11 CHURCH ST - BUILDING INSPECTION 413 The Commonwealth of Massachusetts
V Department of Public Safety <T'J50 a=
V Massachusetts State Building Code(780 CMR) J
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: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
# Ni / 1�y13 'fd-lbw o/9 () Vie, Essplc
M No.and Street City/Town Zip Code Name of Building(if applicable)
N SECTION 2:PROPOSED WORK
Edition of MA State Code used-6t e�Ji tixtIf New Construction check here❑or check all that apply in the two rows below
t Existing Building❑ Repair❑ 1 Alteration Addition❑ T Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 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 Engineering Peer Review I r`equired? / Yes ❑ No ❑
Brief Description of Proposed V1'ork: k ey(%d V'(/l2i t�" eL4"9U Z-�8 t l k e- U,-2 (. B a. '
�rdie+a G`7,10 S a oL Goo telrs 5
6�4-' �
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-I ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: Iii h hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 V R-3❑ R-4❑
S: Storage 5-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 111 ❑ HA ❑ JIB e I IIIA ❑ I11B ❑ 1 IV D I VA ❑ VB Q
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:
Er
Public V Check if outside Flood Zone Indicate municipal A trench not be Licensed Disposal Site
required 41'or trencfi or specify:
Private❑ or urdentify Zone: or on site system ❑ permit is enclosed ❑
Railroad right-of-way Hazards to Air Navigation: MA I h0oric Cosimission Review i'rtx•ess:
Not Applicable- Is Structure within airport ap oach area? I/ is their review completed?
or Consent to Build enclosed❑ Yes O or No G�,4- Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code;_Use Group(s): Z Type of Construction: f B Occupant Load per Floor:
Does the building contain an Sprinkler System?:-e3 Special Stipulations:
G I�t-t.Ir--- p z e j o A . �cPQu o s
rvante anu Aaoress or vroper owner - ]3
i kef d �No
��M lA �rm 0/9
Name(Print) .and Street City/Town Zip
Property Owner Contact Information:
11� is- 3�0 96-550Esh; SQ1177a,i.t.t,
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 act on the propertv 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,wo cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Contr 11
rw w II
��b't� tL�.t �er, ,ca
Name Reg istr nt) Tele ne No. e-mail add s Registr don Number
fyv � _D_14X �,t �hr—�3i-15
Street Addres City/Town State Zip Discipline Expiration Date
10..22 G_eneeral Contractor
—tll-v_r c'Le- D` �d h u� fJr�r bl�
Co m am•Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
_33S _ �crt ( ca� f2 � k� — *c,>- C_tr,
Telephone No. business Telephone No. cell e-mail address
SECTION 11:',ti pRKi ltS'[O�---ATION N-lib NU A_IllDA11T 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 t to issuance of the building permit.
Is a signed Affidavit submitted with this application? YesO, No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_
1.Building $ .2
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ .Z cUUJ appropriate municipal factor)_$
3.Plumbing $ SUv
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $
6.Total Cost $
Enclose check payable to
3v Q(,J. (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
applhation is true and accurate to the best of my knowledge and understanding.
0.�+i cQi Ti,alter tai.,pdQ
�l/ a.u,ed ell_Z i o - z3 f io8o M
Please print and sign name DRV t 11 1./, lc
C.ip'" Title Telephone No. Date
Street Address City/Town Sta e Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block # and Lot# for locations for which a street address is not
available)
{ C� ��
,)(& )TC_ t r ' 1 A IeM t� -rile. Essr,)(
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property die following action was taken:
Water Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No
Gag Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No
Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No
Yes O No Provider notified and Release obtained? Yes ❑ No
Other (if applicable)
Yes ❑ No Provider notified and Release obtained? Yes ❑ No
Other (if applicable)
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
u,p
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): (i_4oS (?y�2 5
Address: S P ,7Yi9.-1 S
City/State/Zip: Phone#: / 17S - 3S' 36AJ
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
( P )
2.P 1 am a sole proprietor or partner- listed on the attached sheet. 7.t Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
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 11.0 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#1 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.
(Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lie. #// Expiration Date:
Job Site Address: d /'01 417,;3 City/State/Zip:SQL
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$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a true
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 Gerd der the p ' and penalties of p ry that the information provided above is true and correct.
Signatui Date: .29 — /,5
Phone#: - J
Official use only. Do not write 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
1.Other
Contact Person: Phone#:
Initial Construction Control Document
To be submitted with the building permit application by a
R a Registered Design Professional
for work per the 8`h edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Unit 413 RPnovat;nnc Date: May 27, 2015
Property Address: 11 Church Street Salem, MA 01970
Project: Check one or both as applicable: ❑ New construction xI Existing Construction
Project description: Interior Renvovations as noted on Building Permit Application and drawings
I Richard Griffin MA Registration Number: 7e14 Expiration date: 8-31-2015 , ama
registered design professional, and I have prepared or directly supervised the preparation of all design plans,
computations and specifications concerning:
[x] Architectural [ ] Structural [ ] Mechanical
[ ] Fire Protection [ ] Electrical [ ] Other
for the above named project and that to the best of my knowledge, information, and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted
engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review,for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building,_offcial.
Upon completion of the work, I shall submit t [c a`Final Construction Control Document'.
Enter in the space to the right a"wet" or
electronic signature and seal: z i
Y814 J
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Phone number: 978-740-9979 d �y mall. richard®rgriffinarchitects.com
Building Official Use Only
Building Official Name: Permit No.: Date:
Version 06 11 2013
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Massachusetts Department of Public Safetyy
Board of Building_f2egulations anrlStandafits -
Construchon Supersisor
License: CS-071854/
CARLOS GOMES-`
701,AWRENCE ST
SALEM MA 01970 _`-
Expiration
Commissioner ,.
Office of Consumer Affairs&Business'Regulation
OME IMPROVEMENT CONTRACTOR -
egistration 135110 Type:
Expiration 3/11,2,f 9& . Partnership _
GOMES BROTHERS CONSTRUCTION - -
i
'CARLOS GOMES
- E° :55 CENTRAL ST.
--PEABODY, MA 01960 Undersecretapy
11t1.e rssex uonaommium
Takphane; 978-63240M 1 Fax:9784532-0028
CrOUMimideld Management Corp.
sSCrourni WeldSnvw
Peabody,MA o1g6o
Janice Tucker Rhoda
Unit 413,The Essex Condominium
11 Church St
Salem,MA 01970
Dear Janice Tucker Rhoda,
The Essex Trustees have reviewed your request for extensive refurbishments of your unit,
including electrical and plumbing work.The Trustees have given their consent for you to proceed
with your project,but with the following qualifications:
The Trustees are not in a position to assess the engineering details 9f your request,nor can they
be assured that the final product will be in accord with the plans.Thus,you the owner retain the
responsibility for ensuring that the finished work is in accord with the Essex Condo Documents*
in that it does not"affect the appearance or structure of the Condominium,orthe integrity of its
systems';that"all materials used and Work performed shall comply with all OSHA,other
federal,state,county,and municipal laws,rules,ordinances,codes and regulations';and that the
work is carried out by the contractor in the manner specified by the Essex Condo Documents*
(vis-d-vis hours,removal of refuse,noise,etc.).
Regarding this work,please be aware that:
`/• The contractor must remove from the Essex Condominium property all discarded materials used in
the refurbishing,including paint cans and also all furnishings,plumbing,and electrical fixtures
formerly installed in the unit
X• The contractor may not use the front circle for parking of vehicles but may use the West Alley if
space is available and should leave a note on the windshield with phone#and unit m aa�. x
• The hallway sham are intended fro residents'use- may be u y e contractor only for
transport of materials that will not damage or deface the cart and must be imatedately returned after
each such use.They are not to be used at any time for temporary storage of materials or as a
workbench or paint cart Frerne✓Pi
�/• The buzzer referenced in the proposal maybe that for the old wired hgm stem from the two lobby lbwk-A01
vestibules If so,it serves no function and could be removed,it has been replaced by a telephone
U—Stm-
717ciffir the Trustees nor our management are aware of any current leaks affecting Unit 413 but cannot Kt ll cyh GH
guarantee that there are none.We advise you to check with the prior owner regarding any recent
issues. TI"py10.
• The refurbishment shall be done by a reputable contractor with a good work record and refer,
and,as required by State Building Code,the contractor must obtain a building permit from the City of coN Salem.This ensures that the contractor is properly licensed and insured.
Please contact the management company if you have additional questions. y ec
Good luck with your proiect be✓12
Signed: ts` Date: May 12.2015 5�►0�?
for the Essex Trustees „t g
*Exhibit C of the Certificate as to the Rules and Regulations,Book 23224,Pg.241,South Essex Registry
of Deeds and Sections 5.2 and 5.15 of the Declaration of Trust,Book 101169,Pg. 94.Both are available in
the black bound copies of the Essex Condo Documents available from the font offim
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