6 Address: IS" fl2 tr`v <tre� City/State/Zip: &.~ C rf Ot }" Phone#: Are you an employer?Check the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/EatingEstablishment 2.❑ I am a sole proprietor or partnership and have no -7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers'comp. insurance required]* 11.❑ Health Care 4.F1 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other -Any applicant that checks box#I most also fill out the section below showing their workers compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. 1 am an employer that is providing workers'compensCation insurancefor my employees. Below is the policy information. Insurance Company Name': 6ArWAA'+�-- S74 S� �� Sy��l�Q, QG.f.1.tWGG �G-• Insurer's Address: p" / �G {fwd it o—l, f City/State/Zip: KW-V 114 M C,55 /}061..5 Policy#or Self-ins.Lic.# ��h1 R-wx `-'u' Expiration Date: Attach a copy of the workers' compen ation 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$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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify, under nder the pains and penalties ofperjury that the information provided above is/true and correct. on S' ature: ; //r•,�hGets /�L.t / DaW b4/ 2.9 2-01-6 Phone#: '7V b,A-L —35-4'1 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do'maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please FII out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and,if necessary, supply your insurance company's name,address and phone number along with a certificate 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 for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned 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 Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary). 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.Where 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 www.mass.gov/dia Form Revised 02-23-15