31 BRIDGE ST - BUILDING INSPECTION (5) The Commonwealth of M Y assachusetts
Department of Public Safety
-�.✓• \la.s.whu..etls State Budding Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1- or 2-Family Dwe tin
lThis Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector.
SECTION 1: LOCATION (Please indicate Block N and Lot N for locations for which a street ad n available)
.\o. and Street Cite /Town Zip Code Nam��Of
Building(if applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition Q-(Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify: alw-�
Are building plans and/or construction documents bring supplied as part of this permit application? Yes ® No ❑
Is an Independent Structural Engineering Peer Review required? Yrs ❑ No,
Brief Description of Proposed Work: L/(rN'e' 1�F 1t) IWh)y� .67. P.6\r" .
-I,Le +�-:FL
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): P
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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 Heigh[(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ - A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-I ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 O, 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 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 ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ 11IB ❑ 1 IV ❑ I VA VBO
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:
PP Y
Public ❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will nut be Licensed Disposal Site❑
require, ❑or trench or specile:
Private❑ or mdenlik Zone:. or on site system ❑ permit d en dosed ❑
Railroad right-of-way: Hazards to Air Navigation: \L\ I hHan:( ooltvu.i.m K,-vr„ Prot to..:
\ot :\pphcable ❑ I.}lructure,cuhin airport approach urea' Is their rep trcv completed.'
.a'lnmcnt to Hrnd vnclnscd ❑ 1'cs❑ or No❑ Yes ❑ \n ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I Jition tit C,Ov: L,v CwLlplsl: r%pe of Construction: C)cnip.u.t Lund per 19oor: _
I)oc. Ihr building a+main an tiprinkl�r'tipslem.': Spacial Stipulations:
ohrr��q��
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Addr•sN of Properly Uwn
CFtr is C- 9 la\OGi ST A PA
Name(Print) Nu.and Street C ily/Town Zip
Pruperh lhvner Contact Information:
1 11 i A �W- Kr PA N T A K1S Q, r
Title �!' Telephone No. (business) Telephone No. (cell) a-mad address V4'
If applicable, pe rtrupertc owner hrrebv authorizes
Name Street Address City'/Town State Zip
to act on the pro pert% owner's behalf, in all matters relative to work authorized by this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(II buildin•is less than 35,000 cu. ft of endos d space and/or not under Construction Control then check here O and kip 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
98a) CoNsT
Cu nxY�Name /' S C) 66
r_T�r �r. r o r! e _ l-
Na of-P5rson Respomible for Construction License No. and Type if Applicable
/� /Y,0 _QANVe rr _ J-A 01973
Street Address �•^/�p/� C�j��)-J� City/Town State Zip
/o/ -T
Tele hone 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 O No
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor (noItem
and Materials) Total Construction Cost(from Item 6) =$J
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ Ss- P,,' GX::t appropriate municipal factor) =$
3. Plumbing �
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipalit
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ S' o 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
pp lication is true and accL rte to the best of my knowledge and understanding.
NUC r 1/r�ra f e �R*a�-Uan sr rL Co+y na r�.� '7W.9S3- 7103 9 zz to
flea>e pnnt and sign name rifle - Tclepho No. Date
r r l�/4NVe-rJ /"1l9 0/ 9 2
Street Addre,N Cit%/Town S to Zip
Municipal Inspector to fill out this section upon application approval: [ V
..Nam ).tte
J ,
Massachusetts- Department of Public Safetc
Board of Building Regulations and St:mthwds
Construction Supervisor License
License: CS 97667 „-
PETER VARONE
78 NORTH STREET w
DANVERS, MA 01923
Expiration: 8/8/2011
o
a
I
f
E'
N y N
d D�
s
All
' 1 I
l : y
l� u+
E t A
\
fJ
m � N.
CITY OF SALEM
PUBLIC PROPRERTY
�F, DEPARTMENT
,.. .
I 1, •;74-'45.9545 x: 1)78J4}.'641,
Construction Debris Disposal Affidavit
(required lbr all demolition and renovation work)
In accordance t�itb the sixth edition of the State Building Code, 7S0 Cv1R section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit f is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
l 11. S 150A.
The debris will be hansported by:
(name oC hauler)
I he debris will be disposed of in
(name of facility)
IEA� o-D �:4
(address ul ficilim
�ignoturc of permit applicant
5 Zz�)a
CITY OF SALEM
PUBLIC PROPRERTY
J DEPARTMENT
>;,�
I,NI Mt I'y:)BhCt a.l.
120WAiMWG ION SMUT 0SALp.\4,MAS!SAUIISI:'I'190197�^ '
978-745.9595 Is P.,x:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
-komlicant Information Please Print Legibly
V 8 nit: l nusiocss/Or�anintinNl nJiv iduul li
Address:
City,Slateil-ip: Phone #-
:%re you an employer•.' Check the appropriate box: 'type of project(required):
. ❑ 1 am a general contractor and I
I.El I ant a employer with 4 G. ❑ New construction
m to ces full and/ur art-tinie).' have hired the sub-contractors
,�,y P Y ( P 7. [letnodeling
2.l(� 1 ant a sole proprietor or Barton- listed on the attached sheet.
ship and have no employees These sub-contractors have S. g3"bemolirion
working for me in any capacity. workers' comp. insurance- 9. ❑ Building addition
No workers' coo 5. El We are a corporation and its
p• insurance 10.9'Electrical repairs or additions
oRiccrs have exercised their
required.) n tion er MGL I I.❑ Plumbing repairs or additions
3.❑ 1 ❑ni a homeowner doing all work right of exu p p
myself. LNo workers'comp. C.
152, q 1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' 13.0 Olher
comp. insurance required.)
-.Any:5,1111eaut that chucks box n1 must also lilt um the section tmuw slowing Ihcir workers cumpensation policy information.
'I Iomcuwners whu submit this anidavir indicating they aie doing all work and then him umside cu,ur:ietom must outm a a new atfd vit indicating such.
Comrxtun Ihal check this box mucl an=11W.m addiliunai sleet showing the nanie of the sub-conlrxwts and their workers'ewnp.prdiry information.
l ani mi employer that it providing)vorkers'c•onpensatiott hisurmice fo•my euiplayees. Before is the policy and job.cite
information.
I nsurancc Company Vane: __—.___ ....
I'olicv 4 or Self-ins. Lie.tl: ___-.. .. .. ._-__ Expiration Date:
Job Sitc Address: City/stawizip:
%ttach It copy of the workers'cumpensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section'_5A of.'IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500,00 and/or one-year imprisomncnt, as well as civil penalties in the furm of a STOP WORK ORDER and a fine
of up to S250.00 it day against the violator. Ile advisad that a copy of this statement may be forwarded to the Office of
Inwxngauuns ofthe DIA for insurance covcragc verification. -
l do hereby certify ttnu,lcr tloe pains rand p iulties jo p7rjury that the infunnurlon provided above is true d correct.
51✓:Inn urd: _
t°/Cr I/a1 Der P l/ �Ut Date: to/G/ rai
o
I11lei /- -7el- (?S3 -7/0-9
Ojjicial use apply, Do not write in this area, to he completed by city or foivn ojJicial.
City or Town: Permit/License-4
Issuing Aulhorily(circle one):
I. Ituard ofllydlh 2. lluildin- Dcpartureut 3.Citi fovIn Clerk 4. Electrical luspcctor 5. Plumbing; Inspector
6. Other
f
Contact Pcrsuu: _.. -._. Phone tl:
Information and Instructions
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
cypress or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of :m Individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment he deemed to be an employer."
MGL chapter 152, $25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
:applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, bIGL chapter 152, y25C(7)states"Neither the commonwealth nut any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the.contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and dule the affidavit. The aff idavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law Or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials .
Please he sae that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to 611 out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in (he permitilicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitllicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by are city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he Of l ice of Investigations would like W thank you in advance fur your cooperation and should you have any questions,
Please do not hesitate to give us a call.
The Ueparunent's address, telephone and fax number:
The Commonwealth'of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 0211 I
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
revised ;-zv-vs
Fax #617-727-7749
www.mass.gov/dia
Find a Licensee Page ] of 1
The Official Website of the Executive Office of Public Safety and Security(EOPS)
Mass.Gov Home
Public Safety
Department of Public Safety Licensee Lookup
The list is current as of Monday,October 04,2010,
You can search/filter the liceruee list by any of the criteria below.
License Businesses Individuals �_
Select a License Type Construction Supervisor
Search by License Number 907667
Search
Select a License Type Select One _
Search by Business Name
Search by Contact Last Name —� First
Search by City Zip Code -
Search
Select a License Type Construction Supervisor
Search by Last Name First F
Search by City Zip Code�—
Search
I
€Search Results
LICENSE TYPE BUSINESS NAME CONTACT NAME LICENSE RESTRICTION ADDRESS STATUS
Construction Supervisor'N/A 'Varone Peter 197667 00 --Danvers,MA 01923 Current
http://db.state.ma.us/dps/licenseelist.asp 10/6/2010