B-19-1079 - 0151 BRIDGE STREET - Building Permit 1U ICJ
The Commonwealth of Massachusetts y.
Department of Public Safety
(� Massachusetts State Building Code(780 CMR)
V 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: Budding 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 apq6able)
SECTION 2:PROPOSED WORK.
Edition of MA State Code used If New Construction check here❑or check all that apply in the tows
\J Existing Building❑ Repair'V1 I Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit pend;
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ 0'N4
Is an Independent Structural Engineering Peer Review required? Yes ❑ +7Tlo t'r
Brief Description of Proposed Work: �Mf'te if a&-J Co aQT-41r\1\
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 Floors/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: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E, Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 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 ❑ IIA ❑ IIB ❑ IIIA ❑- 11I11 ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal:
A trench will not be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: d,�._I_li;toric Commission_Itovii.-w Procc 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 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:
S-U ,
r2 l✓(VI b'")
�v r
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Add ess of Property Owner p'
Name(Print) No.and Streets City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
[ pplicable,the property owner hereby authorizes
Name Stree Address City/Town State Zip
to act on the�roper 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 buildin*ia less than 35,600.cu.ft:of enclosed space-aridi or not under,Construction Control then check here and skip Section 10.1
10.1 Registered 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 ,
Col piny Nam
, CA)e� Cn�L_- '06,(Do
Name of Person Responsible for Construction License No. and Type if Applicable
S�
Street Address City/Town State Zip
0���5� — ( 5� , Lot a tc�,� Uri
c� � tOl a,
Telephone No. business Telephone No. cell e-mail ad ress
SECTION 11:a�c)r.>;t:� `C:O�IPEi\i5r1 L'fC?N lNSU1::1NC}i AF.ETL)AVrr M.G.L.r.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 No ❑
SECTION 12:.00. NSTRUCTION.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 $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check .payable to
6.Total Cost $ DO (contact municipality)and write check number here
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.,
A �o)-�-)i- k5�
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zi
°�l✓.1 �t �10
Nfunicipal Inspector to fill out this section upon application approval:
Name Date
7 ,
Y
/A
K CITY OF SALEM, MASSAGiUSE M
BUILDING DEPARTMENT
120 WASHINGTONSTREET,3'DFLOOR
01a 'ILL.(978)745-9595
KA4BERLEYDRISO0LL FAX(978)740-9846
MAYOR THOMAS STYIERRE
DIRECTOR OF PUBLICPROPERTy/BUILDING 00MNUSSIONER
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.
The debris will be transported by:
CS A
(name of hauler)
The debris will be disposed of in:
(name of facility)
� <!�"L o?
(address of facility)
A �
Sig ure o plicant
(tod y's date)
`i
_»
i CITY OF S.,UX. I. NLkSSACHUSETTS
• BUILDING DEPART%I&NT
`f 120 W 1SHINGTON STREET, r FLOOR
4 ow, TEL (978)745-9595
FAX(978) 740-9846
KI,%,iBEY. FY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO',%LMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anylicant Information Please (Print Legibly
Name(Busin,ssiOrganization/Individual): ' QSnA( LC.
Address:
City/State/Zip: C,)QJ& fl ,VIA (3\ 10 Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
l�l am a employer with /1 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity. workers'comp.insurance. 9. [] Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its lo.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.Q Roof repairs
insurance required.]t employees. [No workers' 13'&]Other n� Ail
comp. insurance required.]
•Any applicant that checks box#I must also rill out the section below showing their workea'compensation policy information.
t I limmowttt is who submit this affidavit indicating they ate 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 name of the suit-contractors and their workers'comp.policy information.
I um an employer that Is providing workers'compensation insurance for my employees. Below Is the policy and job site
information. T
Insurance Company dame:
Policy#or Self--ins.Lic.#: Expiration Date:
Job Site Address: ` 1 I cj� City/State/Zip:.S4�Oj- 1
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
r fine up to S 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 S250.00 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 and pens les of perjury that the information provided above is true and correct
Date.
Phone#:
Official use only. Do not write in this area,to be completed by city or town oJjciaL
City or'rown: _.._. Permit/I.lcense#
Issuing Authority(circle one):
I. Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6,Other
Contact Person: Phone#•
+ eta
. _ Commonwealth of Massachusetts
Division of Professional Licensure t
Board of Building Regulations and Standards
Constructiorlty&A.s,gr Specialty
CSSL-106009 l pires:08I01/2021
GARY CLARI�
58 DERBY S1ItEET, p
SALEM MA 00704' . 1
Commissioner
'Stephen Cummings
From: Brian Giordano <bgiordano.goodnowins@gmail.com>
Sent: Wednesday, September 25, 2019 9:33 AM
To: Stephen Cummings
Subject: Gary Clark
Hi Steve,
I am currently working with Gary Clark on securing a surety bond but he has asked me to send you his policy number and
expiration date while we work on the bond.
Commerce Insurance
Policy number 8008030003984
Expiration Date is 5/12/2020
Please let me know if you need anything else while you wait on the bond piece.
Thank you,
Brian Giordano
President
Alden C. Goodnow Jr. Insurance Agency Inc.
(978)774-2620
www. oodnowins.com
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