11 CHURCH ST - BUILDING INSPECTION 302 GKITooz �33�
The Commonwealth of Massachusett1.ECEIVED
Department of Public Safety
Massachusetts State Building Code(780Ca pEG7`(��RL SERVICES
Building Permit Application for any Building other than a One-or Two-Family
(This Section For Official Use Only) Q
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)
tJ NI 3oz,
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK
` Edition of MA State Code used If New Construction check here❑or check all that aPPY�1 the two rows below
m
Existing Building❑ Repair EVI Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
1
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 Engineering PeezAwiew eq i ed? Yes ❑ Nq �—
BriefDCZriptioroo^ProposedWork: 4 � 7� �'°2 ey%-U —t—
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDTTION,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(fL)
SECTION 5:USE GROUP Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: Fligh Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ M 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&CONSTRUCTION TYPE(Check as applicable)
IA ❑ 1B ❑ HA I1B ❑ IIIA ❑ M13 1 TV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information Trench Permit Debris Removal:Sewage Disposal: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p
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: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
Go �ar� 1 Z LA FOP-
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
(_ -e��a me')W Vl I l IM IMP W10
Name(Print) No.and Street City/Town Zip-
Propertywne Contact h o ation:
Ti Y IYeI 1�s) �le
T 5�► me► ru
Title Telephone No.(business) Telephone No. (cell) e-mail address Moo I
If applicable,the property owner hereby authorizes
amdr�;JA250M)yrl INC- ZE) is r-_Lep►coo
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)
building is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here O and sldp Section 10.1
10.11Re ' tere ofessional Res onsible for Connsttr�uction�1Control /�... /�
V1J1S �7�J -t 3 -�1L7�_hf.s. PW�ro1rFld�/✓ri'Imn l .5. 004 a�,--2,
Name(Regis Te Done No.l e-mail a dress C Regis ati n�j umber
� d
Street Address City/Town State Zip Discipline Expiratibn Date
102 General Con
rLS to 0V
Co any NamoD
Name of Person possible fo Construction License No. and Type if Applicable
Street Address City/Town Sta Zip
_ c112
Telephone No.(business) Telephone No. cell e• ail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 O
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estmated 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 I $ (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 th m kno a and understanding. qy� (���
� \ $ta MP.` of CO • inn -�- �, 11 a51
G
Please prin an ign name C ` ` Title Telephone No. Date
\\
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: D A-w Lam/
Name Date
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x'where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas(Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Enerpy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify) J
*Areas of Design or Construction for which plan are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
-0(4a3?
�e- 6il d ris a `(9 Registration Number
Name(Regis ant Telephone No. e-m il address
fi�4 �ws�� <-h�c� Pr ( olg3� ; �S t Ib
Street Address Ci /Town State Zi Discipline Expiration ate
�• __ NIA, ltiro6`r4
Name(Registrant) Telephone No. e-mail address Registration Number
li•iC � 1
Street Address City/Town State zip Discipline Exp' ation Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration 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)
No.and Street City /Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ 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 lndustrialAccidents
Office of Investigations
1 Congress Street, Suite 100
_ st Boston, MA 02114-2017
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information \ \ Please Print Le ibl
Name (Business/Organization/Individual): V,r S I ZZ
Address: \\ .
City/State/Zip:G1oVice.SVev . 0�'_2'-O Phone 4: `�0 1a3 �aS3
Are you an employer? Check the appropriate b Type of project(required):
1.❑ I am a employer with 4. 1 am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g• ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P n'• i 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
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 I LF1 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] : c. 152, §1(4), and we have no
P
employees. [No workers'
13_E Other e
comp. insurance required.] I
*My applicant that checks box 41 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 sub-contractors and state whether or not those entities have
employees. If the sub-contractors 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: '�Wy\p.I,.e �1 r St,�gv�t e l 0 .
Policy#or Self-ins. Lic. t l(�} silo kul r ��zn sw 7e5O Expiration Date: � l �1p
Job Site Address: C 1nvr�V JW IF M 01g10 City/State/Zip: 501 V°1 e-WX 14- 01g-10
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 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 here/by ce under the pa and pen ies ojp that the information provided above is true and correct.
Signatttc Date: 1 k +a r2 [H
Phone#: ill A �{a��,a U_2_D
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
6.Other
Contact Person: Phone#:
ACO DR ®`..►- 11/24/2014 CERTIFICATE OF LIABILITY INSURANCE DATE INW 0
THIS 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 MOLDER.
IMPORTANT: 0 the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. N 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 endorsemen a .
PRODUCER T raren zager
Carroll X. Steele Insurance Agency, Inc PHONE (978)283-5100 1 FAX .197e)101-0173
32 Pleasant St. E .kzager@cketeele.com
P.O. BOX 1347 INSURERS AFFORDING COVERAGE NAICO
Gloucester MA 01931 INSURERA:Hanover Insurance Company 2292
INSURED INSURER B
Seaside Glass & Mirror Inc INSURERC:
2 A Pond Road INSURER D:
INSURER E:
Gloucester MA 01930 INSURER F
COVERAGES CERTIFICATE NUM13ER:CL14112405129 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 LTR TYPE OF INSURANCE N POLICY EFF Y EJIP LIMITS
GENERALUAMLITY EACH OCCURRENCE $ 11000,000
COMMERCIAL GENERAL LIABILITYPRM $ 300,000
A CLANS-MADE ❑OCCUR DE111561075S /1/2010 /1/2015 MED FXP JAny o S 10,000
PERSONAL S ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS-CCMIPIOP AGO $ 2,000,000
X POLICV PRO- LOC S
AUTOMOBILE LIABILITY E==D SINGLE LIMIT
ANY AUTO BODILY INJURY IPe I,m ) $ —
ALL OWNED SCHEDULED AUTOS BODILY INJURY(P@I ecciUenl) S
AUTOS NON-OWNED PROPERTY DAMAGEy
HIRED AUTOS N
AUTOS Pr wdwl
S
UMBRELLA We OCCUR EACH OCCURRENCE S
EXCESS UAB CIANS-MADE AGGREGATE S
DECRETENTION S
A WORKERS COMPENSATIOM I WCS A LL H-
AND EMPLOYERS'UA&LnY YIN Y l M rrp
ANY PROPRIETORIPARTNEWEXECUTIVE E.L.EACH ACCIDENT S 100 000
OFFICERNEMSER EXCLUDED? NIA S610906 /1/2014 /1/2015
(NINXIM9ly In NH) E.L.DISEASE•EA EMPLOYE S 100,000
R yBS,0asorAN wNr
DESCRIPTION OFO ERATIONS OBIOP E.L.DISEASE-POLICY LIMIT 1 500.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Aeae ACORD 101,Ackftl al Rsumfts ScheW ,Nuu,re space 1."uYea
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Jennifer Meldrum ACCORDANCE WITH THE POLICY PROVISIONS.
11 church Street, #302
Salem, MA 01970 AUTHORWm REPRESENTATIVE
CARR91ILKSWLEiNV AW4AGENCV,W,
ACORD 25(2010105) 01988-2010 ACORD CORPORATION. All rights reserved.
INS026mioos).o1 The ACORD name and logo are registered marks of ACORD
The Essex Condominium
Telephone: 978-532-48001 Far:978-532-6023
Crowninshield Management Corp.
18 Crowninshield Street
Peabody,MA o196o
Ms.Meldru
Unit 302, The Essex Condominium
1 I Church St.
Salem, MA 01970
Dear Ms. Meldrum,
The Essex Trustees have reviewed your request to replace the windows of your unit. The Trustees
have given their consent for you to proceed with your project utilizing Seaside Glass, but with the
following qualifications:
The Trustees are not in a position to assess the engineering details of 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 does not"affect the appearance or structure of
the Condominium,or the 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 a vis hours, removal of refuse,noise,etc.).
Regarding replacement windows and doors,please be aware that:
Windows must be of a quality equal or greater to the original windows;
Installation shall be done by a reputable contractor with a good work record and
references;
The appearance from the outside must be identical to that of the original windows,
specifically as to color(white),number and spacing of mullions(grids),and location
of mullions/grids on the outside the outer pane(not between the panes);
Screens must cover only the bottom half of the windows to match those throughout the
rest of the building;
Flashing must be to Massachusetts code standards.
Please contact the Management Company if you have additional questions.
Good luck with your project.
LAI�-4-
Signed. as managing agent Date: October 29 2014
for the Essex Trustees
*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. 84.
Both are available in the black bound copies of the Essex Condo Documents available from the
front office.
>�t Massachusetts -Department of Public Safety Unrestricted-Buildings Of any use group which
Board of Building Regulations and Standards contain less than 35,000 cubic feet(991M )of
Construction Supervisor 1 enclosed space. -
License: CS M233
CHRISTOPHRR AAP
594 WASfIIIHGSTON31
GLOi7CESTER MQ 01930
.� Failure to posses a currentedition of the Massachusetts
'A
Expiration State Building Code is cause for revocation of this license.
Commissioner 06N3/2016 - For DPS Ucensing Information Nsie w .Mass.Cwv/DPS
lJ�e f(.C:nMrrnHrrK'nll�OC%��nJ:inr�rUn.//' e
$jEx
Ofee of Consumer Affairs&Business RegulationOME IMPROVEMENT CONTRACTORegistra0on 176679 Type: -plra0on 9l17/2015. Intlividual. License or registration valid for individui use only
before the expiration date. If found return to:
CHRISTOPHER ANTHONY PALAZZOI.A Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
? ' CHRISTOPHER PALAZZOLk ` ^ ,: Boston,MA 02116
594 WASHINGTON ST
gas"
GLOUCESTER,MA01930 Undersecretary
Not valid without signature
3{lltite?I States ElfltirRtt ctft8l i0Tittitchan 31geR>:q
Witis is to rutitq that
l Chris A.Palsaola
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11/2 M14 City of Salem,MA-Inspectional Services(Building DepartmenVPublic Property)
Salem City Hall 93 Washington Street Salem,MA 01970
ph: 978-745-9595
Inspectional Services (Building Department/Public Property)
Contact: Thomas J.St.Pierre,Insoectional Services Director,x-5640
Michael Lutrakowski.Asst.Building Inspector,x-5648
Dennis M.Ross,Plumbing Inspector.Gas Inspector,x-5639
Address: City of Salem Inspectional Services, 120 Washington St.,3rd Floor
Salem ,MA 01970
Phone: (978)745-9595 x5641
Fax: (978)740-9846
Hours: Monday-Wednesday 8AM-4PM
Thursday 8AM-7PM
Friday 8AM-Noon
Counter Hours(Inspectors present):
Monday-Thursday 8AM-9AM and Noon- 1 PM
Thursday 5PM-7PM
Friday 8AM-9AM
Inspection Hours
Monday-Friday 9AM -Noon
Monday-Thursday 1 PM-4PM
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1 WSM14 City of Salem,MA-Fees
Fees
Printer-Friendly Version
Minimum Building Permit Fee is$25.00.
Rates are:
$7.00 per$1000 spent for 1 &2 families.
$11.00 per$1000 spent for Commercial Properties.
Archive Search Requests$30.00
Zoning Letters$30.00
Certificate of Inspection basic fee is$60.00 (some properties are subject to a different fee schedule due to the nature of
their use group.)
Certificate of Occupancy where applicable is$30.00.
Plumbing and Gas Permits are granted to Licensed Tr
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