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B-19-737 - 0331 BRIDGE STREET - Building Permit cK1001 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,Dwel LC-C-\ lingng (This Section For Official Use Only) �4 Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not availa.0 .,,, 331 Bridge Street Salem 01970 No.and Street City/Town Zip Code Name of Building(if appli�pble) . �. , 1 SECTION 2:PROPOSED WORK +r .;,; Edition of MA State Code used If New Construction check here VoIr check all that apply in the two s below. Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other voundation Only_ oft Are building plans and/or construction documents being supplied as part of this permit application? Yes x2r No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No xie, Brief Description of Proposed Work: i- , 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.) N Ik Total Area(sq.ft.)and Total Height(ft.) N(/a 000005 SECTION 5:USE GROUP(Check as applicable) 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❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2 Cliff 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) IV ❑ VA ❑ VB ❑IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Sup IF Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public l Check if outside Flood Zone Ur Indicate municipal A trench will not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ required 2or trench or specify: permit is enclosed❑ Railroad right-of-way Hazards to Air Navigation: MA Historic Commission Review Process. Not Applicable Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or Noe 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: SECTION 9:PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 331 Bridge Street, LLC 7R March Street Salem 01970 331 Bridge Street, LLC Name(Print) City/Town Zip No.and Street Pr_. oroer_ty Owner Contact Information978 -745 -8274 978-430 -8147 steQhen®lovetylawQrouQ.com Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Stephen Lovely 10 Federal Street Suite 411 _ Salem MA 01970 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❑and skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control 5294 Slen11 r�iyer tore 978 - 828- 4006 Registration Number Name(Registrant) Telephone No. e-mail address Architect 8/31/2019 Mason Street Salem MA_ 01970 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Salem Sheet Metal Rnv r P 't Name of Person Responsible for Construction License No.and Type if Applicable 06 Wenham Street Danvers MA 01923 btreet Address City/Town State Zip 508 -509-7438 508 -509 -7438 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 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)=$25,000 1.Building � $ Building Permit Fee=Total Construction Cost x.11 (Insert 2.Electrical $ here appropriate municipal factor)=$275 3.Plumbing $ 4.Mechanical(HV AC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical(Other) $ Enclose check payable to City of Salem 6.Total.Cost $ 25,000 (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. Roger Petit. Salem Sheet Metal Manager 508-509-7438 3LL2019 Please print and sign Title Telephone No. Date name Roger Petite` Danvers MA 01923 96 Wenham Street City/Town State Zip Street Address Municipal Inspector to fill out this section upon application approval: 7— r Name Date SALESHE-01 DKULICK ,4coRO CERTIFICATE OF LIABILITY INSURANCE DATE `—� 03/20/20/2019 Y) 019 `HIS 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 policy(ies)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 License#1780862 !CONTA NAME:CT _ HUB International New England PHONE FAX 600 Longwater Drive (A/C,No,Ext):(781)792-3200 (A/C,No):(781)792-3400 1 E-MAIL Norwell,MA 02061-9146 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Commerce Insurance Company_ _ 34754 INSURED INSURER B:Twin.City Fire Insurance Company___ 129459 Salem Sheet Metal Inc.Roger Petit INSURER C: _ 89 Russell Street INSURER D: Peabody,MF101960 INSURER E INSURERF: 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. _ INSR IADDLIMI POLICY EFF I POLIC TYPE OF INSURANCE I D 1 i POLICY NUMBER I MM/DD + MM/DY EXP I LIMITS A X I COMMERCIAL GENERAL LIABILITY I I EACH OCCURRENCE $ __1,000,000 ! I DAMAGE TO RENTED CLAIMS-MADE X I OCCUR 18008030009967 10/2912010; IU12912019 PREMISES(Ea occurrence) $ 1��'�� 5,000 MED EXP(Any one person) 1$ PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: I ! I GENERAL AGGREGATE $ 2,000,000 PJECROT- If lI I i X POLICY� LOC ( I PRODUCTS-COMP/OP AGG I$ 2,000,000 OTHER: ( 1 ! I I $ A AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT I 1,000,000 ! (Ea accident) $ ANY AUTO iBBLXBV i 03/31/2018 103131I2019 I BODILY INJURY(Per person) !$ _ OWNED F —{SCHEDULED AUTOS ONLY 1 AUTOS BODILY INJURY(Per accident)I$ I HIRED I � NON-OyyNED I I PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY I(Per accident) I$ I I I 1$ A j X UMBRELLA LIAB Il x iI OCCUR I i EACH OCCURRENCE $ 2,000,000 ! EXCESS LIAB I I CLAIMS-MADE I i TBA I 02/15/2019I 02/15/2020AGGREGAT E I$ 2,000,000 j DED il X I RETENTION$ 10,000 Is B WORKERS COMPENSATION I I I I ' PER OTH- AND EMPLOYERS'LIABILITY STATUTE I I ER Y/N 08WECAA8678 1 07/07/2018 101/07/2019 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N/A I E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? SOO,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE!$ If yes,describe under ! I 500,000 I DESCRIPTION OF OPERATIONS below 1 I I E.L.DISEASE-POLICY LIMIT $ 1 1 I I DESCRIPTION OF OPERATIONSi/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Stephen LovelyTHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD I CITY OF S j ALEM, lvltiS$AQ-iCJ$E 1"IS 1" BuimiNG DEPAR-naxr 120 WASHINGTON STREET,3'm FLooR TEL.(978)745-9595 g;MERLEYDRISOOLL FAX(978)740-9846 MAYOR THOMM ST.PlERRE DIRECTOR OF PUBLICPROPERTY/BUILDING OON&SSIONER 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: (name of hauler) The debris will be disposed of in: (name of facility) a (address of facility) Signature of applicant 12 1 (today's date) 1 CITY OF S.U.&M. %LksSACHLSETTS t-y BuILDING DEPARTMENT N 120 WASHIINGTON STREET, r FLOOR T EL (978) 745-959S FA..c(978) 740-9846 KI\tBFRi FY DRISC::OLL ,ue'►YOR �loltt�►s ST.PiERRr DIRECTOR OF PL:BLIC PROPERTY/BUIIDIING CONMSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant iInformation Please Print Leyihly Name(Businr:s&Organ ization/lndividual):RfIGER L.PETIT Address: 96 WENHAM STREET City/State/Zip: DANVERS, MA 01923 Phone #:S08-SO9-7438 Are you an employer?Check the appropriate box: Type of project(required): 1.X l am a employer with_4 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time)-' have hired the sub-contractors 2.❑ 1 am it sole proprietor or partner- listed on the attached sheet. 7 X Remodeling ship and have no employees These sub-contractors have & ❑Demolition working for me in any capacity. workers'comp.insurance. 9 ❑ Building addition (No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ i am a homeowner doing all work right of exemption per MGL L LC]plumbing repairs or additions myself_(No workers comp, c. 152,§1(4),and we have no insurance required.]t employees. [No workers' l2.❑ Roof repairs comp. insurance required.] Other comp. Any applicint that checks box 91 must also fill uut the section below showing their workers'compensation policy information. 1 114MWUWDLrs wlso 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 name of the subcontractors and their workers'comp.policy information. I am an employer that Ls providing workers'comepensadon insurance for my employees. Below Is the policy and Job site information. insurance Company Name_Twin CITE'FIRE INSURANCE Policy#or Self-ins.Lie.#:_08WECA A8678 Expiration Date:2/15/2020 Job Site Address:331 I3RiDGE TREET 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 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 investigation,of the DIA for insurance coverage verification. do hereby certij under the pains and penalties of perjury that the information provided above Is true and correct: Signature:_ `' Date: Phone 9: (T i 1 k 1 _ oq q Official use only. Do not write in!iris area,to be completed by city or town nJjrciaL City or Town: Permit/License Issuing Authority(circle one): 1. hoard of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact !,Person: i__�__�__ Phone#: