B-20-583 - 0129 BRIDGE STREET - Building Permitr
The Commonwealth of.Massachusetts
Department of Public Safety
1 Massachusetts State Building Code(780 CMR)
i Building Permit Application for any Building other than a One-or Two-Family Dwelling
(Mis.Section For Official Use Only):—
Budding Pemiit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is'not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK.
�• Edition of MA State Cade used If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair Alteration "Addition❑ 1 Demolition,❑ (Please fill out anti submit Appendix 1)
Change of Use ❑ Change of Occupancy ` ❑ Other ❑ Specify:Ce»`f yC`12� C1d&J
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Er
Is an Independent Structural Engineering Peer Review required? Yes ❑ No Il"
Brief Description of Proposed Work: 1 L. C—�," C 0 oOJ- :k, A LQ QK—V
a IVC?O
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) 0
Existing Use Group(s): Proposed Use Group(s). O
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3
Total Area(sq.ft.)and Total Height(ft.) *ble
SECTION 5:USE GROUP(Check as a li
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-1W 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 td ;ti IB O IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl . Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Eir Check if outside Flood Zone❑ Indicate municipal A trench ,I'not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required or trench or,specify�i 24
permit is enclosed❑ if_W(S Sj A)I-- .
Railroad right-of-w 1 f Hazards to Air Navigation: ;�.I f H.-Aoric C:_ommission Roview Process:
Not Applicable Is Structure within airport approach area? Is their review comple d?
or Consent to Build enclosed❑ - Yes❑ or No 12" Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: �p Use Group(s): Type of Construction: 11,0Ccupant Load per—Floor: r
Does the building contain an Sprinkler.System?:_1./ >- Special Stipulations: 11o& — 0� f-0
cad- eo
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
G. Lt_ C f OWL C;� 1Y_L 7s ock f.,r.JtF 1-W f�r6�� o �-
Name(Print) No.an Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
�' [f applicable,the property owner hereby authorizes
Name Stree Address, City/Town •State Zip
to act on the ro er owners behalf,in all unatters relative to work authorized b this buildin ermit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please f%Il out Appendix 2)
f buddin 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
Name(Registrant) Telephone oonfee Nl.` e-mail add Registration Number
Street Address City/Town State d1i Discipline Expira on Date
0
101 General.Contractor
Company Name
f`C
None of Person Responsible for Construction License No. and Type if Applicable
Stret Address City/Town State Zip
Oele-p4honeo.
ICA 0, DAc-ke �rr�e
bu`siness Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVITr 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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEN :
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ d(�j �
Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical $ 14>a appropriate municipal factor)_$
3.Plumbing $ e,> o c
d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other -$ foZO&I Enclose check payable to �2
6.Total Cost $ 70 po - V (contact municipali )and write check number here
ION 1 SIGNATURE OF BUILDING PERMIT APPLICANT
By tering y na be Ili the pains and penalties of perjury that all of the information contained in this
plication' < t nowledge and understanding.
0 c 6 5y3H
Please print and sign n Ile
�M Titlg Telephone No. Date
�T 1�r-R L � Q 20 Z-6
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
<
r .
The Commonwealth'of Massachusetts
Department.of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-201 T
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers:,
TO BE.FILED WITH THE PERMITTING AUTHORITY:
Applicant Information Please Print.Ledbly;
Name.(Business/Organization/Individual).:]/,C—14 t,/g- P/'LL(h'M L2r
Address:
City/State/Zip: m i/40 M 04�- 0, Phone#
Are you an employer?Check the appropriate box:
Type of project(required):
I. a employer with employees(full and%rpart tune}:° 7. New construction
2. am sole proprietor or partnership and have no em1.ployees working forme'ia $; modeling
any capacity.[No workers'comp.insurance required.]
0. ❑Demolition
3.❑1 am a homeowner doing all work myself.[No workers'comp:.insu'ranee requiredj.Y
10 Building addition '
4. ma homeowner and will be hiring contractors to conduct all work on my propertyi,I will
ensure that all contactors either have workers'.compensation insurance or are sole 1'l,[ EIeC at repairs.or additions'
proprietors with no employees: f„ 12 lumbing repairs of additions
I ltese sub contractors have em to ees and have workers'coin ."insurance.
5. am a general contractor end I have hired the sub contractors listed on the attached sfieec
-Ml p y _ p t 13. Roof repairs
'60 We are a corporation and its officers have exercised their right of exemption per MGL,:c.` 14.Q Other `
,
152,§i(4),and We have no,employees..[No Workers'comp,Iinsurance requiied.j
"Any applicant that checks box-#l-must also fill out the section below showing their mpen:workers cosation 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,such.,
:Contractors that check this box must attached an additional:sheet showing the nine of the subcontractors and siaie whether or not.those entities have
employees. If the sub-contractors have emptoyJm,ttfey,must provide then workers'comp:policy number. j
I am an employer that is providing workers compensation insurance for my employees. Below is the,policy and job site
information.
Insurance Company Name: L.,j GUi( /
Policy#or Self--ins.Lic.#: .U-)C�.'.�l �125 �--6 Expiration Date.
Job Site Address: ity/State/Zp:t�NamJAr( _yn4 ! �c -
Attach a copy of the workers'compensation policy declaratton page(showing the policy number and expiration date).
Failure to secure coverage as required under.MGL c"152,§25A is a criminal violationptmishableby a fine up to$1,500.00
and/or one 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.A copy of this statement may be.forwarded to the Office of:Investigations"of the,DIA for insurance
.coverage verification;.
do hereby certryv under paigs an enal 'es o erj ry'that theinfor6iation pr`ovided,aborve is true and correct
Si nature: Date: 2 02
Phone.#: 02
Ofeial use only;,Donotwrite 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#:
DALLA-2
,d►��` CERTIFICATE OF LIABILITY INSURANCE D0910812n2YI�
Ofi10812020
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 pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement s►.
PRODUCER 508-879-1310 W.,CT Ronald F.Jewell
Jewell Insurance Agency,Inc. PHONE 508-879-1310 FAX 508-872-
1101 Worcester Road WC,No,Ext): 2764
Framingham,MA 01701 ss:
Ronald F.Jewell
INSURE AFFORDING COVERAGE NAIL#
INSURER A:Li berty Mutual Insurance Co
INSURED INSURER B:
Kenneth Dallamora
9 Cherry Oca Lane INSURER C:
Framingham,MA 01702
INSURER D:
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 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 AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR NSR TYPE OF INSURANCE ADDLINSD SU WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE OCCUR DAMAGE TO RSEStE.ENTEDPREM $
MED EXP(Any one rson
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY❑j LOC PRODUCTS-COMPIOP AGG
OTHER:
AUTOMOBILE LIABILITY Ea eBI E DtSINGLE LIMIT $
ANY AUTO BODILY INJURY Per erson
OWNED SCHEDULED BODILY INJURY Per accident $
AUTOS ONLY AUTOS BODILY
Ep p�
AUTOS ONLY At1TOS ONNLY Pe�accRdent AMAGE $
4DUMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE ED RETENTION$ AGGREGATE $
A AID EMPLCOMPENSATION
YES N ABILITY X SPTEARTITE
OTH-ANY PROPRIETORIPARTNERIEXECUTIVE YIN C2-31 S$12542-021 0412W2020 04129IM21 E.L.EACH ACCIDENT $ 100,000
QEFICERIM EXCLUDED? N❑ N 1 A
MMandatory In .,IP0 000
If yes,describe under E.L.DISEASE-EA EMPLOYEE $ i
DESCRIPTION OF OPERATIONS belowE.L.DISEASE-POLICY LIMIT S�A��
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Addidonal Rernarks Schedule,may be attached If more space Is requl►ed)
�ICRTIFICATE HOLDER CANCELLATION
SALEMCI
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BED€
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED-11N
City of Salem ACCORDANCE WITH THE POLICY PROVISIONS.
44 Lafayette Street
Salem, MA 01970 AUTHORIZEDREPRESENTATWE
ACORD 25(201601) 4D1988.2015 ACORD fed:
The ACORD frame and logo are regieterud marks of ACORD
I -
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Re ulations and Standards
Consrvisor
dl
CS-000195 15 pires:06/30/2021
KENNETH G7ALL�M
9 CHERRY OP�fs 4 LADE
FRAMINGHAM+�MA°s0.
s �
Commissioner
CITY OF SALEM MASSACHUSETTS
BUILDING DEPARTMENT
98 WASHINGTON STREET,2ND FLOOR
TEL: 978-745-9595
! KIMBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition & renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111, S150A.
' I
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
_ 5 �
(name of facility)
vl�-o/,G 1
(address of facility)
Signature of applicant
(today's date)
Your Confirmation number is 202006221036906
Date of Confirmation:6/22/2020
NOTE:When paying by ACH (Checking)it will take two business days for the payment to be debited from your bank account.Your
account number is not verified until this payment is presented to your bank.They have the right to return this payment if unable to
process this transaction against your account.
Your request for payment(s)of$79.50 has been received and is subject to approval by your financial institution. No email was entered
so a confirmation was not sent.
Account Information Payment Information
Name: KENNETH DALLAMORA Payment Type: Credit Card
Note: QUICK PAY TRANSACTION Payer Name: KENNETH DALLAMORA
Card Number: *************8003
Transaction Information
Transaction Quantity Amount Fee Payment Type
City of Salem-Inspectional Services 1 $77.00 $2.50 Credit Card
Building Permit
First Name:kenneth
Last Name:dallamora
DBA/Company Name,if applicable:
Name of permitted/inspected property:
129 bridge street
Address of permitted/inspected
property:129 bridge street
Phone M 508-326-5438
Contact Email Address:ken@kdalla.com
Total:$79.50