110 DERBY STREET - BUILDING JACKET G
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`���' Department of Public Safety
Massachusetts State Buildi>� c� '�tR(X'Illh�& $9 .
Building Pemtit Application for any Building of 1�S e-or wo- amily Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
11 SECTION 1: OC ION glease ndicate Block#and Lot#for locations for which a street address is not available)
(� a e b G
No.and Street City/Town Zip Code Name of Building(if applicable) _
SECTION Z PROPOSED WORK
f� Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
1 1 Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill t and subr 't Append'r 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: P O'L . C P r i ►=K/h
Are building plans and/or construction documents being supplied as parrot this permit application? Yes ❑ No
Is an Independent Structural En ineering r Review required? ` Yes ❑ No ICJ
Brief ascription of Proposed ork:. r� /�
0
c d
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building fnvest'gation and Ev uation is enclosed(See 780 CMR 34) ❑
Existing UseGroup(s): Proposed UseGroup(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) ia5
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B.
Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1 ❑. - ❑ H73 ❑ H-4❑ H-5❑
h Institutional I-I❑ 1-2❑ 1-3❑ t:4❑ M: Mercantile❑ : Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ I U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ 118 ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Debris Removal:i Permit.Wafer Suppl Flood Zone Information: Sewage Disposal: Trench Licensed Disposal Site❑
Publi Check if outside Flood Zone❑ os d Indicate municipal❑ A,trench will not be P s
required❑or trench ur specify:_
Private❑ or indentity Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: �.i,-\I_I. t ri, �;111�111H I .1 tl;Wa1 [r.�L 1:
Not Applicable❑ is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICA'iE OF OCCUPANCY .
Edition of Cud¢: Use Gruup(s) Type of Construction:_ Occupant Load per Flour:
Dues the building contain an Sprinkler System?:_ Special Stipulations:
MfAILktg:�) -11zlas
�y LIASi
SECTION 9- PROP ER AUTHORIZATION
Na e and Address of operty Owner
0 a h/� alg7v
Name rint) No.and Street City/Town Zip
Prop e n rty Ow ter Contact fnf oration:
7�-606
Title Telephone No.(business) Telephone No. (c 11) / e-mail address
If applicabl• ca. operty or ner hereby authofrze h U ( d l 97a
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized b this buildingermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.R.of enclosed space and or not under Construction Control then check here Cl and ski Section 10.1
10.1 Registered Pr essional es onsible for Construction Control
q�g3�7-338/ . &9 es as6rsy.
Marne c i raipty Telephone No. -tf I�gl�frEssc.ay� Registration Numbe
Street Address City/Town State Zip Discipline Ex irati n Date
10.2 General Contractor
Company Na
Name so I+�spons' le for Construction License No. and Type if Applicable
Street Address City/ own / State/ Zip
--_ QZ, Z 223e11 Ore�i4Qla�ia i d�.5���lolSly� svc
Telephone No. business Tele hone No. cell 7 e-mail address
SECTION 11:1Y0RKF:RS'CONIPFNSAI UN INSURANCE AFV1lMv l' 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 ,r�
and Materials) Total Construction Cost(from Item 6)_$ d G
1. Building $ tl 00Ur 00 Building Permit Fee—Total Construction Costx—(Inserthere
2. Electrical $ t;-(f` o r'. UG appropriate municipal factor)_$
3. Plumbing $ �CiUG , Gp
4.1%lechanicrl (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Nfeeha nical Other $ Enclose check payable to
6.Total Cost $ Q U (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the sins and penalties of perjury that all of the information contained in this
application is true and accurate to the X
t of my kno vledge and understanding.
lyf 5r -- - _�� 73 3 61
Pleas rin and s' n vne Title p1, Z/felephone No. Date
e c� oc9w
Si cet Ad r s/ City/Town State Zip
( G
Municipal Inspector to fill out this section upon application approval: O 3G
Name D,
VIA 01 a-
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y
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family D Ili
(Phis Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block N and Lot#for locations for which a street address is not available)
110 a-Aa L t r 54te no ayw
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION Z PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ 1 Alteration ❑ 1 Addition❑ 1 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 &7
Is an Independent Structural Engineerin °er Review required? Yes ❑ No
Brief Description of Proposed Work: " O
/-
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY '1
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&a Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
- SECTIONS:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-S❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ W❑ M: Mercantile❑ 1 R: Residential R-1 R-2❑ R-3❑ R4❑
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 ❑ I[A ❑ IIB ❑ ILIA ❑ 11I113 ❑ IV ❑ 1 VA ❑ VB ❑
SECTION T.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: - Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public gr Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site.R1
required❑or trench or specify:
Private❑ or indentify Zone: or on site systenpo permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \iA I Int ri i:,,t„ink sir n u,,un i. nna,s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIF[CA'CE OF OCCUPANCY
Edition of Code. Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
z - 111F
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Ad i ress of Prope ty Owner
vT N l- VWY 5AdieaM
Name(Print) No.and Street City/Town ip -
Property Owner Contact Information: ,
A) 12q
Title Tel ne No.(business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property 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 O and skip Section 10.1
10.1 Re istered Professional Responsible for Construction Control
in ne(Re strand Tclephon o. e- ail add ess Registration Number
p des n�� -
Street Address City/Town State Zip Discipline Expiration Date
10.2 Ge W al Contractor A -
Comp. Name
Name of Person Responsible for Construction License No. and Type if Applicable
.��/
46 6AIM20S Ml �At� ��s�� �-S
Street Address City/Town State Zi
/
/� _hone No.(business) Telephone No. cell e-mail address
SECTION 11:11'ORKIi2S COh-0PI:N:'iA'CION INSURANCE AFFIDAVIT' M.G.L.C.152.925C(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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ COO appropriate municipal factor)_$
3. Plumbing
A. Mechanical (HVAC) $ Note:Minimum fee=$ (contact mumdc alit ) _
S.Mechanical Other $
Enclose check payable to _
6.Total Cost $ (contact municipality)and write check numti -mere
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. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
110 DERBY STREET 635-14
G`s#: 11972 COMMONWEALTH OF MASSACHUSETTS
r
Map: 41
Block: CITY OF SALEM
Lot: 0033-201
'Category RENOVATIONS
Perrtut# 635-14
BUILDING PERMIT
Project# JS-2014-001592
Est. Cost: 1$19,500.00
Pee Charged: 1$225.00
Balance Due: $.00 PERMISSIONIS HEREBY GRANTED TO:
'Const Class: Contractor: License: Expires:
Use Group: ,., * .� ,,,- REGINACDO PICCINATO CONSTRUCTION SUP'R-CS-104957
!Lot Size(sq ft.): 4150 7iOwner: ANTHONY SOBIN
EZontng ,
jUnrts Gained: :Applicant: ANTHONY SOBIN
,Units Lost: ; '-' AT. 110 DERBY STREET
Dig Safe#:
ISSUED ON. 28-Feb-2014 AMENDED ON: EXPIRES ON: 28-Aug-2014
TO PERFORM THE FOLLOWING WORK:
635-14 REPLACEMENT DOOR; 1 ST FL BATH FROM 1/2 BATH TO FULL BATH; FRONT ENTRANCE BUILD IN
'HALL;TWO DOOR;ADD BEDROOM
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 q Smoke:
Treasurv'
Water: Alarm: Assessor
Sewer. Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
t,.
Signature:
ihcrag'Fee Type: Receipt No: Date Paid: Check No: Amount:
i,
�IDUILDING REC-2014-001604 28-Feb-14 cash $225.00
GeoTMSO 2014 Des Lauriers Municipal Solutions,Inc.
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Marcia Kirkpatrick
S
From: Michael Lutrzykowski
Sent: Thursday, March 06, 2014 2:11 PM
To: Marcia Kirkpatrick
Subject: FW: License Copy
Attachments: SCN_0006.pdf
From: Reginaldo Piccinato [mailto:regispiccinatoCabhotmail.com]
Sent: Monday, March 03, 2014 5:20 PM
To: Michael Lutrzykowski
Subject: License Copy
Att: Reginaldo Piccinato
617-895-9410
Address Job: 110 Derby St, Salem, Ma
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BZING GRANTED
Locadom of !wMmg
Building Peradt AppUcatioo For.
'(Circle whichew applies) Roof.Remf. hwall Siding,Consum Deck,Shod, Pool '
Addition, Alleratiom Rgmk/Popiam Foundation Only. Wrecking
Other:
PLEASE FILL OUT LEGMLY& COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Irupepor of Bui)diggs:
Tho undersigned hereby appliess for a permil to build acwnh%to&a hHowiog apac>icatioos:
OwawiNaoe; �Gl//ti�l �__ Cootractor._P}�IL/i (�042fluGh'
t�� b Cil)•-�,( e% Sam_0 Lkyllicll /�✓�, City_f��F✓z1Uld r�1/�
State Phone Sate PMoM67 > G33 8`l�fl
ArtWtect:_ City of sale.Lidl ,
Street City. State UaY Cj U 28 2 Ev iv %4,?72
State phone( ) Ho.aow.en Esapt Foro..jm - >o
Stntop m (please c ucle) Siugle Famil). Muth Family 0wer
Lowsatcd Cant of job S
WW MriWirt ��� ��
i oafit>.to htar!,�� �
Aabo n?___ es Koo /
DesuiptiN of t►orik/o he dw:-- �� F l-ed, /i'L-
Dra bitted:�,a —no Mail Penit to:
z%ln 1 2el ST 5ALI�v-1
x
of APPkWONs$ GNED UNDER THE PENALTY OF PERJURY
CONSTRUCTION TO BiOMPLETED WITHIIw SIX(O MONTRS OF PERMIT ISSUED DATE
Dapartmem use only: PM*o�_ B
Permit he
COltttMS:
• a •
DISPLAY PERMIT IN A CONSPICUOUS PLACE ON THE PREMISES
co `A� Commonwealth of Massachusetts
City of Salem
120 Washington St, 3rd Floor Salem, MA 01970(978)745-9595 x5641
Kimberley Driscoll PLUMBING PERMIT
Mayor
Date: 4/2/2014 Fee: $25.00 Parent Pin: NO. P-14-503
Building Location: 110-U1 DERBY STREET Applicant Name:
Type of Occupancy: Residential Type of Work: Remodel Kitchen or Bath
Work Description: 1 LAVATORY, 1 SHOWER STALL, 1 TOLIET,WATER PIPING P450
Location Fixtures Number
Contractor Name: STEVEN FITILUS Contractor Phone: (978) 750-6996
Contractor Address: 2095 MAIN ST MIDDLETON MA
License Type: Master Plumber License No: 16495 License Exp: 1/1/1900
The recipient of this permit accepts this permit on the condition that, as owner or as agent of the owner, he/she agrees to
comply with all Building &Zoning Ordinances of the City of Salem &the State Statutes of the Commonwealth of
Massachusetts regarding the use, occupancy &type of building to be constructed, added to, or altered. Additional conditions
listed below:
All permits approved are subject to inspections performed by a representative of this office.
4/2/2014
Dennis M. Ross, Plumbing/Gas Inspector Signature Date
Call (978) 745-9595 x5641 For Inspection
c, ? CITY OF SALEM, MASSACHUSETTS
r BUILDING DEPARTMENT
k o ,,;';'(��" 98 WASHINGTON STREET,2\D FLOOR
' SALEM,MA 01970
KIMBERLEY DRISCOLL TEL. (978) 745-9595
MAYOR
THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
CERTIFICATION
I, Thomas St. Pierre, Director of Public Property/Building Commissioner for the City of
Salem, hereby certify that the attached are true copies of records in the possession of the
Building Department with respect to the property at 110 Derby Street, Salem, Massachusetts.
Signed under the pains and penalties of perjury this 3 I day of October, 2019.
6:14-144 Ptai/ _
Thomas St. Pierre