B-19-684 - 0001 BROAD 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.Sechon For Official Use Only)
Building permit Number: Date Applied Building Official:
SECTION 1:LOCATION .
No.and Street City/Town Zip Code Name of Building(if applicable)
Assessors Map# Block#and/or Lot #
SECTION 2 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❑ Alteration Addition❑ Demolition ❑ (Please fill out and submit Appendix 2)
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
Is an Independent Structural Engineerin Peer Review required? Yes ❑ No
Brief Description of Proposed Work: ON is V+A-.
i?
SECTION 3:COMPLETE THIS SECTION IF EXISTING.BUILDING UNDERGOING RENOVATION,ADDI N,O ,A
k
CHANGE IN USE OR OCCUPANCY
Check here if an Existiri Building Investigation and Evaluation is enclosed See 780 CMR 34 ❑
g 8 ( )
Existing Use Group(s): Proposed Use Group(s): Tj
`r
SECTION 4:BUILDING HEIGHT AND AREA
Existing Fropos�d
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❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ 1 R. Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S 1❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ TA ❑ JIB IIIA ❑ IIIB ❑ IV ❑ I VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or 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 No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
Name Street Address City/Town State Zip
to apply for and 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 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 13.,
Otherwise provide consiruction control forms see section 107 in the code as r; aired.
10.1 Registered Professional.Res onsible for Construction Control(the professional coordinator document submittals),
3 -3fti%Decc 0 V*gx.Coo CS lCo 3
Name(Registrant) elephone No. e-mail address Registration Number
ar,4 0 9� uN�er�sc7r9 CSC f� a,
Street Address City jown State Zip Discipline Expiration Date
10.2 General Contractor
ei t f AV
Company Name
,TA,g�z &cSd
Name of Person Res onsible for Construction License No. and Type if Applicable
3 s� a. Afl Dl a..
Street Address l t City/Town State Zip
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 VNo O
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 $ 14000 appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ /�� N,o�te�:Minimum fee=$ (contact municipali. )
5.Mechanical Other $ \J��''���L..
Enclose check payable to
6.Total Cost $ 2 o O p_ `-d (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under airs and penalties of perjury that all of the information contained in this
application is true and ac r to to the best o ledge and understanding.
(>c540C C`CAs��im — (od3 -5-71 _ 7 22F 6 LV
Please print and sign na ej Title Telephone No. Date
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval: —/
Name Date
The Commonwealth ofMassachuseas
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
Aanlicant Information Please Print Lei ibly
Name(Business/organization/lndividual):
Address:_ 3 �eue y l
City/State/Zip: �r� �> Rk Phone M 6 D � 3 2 '
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. I am a general contractor and I
,employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.# 9. Building addition
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 11.❑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.❑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 such.
tContractors 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 the suit-contractors have employees,they must provide their.workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-his.Lic.M Expiration Date:
Job Site Address:. City/State/Zip: 'S1nEVE &A 007 '7 0
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$250.00 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 under the p ' d enaNes of perjury that the information provided above:'s a and correct,
Si atu Date: a ? l
Phone#: �z .,6D 3 -2 ( " ? Z 2,g
Qokial use only. Do not write in this area,to be completed by city or town offwiaL
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 M
CITY OF SALEK AWSAC HUSE TTS
BULDING DEPART) ENT
120 WASI•IMMNSTREET,PFLOOR
TEL(978)745-.9595
FAX
KnMERLEYDRISOML (978)74a9846
MAYOR 71MMAS STAERRE
DIRECTOR OF PUBLICPROPERTY/BIImmr-OONI assiomR
Construction Debris Disposal Affidavit
(requiredfor 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:
�0 S
name of hauler)
'The debris will be disposed of in:
(name of facility)
(address of facility)
7
j
aturZof pplicant
l
(toda date
0- �
I 6ifice of Consumer Affair ion
HOME IMPROVEMENT CONTRACTOR
Ty QIndividual
Re ist o DMiration
06/26/2021 i
ia(
JAMES BISHOP��
JAMES M.BISHOP,
3 KELSEY RDy
I
BOXFORD,MA 01921" Undersecretary i
wj
" i
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
ConstrubtI Aborvisor
j.
CS-069613 xr E5;pires:06/01/2021
JAMES M BI,IOP ix ,
3 KELSEY RDy<
BOXF()RD MIk Oi92�1 0w
�'O/SS�:I��`
Commissioner
9 ,
r
Your Confirmation number is 2019062710118203
Date'of Confirmation:6/27/2019
NOTE:When paying by ACH(Checking)it will take two business days for the payment to be debited from your bank account.Your
account numbi�r 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$28.95 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: JONATHAN EDWARD HALL Payment Type: Credit Card
Note: QUICK PAY TRANSACTION Payer Name: JONATHAN EDWARD HALL
Card Number: **************7852
Transaction Information
Transaction Quantity Amount Fee Payment Type
City of Salem-Inspectional Services 1 $25.00 $3.95 Credit Card
Building Permit
First Name:J,:3mes
Last Name:B'shop
DBA/Company Name,if applicable:
SAME
Name of permitted/inspected property:
1 Broad Street,unit
Address of permitted/inspected
property:1 Broad street
Phone#:603-371-7228
Contact Email Address:
jmbishopccC-yahoo.com
Total:$28.95
I
Lesley
Management
June 20, 2019
Re: Andrew L. Marchese
1 Broad Street
Unit# 1
Salem, MA 01970
To whom it May Concern,
Please allow this email to confirm that The One Broad Street Condominium Trust is
aware and approves of the following improvements to the One Broad Street,Unit# 1,
Salem, Massachusetts.
o Remove existing vanity in 1 upstairs bathroom
o Install hookups for Washing Machine and Ventless Dryer in vacated area
where previous vanity was located
o Install new vanity in opposite side of bathroom
o Replace existing tile in bathroom.
o Move Light fixture from existing location to above new location of vanity
If you need anything else, please do not hesitate to contact our office.
Sincerely,
K%vwberly LarcL
Kimberly Lord
P.O. Box 946 Marblehead, Massachusetts 01945
Telephone (781)639-0534 Facsimile (978)374-4852
Lesleymanagement@comcast.net
Enclosures.
P.O. Box 946 Marblehead, Massachusetts 01945
Telephone (781)639-0534 Facsimile (978)374-4852
Lesleymanagement@comcast.net