60 WHARF ST - BUILDING INSPECTION 4
►. ', The Commonwealth of Massachusetts
1 Department of Public Safety
fl ./ \I,t..,tchu�alth tit.ur BudJml;Code l-80 C\IR)<rvenlh Ei6tlnn
v City of Salem
Building Permit A iilding other than a I- or 2-Family Dwelling
l Phis SraLon For Off ct.11 Use Only)
building Hermit Number: D.ne Applied: l9 Bwldmg Inspector:
SECTION 1: LOCATION (Please indicate Block s and Lot s for locations for which a street address is not available)
.No.and Street Ott' /To%,n Lip Cade ?lame of Budding Ir!.ipF+bcablrl
SECTION 2: PROPOSED WORK
I New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Allerahun W, I Addition 13 1 Demolition D (Please fill out and submit Appendix I)
Change of Use D Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or constructiun documents being supplied as part of this permit applicatiun? Yes No 0
Is an Independent Structural Engineering Peer Review required? �J���j•� .yam Yes ❑ Noit,
Brief Description of Proposed Wurk:
/a�4
—�
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) D '
Existing Use Group(s): g"4C-- - I Proposed Use Group(s):
Existing Hazard Index 780CMR 34: Proposed Hazard Index 780 CMR J4:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Propose
Nu.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.) 2
Total Area(sq.ft.)and Total Height(ft.) �X l
SECTION S:USE GROUP(Check as a licable)
A: Assembly A•1 ❑ A-2r ❑ A-2nc❑ A-3 A-4❑ A-5❑ B: Business ❑ E: Educational D
F: Facto F•1 ❑ F2 D H: HI Hazard H-1 O H-2❑ H-3 ❑ H-4 D H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4 0
S: Storage $-I ❑ S-2 ❑ U: Utility❑ .Special,Use❑and pleasv describe below.- -
SpecialUse:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 18 ❑ IIA ❑ (IBD IIIA ❑ (IIB ❑ 1 IVA I VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Sly: Flood Zone Information: Sewage Disposal: Permit:
Debris It emuvil:
up
i ,,,r A trench w 11 not be Licert,cd D"po..rl�il�
I'ublii Check il,nu.rdr Fl,"�.IGm' b+Jicrtr mumrry,al aC
required Ar trench ,.r.periic.. _
I'ncaty❑ ,�r mJcn hit Zone:_ ,.r..n.qtr�r.trm ❑ )•rrmrt r.enclu�rJ O
Railroad right-of-way: Hatirds to Air Navigation: \I \ Ili d, n, i ..,i„u,.-n•.,H,,,,,, !',.,
\,.1 \i)•L,dbh� L�Iru.luic+,nhm au')•url appuadtarv.r' Llhcir n•,is„ t,nn) Ic1,.i
. i 1 ,.n•rnt i,. liiold ond,wJ D I 1e,0 , r\„v l r.❑ \� 0 QJ ,,
SECTION A:CONTENT OF CERTIFICA fE OF OCCUPANCY
I ,lilnvt •Il „Ic _ .___ L-c l.rupnr _A- r.i,, •-IInm 46BQ -L-Z____ ___.
I L.r. Ihr Duddw,:,- nl,int in spnnAlet�,-.lent` _ ��prc.. ...n.
e
SECTION 9: PROPERTY OWNER AUTHORIZATION
\'.one.,n.l A.LlreaSol I'n q,crlr lhvnrr
\,one(Pant) No.and Street Ch , T.ncn Cip
Pn,perl% l/.u+a•r Contact h+lurmuuun:
9�
Mlle Telephone No. Ibustness) Telephone No. (cell) em,uI.IJJrv— i
I(appllc.dble, the pn,pvrty uc.ner heretw authorizes
N.Ime Street Addrees Cih'i Town Slate lrp
lo.io...i the m, pule.„ ,ner.behalf, m all ma(tern rola to a it,work,nn honer)by this bill l.bn • ,unit n pi,I tc.,I on.
SECTION 10:CONSTRUCTION CONTROL Wfease(ill out Appendix 2)
111 IvJ.hn•,s lo.than 1i,UlU.u.tt.ut vndovJ:+an•.uW/or nut m,.lc•r Gn+>In,chun C.mtnrl thcn check here❑an.f.k ,Svt,on to It
10.1 Registered Professional s onsible for Construction Control
Name(Registrant) rrlephune Nu. e-malladdress Registration Number
Street Address City/Town State Zip Discipline Expiralun Date
10.2 General Contractor
K
Company N e:
cs X7/7 �r
Nameof Perm)n R�msibl=sjuftiun �j_ f LicXnsr No. and Type ifApplicable p�/ 6}00
Street Address ity/Town State Zip
Telephone No.(business) Telephone No.(cell) a-mail address
SECTTON 11:WORKERS'COWENSATION 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? Yee O No ❑ °
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item b)_$
1. Building $ BuildinLEnclo.w
Permit Fee=Total Construction Cost x
f _(Insert here
2. Electrical appropriate municipal(actor)=f
3. Plumbing f
J. Mechanical (HVAC) f e:Minimum fee=f (contact municipality)
5. Mechanical (Other) f heck s tble to
f 67(” rQQP•y'nici alit )and write check number herr
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
IRv entering my name below, I herebv,tltest under the pains and penalhr.of penury that•dl u(the m(nrmohon -nt.uned ,n this
.+ppluauan t.,true.md accurate to the best.d my knowledge.md under.hmdmg.
iI'L•.i.r print .,nd •ign mimv Title
H,rcl \.hire.. CIt% Tonn Ufa tr Gt1/
( Municipal hispertor to till out this Seltion upon application approval:
,unr
This letter is to certify that the second floor of 60 Wharf Street, Salem,
MA 01970 (Jahn Coffee Roasters & Tea Merchants) will only be used as
an office, as stated in our application.
The unit will not be used as a residence by anyone because it does not
meet residential unit requirements.
Thank you,
Anil Mezini, Owner
Jaho Coffee &Tea
60 Wharf Street
Salem, MA 01970
978-223-8982
Massachusetts Jurat
Commonwealth of Massachusetts
l
County of�%�,Q,Sc 1 ss
On this the c� day of� -Ot9au-&L/j L7/D , before me,
Day Month Year
Da- L , the undersigned Notary Public,
Name of Nortary Public
personally appeared Zjl
Name(s)of Signer(s)
proved to me through satisfactory evidence of identity, which was /were
Description of Evidence of Id City
to be the person(s) whose name(s) was /were signed on the preceding or attached
document in my presence, and who swore or affirmed to me that the contents of the
document are truthful and accurate to the best of his / her/ their knowledge and
belief.
i
nature of Notary Public
-ID4Sa'-T)iA�2 P��i4i-lav
Printed Name of Notary
Place Notary Seal and/or Stamp Above My Commission Expires
DIANE SAS,
7ERESA Pub"r
1> NotarY scar. :.
Comm
OnN081th 0t Mas •;
CommisslonExPiresJunN . '
firm_Notary_Jurat Revised: 03/12/04
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\1]YUN 12-.WAGa MG l Os SIR UT •SAt E.M.M.W%.%CI n it I I N6197
1'r.t.:'778•F43-9i95 Is 1:%X.918.740.1846
Workers' Compensation Insurance :affidavit: Builders/Contractors/Electricians/Plumbers
li ) )licant Information Please Print Le ibly
V81netllu<incsvOrp,3nnir3rioNlndlvl(luul):
City,State,Zip- 1il'f 91 PC (o I'hone -1-6 22 52 7 3
:\re ou tut emjiloycr!Check the appropriate box: 'Type of project(required):
1.C3'1 am a employer with 4. ❑ I am a general contractor and 1 ' 6. ❑ New construction
�r�r{I enlpluyces(full and/or purbtinte).• have hired the sub-contractors 7. E] Remodeling
2..0X1 am a sole proprietor or partner- listed on rhe anachcd sheet.
These sub-contractors have S. ❑ Demolition
ship and haw no employees
working for Inc in any capacity. workers'comp.insurance. 9. ❑ Building addition
I No workers'cutup. insurance 5. ❑ We are it corporation and its 10. Electrical repair or additions
rc luircd.] officers have exercised their .
3.❑ 1 ant a homeowner doing all work right of exemption per MGL I I.[] plumbing repairs or additions
myself. (Ko workers'comp, c. 152, g 1(4),and we have no 12.❑ Roof repairs
insurance required.] r employees. [Ko workers' 13.0 Other
comp. insurance required.]
•bty upphcaA Ihut chucks boa Bt mull:dao till out she wcuou W.ow,showing?hvir w•orka%cumponsueiws policy intiunuriun
'l lumn,wmrs who submit this aflWavit indicating Ihuy ue doing ull workalttl drcn hire oueside culursnon must.uhmil a new alydavil indi"ing.uch.
-C',mtrwlurs Alai check this box mime anuhcd,m addiriunal ehect.hawing 1W name of the sub.omruton and their wurkm'comp.policy information.
I one un employer that is providing workers'compensation insurance jar my eneployees. Below is the policy and job site
information.
Imurance Company Name:___
Policy 4 or Self-ins.Lie.n: -._.. __._ Expiration Date:
lob Site Address: In C2 Vy&-,2CnyiSlateiZip:
Attach it copy of fire workers'compensation policy declaration page(showlnl;the policy number and expiration date).
Failure to sccuie coverage as required under Section 25A of>IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 and/or une-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of op m 5250.00 it Jay against the violator. Ile advised that a copy of this,i may be l'6'rwarded to the Oil tee of
Ins'esllgaunns ul the Uh\ Ipr insuru:ee coverage serilic.rtion.
I do hereby certify ander the paim'lord pemr(ries of perjury that the information provided �Ile and correct.
tiie:cunrc: __. . Date' 7 /
Ph e i �D S ?22, TL 73
O/fic•iul use only. Do not write he this area,to be completed by city or town official
City or Tatvie: __ _ PerniUlAcume
Issuing Authority(circle one): i
1. Board of llcalth 2. Buildiu". Department 3.City/fawn Clerk 4. Llectrieal luspector 5. Plumbing luspector
6. Otho
0,11lacl femme _. Phone 7:
Information and Instructions
\lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
i'unuant to this,utute,in employee is defined as"...every person in the service of another under any contract of hire,
cypress or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or titherlegalentity, or any two or snore
of the tbregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of:m individual,paimership,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."
.tIGL 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, NIGL 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 rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s),address(es)and phone nwnber(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 the affidavit. The affidavit should
he 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 u space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sue to till in the permit/license number which will be used as a reference number. In addition,an applicant
that mot submit multiple pennitilicensc 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 fele for future permits or licenses. A new affidavit must be filled out each
year. Where a hone owner or citizen is obtaining a license or permit not related to any business or commercial venture
f i.e. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
Ilse of I ICI'of Investigations would like to thank you in advance fur your cooperation and should you liave:uiy questions,
please do not hesitate to give us a call.
rhe Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. 11 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
i2;rincd i-26415
www.mass.gov/dia
60 WHARF STREET_ 580-09
cIS- a: X480 _ COMMONWEALTH OF MASSACHUSETTS
Map: _�34 i
Black: CITY OF SALEM
Lot: 10481
[Category: OFFICE FIT UP� D
iPeraut# 580-09 BUILDING PERMIT
[Project# JS-2009-001087
Est.Cost: $10,000.00
jFee Charged: $115.00
sa aance Due: $.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License: Expires
Use Group: _Gray Architects Inc.
Lot Size(sq. ft.): 1825.164
Zoning:
Owner. MEZINI ANIL
_ -- _-
;Units Gained: Applicant: Gray Architects Inc
Units Lost: AT. 60 WHARF STREET
Dig Safe#: 1
ISSUED ON.' 26-Feb-2009 AMENDED ON: EXPIRES ON: 26-Jul-2009
TO PERFORM THE FOLLOWING WORK:
CONSTRUCT 2ND FLOOR OFFICE(NOTE: BUSINESS OCCUPANCY ONLY NO RESIDENTIAL USE ALLOWED)jhb
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
Underground:- - Underground: Underground: Excavation: -
Service: - Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
- Meter: Oil:
Final:
House it Smoke:
Water: Alarm:
Assessor Treasury:
Sewer: Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPONCLATIO� ,OF ANY OF ITS
`RULES AND REGULATIONS. / '' .
„iv w
Signature: � c
Fee Type: Receipt No: Date Paid: Check No: Amount:
C„ $,aUII.DIN,G„ REC-200090012551 26-Feb-09 4611 $t15oo
r
"e`'o"
� mss.��6��.
Call for Permit to Occupy.
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GeoTNIS®2009 Des Lauriers Municipal Solutions,Inc.
CITY OF S.U.E.AvI, NLASS.ACHUSETTS
• BULDLNG DEP.\RTME,NT
' 120 W.iisHLNGTON STREET, Yo FLOOR
TEL (978)745-9595
FAX(978) 740.9846
KIMBERLEY DRISCOLL
MAYORTHo.+us ST.PtFRRs
DIRECTOR OF PUBLIC PROPERTY/BCILDNG CONNISSIONER
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 l 1.5
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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
GC�
asigUnatureo rmi applicant
�f �j
date
I.bn�if Jk