51-53 WASHINGTON SQ - BUILDING INSPECTION The-Commonwealth of Massachusetts
\ 1 r Department of Public Safely
I �. j - - \f.leo ch it,,'It,?tale Budding Lode(,SO C\IR)}ecen I E.h III
City of Salem
1 Building Permit Application for any-Building other than IN I-or 2-Family Dwelling
(rhis hcuon Fur ofha.il U,e Onlv)
Building I'ermtt.Nualb• : Dale Applied:
Building Impechrr
SECTION I: LOCATION(Please indicate Black t and Lot s for locations for which a street address is not available)
51- 53 ,d Ni--L1Ls �`1 om 4 i
IN and'Sceel lilt. /rotvn Lip Cade .Name of Building(a ippbcoble)
SECTION Z:PROPOSED WORK
It New Construction check here❑or check all that apply in the Iwo ruws below
------ -E"ticting-BmidinF O -Rrp:sir-❑ -Alteration-O -Addilkm13 mulilion�-(-1'aeax-fill.tut-aaci�ubntiFA}tprndix-14
Cha nge of Use ❑ Changeof Occup.tncy ❑ Other ❑ Spec:fy:
r Are bmlding pians and/or cur trnatiun documents being supplied as part of this permit applicanun? Yes ❑ Nu
Is an Independent Structural Engineerin•Peer Review required? - Yes ❑ No ❑
Brief Description of Proposed Work:iyHP.Ptpr CaZWI�i.11t;A got f?1CiYlnlnel Qa.ln'U"';" a.ed
9MQD Far Cs�t.WE•irUtz An
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
- CHANGE IN USE OR OCCUPANCY
Check here i/an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): f
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
Nu.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq. ft.)and Total Height(ft.) S 5001
SECTION 5:USE GROUP(Check as a liable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2 O H: High Hazard H-1 O H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I.1 O 1-2 ❑ 1.3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4 ❑
S: Storage S-1 O 5-2 ❑ 1 U: Utility❑ Special Use❑and please describe below:
Special Ilse, '
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ to IIAO IIs ❑ IIIA C3 -1118 13 IVO VA 13 VII
SECTION 7:SITE INFORMATION(refer to 780 CNR 111.0 for details on each item)
Water Suppiy: Flood Zone Information: Sewage Disposal:
rrench Permit: . Debris Reinoval:
Pubhc❑ Chcik it nulxde Fh+nl Zone❑ Indic.tte'"LU al❑
:\ trench will not he � Liirmcd Unix�..d fur❑
� rcyuovJ ❑ur Ircnch „r i•nnc.
I'ncale❑ , r utJenah Zone:_ or„n.dr•%,tem❑ i,ermd i.endnwd ❑ _
Railroad right-of-way: Hazards to Air Navigation: \r\ 1 L.n•n. i nnm-nm f'---
\rl \pl•Ip.ible❑ L (h'Ir act ica , nni'Icir.l•
.,, 1 n•cn( n. 11u d.1 cndo.e,l ❑ I l c.Cl .v\n❑ l.-'❑ ❑ .._�
S ECTIO.N 8:CON TENT OF CERTIFICA rE of OCCUPANCY
..1, . .__ L•c(.i,•ul•i.1 _ fil•c�gl•�ndnnll�n l lc Cu lean( I IN.]If For llw ._. ._..... _...
IIIc I•od,lu+ le in.tn IN 11 IN,ler?t.Icm' moi`.I is l�nl•u 1.1114 ln.
1
SECTION 9: PROPERTY OWNER AUTHORIZATION
13
.n i.l .\.Idn•s.of 1'rupurt% Owner
r tA�
\•one t1'rint) No.and Nrcet lilt , rutyn !ih
I Property t)..ner Contact Inlurmalton:
koniAf u sT ea I�Q}2,!M- 121 rte F Jl Gte l"C`�"
ride telephone No. (bu.mess) relephone No. (cell) e mad jddrv— -
ll.tpldiclble, the prupertt'owner herebv authonres
\'eine Mrcrl.\Jdrr>. lin'/Town Stole Z I V
w act&n, the aro pert%ow ner'•behalf• in all matters relatn'e to work authorized by the buddin • 'rrmt a + .he.uwn.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appindix 2)
tit huddin•is Les than 35,M)cu.It.ul rnduxJ.un•.uWPor nut under Control then check here❑a d k,f,\•.by 1 IU 1)
10.1 Rr istered Professional Responsible for Conlin%tion Control
Rvgistrmt rep one No.
a-m.0 a rens Registration Number
Street Address - City/Town State Zip Discipline Enpaadun Date
10.2 General Contractor
Cs pan
me:
uA��1;o nAatA'ri+�e oC
Name u(Perwn Responsible(or Construction License No. and Type if Applicable ���•'�
13 94W
Str t Address City/Town State - Zip
Telephone No.(business) Telephone No.(cell) - e-mail address
SECTION 11:WORKERS'COIAPENSATION 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 O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building f Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=f
3. Plumbing $
d. Mechanical (HVAC) f Note:Minimum fee=-f (contact municipality)
5. Mechanical (Other) f Enclosecheck payable to
6. Total Cost f �_ lamlact munici alit )and write check numb•r here
5ECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Hventering my name below. I hereby attest under the pansand penalhes of perjury that all of the information omuiined in this
.tpplicalum o true and accurate to the bast of ms• knowltdge.tnd underdandmg.
-IMU►2110 I�/��2�[lcn,�. - r2 20z�3�P�_
-!7Lprnnl ,n.l •ipn n.nnr (ltt:7otsfn .rte itly 1
F�� �/} /�WIX'ut9o•2tol:�q fele .h. ` \ii I)atr
�u rot 1J.1�•.• - �
/.
- Municipal Inspector to till out this section upon application approval:
ne f/
January 26, 2011
Dear Tom,
The undersigned Owners of 53 Washington Square North authorize William Wharff and
or his General Contractor to apply for and receive any and all permits required to
begin, continue and complete the previously approved 3-unit demolition and
renovation of 53 Washington Square North.
Thank you,
Paul P. S a Date
/f
Robert Marcey D to
9 �hissadmsetls - Department or Polioafet}
Bna rd of Builditi° Rc_ulatum.. :uul $
Construction Supervisor Licensetttd.trd.
License: cS 82584
Restricted to: 00
DIONEI DASALVA
12 PORTER ST '
a+'
EVERETT, MA
02149
t Expiration: 11/18/2017
nuuisinncr
Tr..: 9254
t7 _ Office ofCopsamer A�roiurc l�� a�✓l "°e�,x
HOME IMPROVEM 81rs&Bosfaess Regulation
Re9Strattoi n:. ENT CONTRACTOR
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EXPlration _11/8/2(171
TYPe Ina' . Tr* 290388 -
rvdual
DIONEI DASILVA - -
DIONEI DASILVA _
729 A WILSON RD
NAHANT.MA 01908
AcoRa CERTIFICATE OF LIABILITY INSURANCE DATE(MUDoYYYY)
`� 9/17/10
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endomemeaL A statement on this certificate does not confer rights In the
certificate holder in lieu of such endorsement(s).
PRODUCER
NAME:
Margaret M Lapre Insurance Agy PNDNE (617) 278-9844 FAX N (617) 731-2443
16 Lebanon St D
ADDRESS:
Malden, MA 02148 8172
INSURE )AFFORDING COVERAGE NAIC0
INSURED INSURER A:WESTERN WORLD INS. COMPANY
Four Seasons Construction, Inc INSURER B:GRANITE STATE INS. CO.
13 Frye Street INSURERC:
Marlborough, , MA 01752 INSURER D:
INSURER E:
INSUREt F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED 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 ANDCONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE OF INSURANCE AWL SUER F POLICY EFF POLICY EXP
INSR POLICY NUMBER M=N MMAIOYYYY UMrrS
GENERAL W1aUTV EACH OCCURRENCE $ 1,000,000
A X CONMERCIALGENEPALLIABIUTY 8279908 8/21/10 8/21/11 DAMAGE TO RENTED $ 50,000
CI-AIMS-MADE OCCUR M=D EXP(AM one peen) $ 5,000
PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2.000.000
GEN'L AGGREGATE LPAITAPPUES PER PRODUCrS-cOMP/OP AGG S 1,000,000
POLICY PRO- LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMB
(Eaamdert) $
PNV AUT° BODILY INJURY(Per person) $
ALLOWFEDAUTOS BODILY INJURY(Per a deny $
SCHEDULED AUTOS
HIRED AUTOS PROPERTY DAMAGE $
per
era¢smid itlem)
NOWOWf DAUTOS $
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE
RETENTION $ $
NORKERS COMPENSATION —
WC STATU- OTH-
AND EMPLOYERS'UABILITY
B ANY PROPRIETOR/PARTNERIEXECUTNE YIN WC-02-749939 8/21/10 8/21/11 EL.EACH ACO DE Nr $ 1,000 000
OFFI(ERMIEMBER IXCLIDED? NIA
(Mandawry In NH) EL.DISEASE-EA EMPLOYE $ 1,000,000
UseUse,describe under
,
OF OPERATIONS below E.L.DISEASE-POLICY LIMB $ 1,000,000 000 000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Renerls Sdmdule,amore apace is regrired)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORID REPRESENTATIVE
MARGARET M LAPRE
0 1988-2009 ACORD CORPORATION. All rights reserved.
CITY OF S.U.E.NI, %L-1SSACHUSETTS
• BUItDIING DEP.ARr.t&NT
' 130 W.IMLYGTON STREfiT, 3 °ROO&
TEL (978) 74S-9595
FAX(978) 740-9846
tClSBERLEY DRISCOLL
NMAYOR THo.+us ST.P>ERas
DIRECTOR OF PUBLIC PROPERTY/BCILDLYG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit# 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
I 11, S 150A.
The debris will be transported by:
J(name of hau )
The debris will be disposed of in
t
(name of facility)
(address of facility)
gnature of permit applicant
date
lebnvif d,w
CITY OF SALEM
` PUBLIC I ROPRERTY
arta ?y, Ir� �
DEPARTMENT
.iue:M:1'Y:)AM 01 I.
I2,^.WAii-IL x;IV\51xEL•T •SAuas,M.WS\Cl 11 it.I 1 u197.
97&743-9595 • f.xx.97H-740-9S46
Workers' Compensation insurance Affidavit: BuilderstContracturs/Electricians/Plumbers
\nnlicant InformationPlease Print Leeihly
N tAITIC illudlwssit)rg3nlratiorvindlvlduu4CC: 7W , 5 (1466,�,
Address: a iVG I—
City,stalci/.ip: la4Z Thune i/: 500 �24 3037--
:\,,r.,e(You ern employer!Check the appropriate box: 'Typo of project(required):
1.U I are a employer with I( 4. El :un q general contractor and 1
� G. [3 New construction
engaloyces(full and/or part-tune).' have hired the sub-contractors
_.C3 am a sole proprietor or partner- listed on rhe attached sheet. �• C] Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working liter me in any capacity. workers'comp. insurance. q, ❑ Building addition
No workers'comp. insurance 5. ❑ We are a cotporation and its
required] of icers have exercised their 10.C:] Electrical repairs or additions
3.❑ 1 um a homeowner doing all work right of exemption per NIGL I L❑ Plumbing repairs or additions
myself. [No workers'cutup. c. 152.§1(4),and we have no 12.❑ R of mpalrs
insurance required.) r employees. [Ko workers' 13.❑Other
comp. insurance rt yuired.]
•Wiry:,,phcaoa that checks box al muss alba rill uut the wcuou below showing their w•urkui cumpenwiwo pulicy inrlunmtion.
'I lumcuwnen who stitimil this anWavir indie:uing they arc doing all wart agog dwn hire outside cutaxton must.uhmil a new atfdavil indivaing umh.
d"omrwtoav oral chuck this box mime mtachsd an additional shcel ehowinitthe pante of the sub.omrxtors and their %urkee'comp.policy information.
/aero un erupfoyer that Ls pruvidiu,K warkers't•onrpen.mtion iasuranre jar ray eurplopeer. SeMry is the pulity mu/job.rife
iufurueation.
IrtsuranceCompany Name: r
Policy A or Sclf-ins.
�L'ic.t!:U)C- 1- a71�. Expiruuon Date: 8121 �11 II
Job Si(c Address: ►sit i Cityi5tate/Zip:5d6a M�
Attach it copy of the workers'cumpenra ion pnli y declaration page(showing;the policy number and expiration date).
Failure to secure coverage as required under Seaton 25A of NlGL c. 152 can lead to(he imposition of criminal penalties of a
tine up ht 51.5110.00 and/or one-year in,prisulunent, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up u))250.00 it day agalni,l the va)lahX. lie advised that a copy of this si Relent may be lorwafded to the Office of
Invcallgaunns of the UTA for iosuruxe awcra�e �crilic.11iun.
I do hereby certify antler die pains and penuhicv ofiteritery that the information provided above is true and correm
--
Data
tii �nauoa: j
Ph�,i:c :, SOB i�23Y'ICMJ
Official ase only. Dd not tri-he in this urea,to be completed by wiry ar teucn o/Jirial.
City ur Tnwn: -_ _ Permit/lAcc ise 4,
Issuing Aulhurity (circle one):
I. Board of llealth 2. Building Department 3.City(fonu Clerk 4. Llectrieai Inspector 5. Plumbing Inspector
6. Other
Cuutacl Penult. - I'hmtc#:
Information and Instructions
.Massachusetts General Laws chapter I j2 requires all employers to provide workers' compensation for their employees. ,
Pursuant to this statute, an empforea is defined as"...every person in the service of another under any contract of hire,
e,tpress or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or tither legal entity,or any two or more
,it the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of :un 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.thefissuance 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, :\,IGL 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 compliunce with the insurance
requirenicru of this chapter have been pieser-ted to the contracting authority." �^
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors)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 for confirmation of insurance coverage. Also be sure to sign and date(he affidavit. The affidavit should
be retumed 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 lino.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. -rhe 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 yuu regarding the applicant.
Please be sure to fill in the permitilicense number which will be used as.3 reference number. in addition,an applicant
that must submit multiple penniUlicmnse applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write:'all locations in (city 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. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dog iicense or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I be t)If ICC lit Investigations would mike io thank you in advance fur your cooperation and Should you have:my questions,
please du not hesitate to give us a call.
The Departmcnt's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OtHce of Invesdgadons
600 Washington Street
Boston, MA 02111
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
R;viscd i-26-0
www.mass.gov/dna