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B-19-963 - 0002 BRIDGE STREET - Building Permit 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 Dwelling (This Section For Official Use Only) (— Building Permit Number: Date Applied: Building Official: SEC R ION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 2 BRIDGE ST Salem 01970 : No.and Street City/Town Zip Code Name of Building(if applicab? SECTION 2:PROPOSED WORKR r$ Edition of MA State Code used 2015 If New Construction check here❑or check all that apply in the two rowstbelow�A Existing Building❑ Repair❑ Alteration Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) MTV Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: + a Are building plans and/or construction documents being supplied as part of this permit application? Yes O No Is an Independent Structural Engineering Peer Review required? Yes ❑ No rf Brief Description of Proposed Work: Removal and Disposal of Interior Finishes 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): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flpors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A. Asseanbly A-1❑ A-2 V Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ R Facto' F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I4❑ 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 ❑ 1110 IIA ❑ IIB MA ❑ MB ❑ I TV ❑ VA ❑ VB ❑ SECTION 7: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❑ Check if outside Flood Zone❑ Indicate municipa4 A trench will not be Licensed Disposal SiteV Private❑ or indentify Zone: or on site system.❑ require4or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 91 Is Structure within airport a proach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or N6 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: ' " "�c''�`k Fs* �i• t it ' t 'y,+�"•ir�e,yr+`irwy,7h`+'�.'y �_a•4:,,+R '" .." 1' '.�k'�'� :.. r • ',• . ,• 'Sep f �` Ti � x tNs°[} e�4 § '_hu3`EaA Zs �. s,�J�4'�F`rRy� 4',°' 'y\'w'' iS Construction � c Restricted • UnrestrictedBuildings • any usegroup whichcontain .1 than 36,000 cubic feetJ991. cubic. meters) of enclosed s ace. eSsr Failure I to • • dition of State Building Code is cause for revocation of this ficense.- i' i ! informationWWW.MA.SS.GOV/DPS I 1 f E , SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Addh'•ess of Property Owner M&A Hospitality Group LLC 2 Bridge St. Salem 01970 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Alan DeAngelo alan@mahosptalitygroup.com Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Gary Strack 567 Massachusetts Ave. Cambridge MA 02139 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 pen-nit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix2) building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and sldp Section 10.1 10.1 Re 'stereo Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Justin Kelly Contracting Company Name Justin Kelly CS -094483 Name of Person Responsible for Construction License No. and Type if Applicable 476 Windsor Street Cambridge MA 02141 _ Street Address City/Town State Zip 617-945-0143 617.838-7666 Office@Justinkellycontracting.com Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION 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' suance 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 20 0®0.00 and Materials) Total Construction Cost(from Item 6)=$ 1.Building $20,000.00 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $20,000.00 (contact municipality)and write check number here SECTION 11 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 J6 true and accurate to the best of my knowledge and understanding. Justin Kelly /X�94 President 617.838-7666 09/02/2019 Please print and sign namevll Title Telephone No. Date 476 Windsor Street Cambridge MA 02141 7 Street Address City/Town State Zip Municipal I,nspector to fill out this section upon application approval: Name Date 1 CITY OF SM E�M, 1NI.�SS�LCHUSETTS h BL'UMLNG DEP.ARTNIE,�iT 120 WASHINGTON STREET,Yn FY.00R TEL. (978) 745-9595 FAX(978) 740-9846 KI�tBERI.EY DPJSCOLL ;MAYOR T HONW ST.PIEM DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLMIISSIONER 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 111.5 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 150,A. The debris will be transported by: G/J Hauling (name of hauler) The debris will be disposed of in (name of facility) (address of facility) signs of permit applica �r9 date anr��lr.a�: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Justin Kelly Contracting Address:4*76 Windsor Street City/State/Zip:CAMBRIDGE/MA/02141 Phone#:978-945-0413 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 6 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ®Demolition. workingfor me i capacity. employees and have workers' n any p �'• 9. ❑Building addition [No workers'comp.insurance comp,insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suck :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If thc sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: STAR INSURANCE COMPANY Policy#or Self--ins.Lic.#:WC - 0869938 Expiration Date:08/16/2020 Job Site Address:2 BRIDGE ST City/State/Zip:SALEM/MA/01970 Attach a copy of the workers'compensation 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$256.00 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. I do hereby certify under the pains andd ppenaldes of perjury that the information provided above is true and correct Signature: 9�� � Date: 09/02/2020 Phone#:617-838-766 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact:Person: Phone#: Authorized Signature: ture: Justin Kelly Acceptance of Proposal: The above prices, specifications and conditions are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Accepted: Authorized Si naq tune: H.I.C. REG#'181681 it Ustin contracting tr 11 9/02/2019 To whom it may concern, Christian Simmon is hereby authorized to act on behalf of Justin Kelly Contracting for the work being executed at: 2 Bridge Street Salem, MA 01970. Justin Kelly Justin Kelly, President Justin Kelly Contracting Inc. 476 Windsor St. Cambridge, MA 02141 M: 617-838-7666 0: 617-945-0143 F: 617945-0658 Justin@JustinkellyContracting.com www.JustinKellyContracting.com • 47�6 Windsor Street Justin Cambridge, ',MaaKellyztracti,g OFFICE:617.945.01431 FAX:617.945.06581 BILLING@JUSTINKELLYCONTF ACTING.COM Contract 09/02/2019 ICI&A HOSPITALITY GROUP LLC 2 BRIDGE STREET Salem MA, 01970 1) REMOVAL AND DISPOSAL OF INTERIOR FINISHES $20,000 TOTAL $20,000 Payment is to be made upon completion. All material is guaranteed to be as specified. All work to be completed in a professional, workmanlike manner according to standard practices. Any alteration or deviation from the above specifications involving extra costs, will be executed only upon writteniorders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accident or delays beyond our control. This proposal is subject to acceptance within 14 days and it is void thereafter at the option of the undersigned.