11 CHURCH ST - BUILDING INSPECTION (39) R
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l 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 Section For Official Use Only) III
Building Permit Number: Date Applied: L Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
U :S;r SALSOIA `l �SS�x CI1nlD�Y1N�� 5
N . nd treet 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 apply in the two rows below
Existing Building❑ Repai I Alteration ❑- I Addition❑ Denwlnion ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 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 required? Yes ❑ No
Brief Description of Proposed Work: �'�r+ ���.�t ln-rE7--r
N/rT11 6,QM� SPEC r 1?��Et.1SZC'`d^lS T�Z�CSP_ . _._-
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): I 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-1❑ A ❑ Nightclub ❑ A-3 ❑ A-4❑ A-5 ElB: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ [-2❑ 1-3❑ 1-4❑ 1 M: Mercantile❑ 1 R: Residential R-10 R-2❑ R-3❑ Rd❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use[land please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ [IA ❑ IIB ❑ IIIA ❑ IIfB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Tre=nb
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A tren P
requiror specify:
Private❑ or indentify Zone: or on site system❑ permit
PP P pp > Is their review completed?
Railroad right-of-way: Flazards to Air Navigation: \I\I,�i i�n n.....
Not Applicable❑ Is Structure wuhin air art a ranch arcs. eel?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Gruup(s): Type of Construction: Occupant Load per Floor:
Does the building conlain an Sprinkler System?: Special Stipulations:
UQI-r H
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nance and Ad tress of Property Owner
IA-A" I aoa-cN -sr M A Oci]b
Name(Print) No.and Street City/Towr� Zip
Property Owner Contact Information: {MQRY-MAgE� _ MUV-FA1-/9
- 46-7-2 146rMAtC, COM
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable, the property,.uwner hereby authorizes
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 O❑nd skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address " Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
0 012?- 0A:0n11Zy/ *M62E
ompany Name
>AM VT-CL-r-AVMf4:W C) a
Name of Person Responsible fur Construction � License No. and Type if Applicable
Street Address City/Town State Zip
-- _g36 q0r AoAnnw ►1610-1 E GUIQV� COM
Telephone No. business Telc hone No (cell e-mail address
SECTION 11:bVONKE16'COMIIENSA'I'[ON INSUNANO: At i IDAVI'f M.G.L.c.152.9 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 e issuance of the budding permit.
Is a signed Affidavit submitted with this application? Yes No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE. -
Item Estimated Costs:(Labor
and Materials) "Cola!Construction Cost(from Item 6)_$
1. Building 5q03, Building Permit Fee=Total Construction Cost x—(Insert here
2. Electrical $ appropriate municipal factor)_$ -
3.Plumbing $
Note: Minimum fee=$ contact mania Ili
d. Mechanical (HVAC) $ (�
$. vlechanical Other $ Enclose check payable to C� L-�cJ
6.Tool Cost $ &I0z,zz (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest undeVite pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of owledge and understanding.
sUal✓R �4y
.A>,ntt wc.Lts�,w, � 6 2f7i I B
Please print and sign name Title Telephone No. tt
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF Si1LlNI, NUiSSACHCSET"I'S
I B1:111)NG DEPARTNIE.NT
120 WASHNGTON STREET, 3 FLOOR
�a a� T E.L. (978) 745-9595
F.tx(978) 740-9846
K1\IBERLHY DRISCOLL
vYAYOR T�tonlAs Sr.PI>✓elts
DIRECTOR OF PUBLIC PROPERTY/BUfLDNG CO>RIISSI.ONER
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Amilicant information Please Print Legibly_
V;Ilnc(13usioess.Organ ization,lnuividual):r 11/�.QR,� 1 I��N�1j �,/fit 1��� �61Z17
Address: (a
City/State/7.ip: SAI.`�_: M VGA 61e]f 0 Phone It:973yBL6 Z6e5 i
Are you un employer?Checlylhe appropriate box: 'Type of project(required):
144
14 I am a employer with g 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.0
I ana a sole proprietor or partner- listed on the attached sheet.: 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
(No workers'comp. insurance' 5. ❑ We are a corporation mid its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 tun a homeowner doing all work right of exemption per MOIL 11.❑ Plumbing repairs or additions
myself.(No workers'cutup. c. 152, §I(a),and we have no 12.❑ Roof repairs
insurance required.1 t employees.(No workers' 13.0 Other
cutup, insurance required.)
-Any applicant due checks box BI most also rill out the section below showing ibeir workea'compensation Policy inliumation.
'I fomcowncra who suhmil this alfldavit indicating they am doing all work and then hire outside centnctors midi submit a new aftidaviI indicting such.
$:,mrmcturs thin check this box must anachal an odditiorutl sheet showing ate and their workers'romp.pulicy inforn,ation.
I ant an employer that is providing workers'compensation insurance jot my employees. Balow Is the pulley mtdjob rile
information. r�
Insurance Company Name:— m. V_Eeoz_�,->
Policy A or Self-ins. Lic. d: Expiration Date:
Job Site Address: City/State/Zip:
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 ut'kIGL c. 152 can lead to the imposition of criminal penalties of a-
fire up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S250.00 a Jay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invesligotions of the DIA for insurance coverage verification. -
l do hereby certify under the pains and penatles of perjury that the h1fornatiom provided above is true cord correct
Sicnannrt: Oats
Phone N:
OJjiriul use only. Do not write in this area,to be caurpleted by city or town oJjiciut
City mr'fusvn: Permit/License N
Issuing,luthurily(circle one):
I. Board of Health 2. Building Department 3.Cilylrown Clerk 4. Electrical Inspector 5. Plumbing inspecmr
6. Other
Contact Persnnt Phone p:
(
CITY OF Sj1L.E1 t, tiL1SS:ICHUSETTS
t_ BLIIDL\GDEPARTMENT
120 WASHNGTON STREET 3iO FLoort
fi� ptn .I�.I.. (978) 745-9595
F.Aa(978) 740-984S
ICI\®F1tLEY DRISCOI.L
NLAYOR Tuonxs ST.PIEM
DIRECTOR OF puquC PROPERTY/HCILDLNG CON061ISSIONER
Construction Debris Disposal At'tidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I l I.5
Debris, and die provisions of NIGL e 40, S 54;
Building Permit Ik is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c
111, S 150A.
The debris will be transported by:
y
y {yl(le5i'A�I IrLn � ,Py�
(name ofhauler)
The debris will be disposed of in
G�lz- n
(name of facility)
— --(address of facility)
' a
signature of permit applieant
iU
date
1/8/14 Gmail-Waknofificadm
Adam Williamson <adamw110107@gmaii.com>
Work notification
2 messages
Adam Williamson <adamw110107@gmail.com> Sat, Jan 4, 2014 at 6:31 PM
To: nbrown@crowninshield.com, Mary Murphy <mary_mabel_murphy@hotmail.com>
Hi Nathaniel,
My name is Adam Williamson, I am a contractor doing work for Mary Murphy in until #111. 1 would like to
notify you that I will be replacing an exterior door and performing some punch list duties during Jan. 9th - 11th. I
understand the restrictions of the condominium and will conform. If you have any questions feel free to message
me. Thank You
Nathaniel Brown <nbrown@crowninshield.com> Tue, Jan 7, 2014 at 3:30 PM
To: Adam Williamson <adamw110107@gmail.com>, Mary Murphy <mary_mabel_murphy@hotmail.com>
Hi Adam,
Thanks for the notice. I am aware you will be replacing an exterior door.
Thanks,
Nathaniel Brown, cmcA
Property Manager
Tel: 978-532-4800 Ext. 261
nbrown@crowninshield.com
From: Adam Williamson[mailto:adamw110107@gmail.com]
Sent: Saturday, January 04, 2014 6:31 PM
To: nbrown@crowninshield.com; Mary Murphy
Subject: Work notification
Hi Nathaniel,
My name is Adam Williamson, I am a contractor doing work for Mary Murphy in until #111. 1 would like to
notify you that I will be replacing an exterior door and performing some punch list duties during Jan. 9th - 11th.
understand.the restrictions of the condominium and will conform. If you have any questions feel free to message
me. Thank You
hHM:/lmail.google.conVmaillul0/?ui=2&ilF46e5213923&Hevr-pt&searct--inbodth=1435i984eb9beBd6 1/1
11 CHURCH STREET 521-14
iS# 14877 COMMONWEALTH OF MASSACHUSETTS
Map: 35
31ock: CITY OF SALEM
lot: 0207-807
(Category: REPLACE ENTRY D'
Permit# 521-14 BUILDING PERMIT
iProject# JS-2014-001136
'Est. Cost: $900.00
IFee Charged: $25.00
Balance e Due:—$.00 PERMISSIONIS HEREBY GRANTED TO:
�Const. Class: Contractor: License: Expires:
jUse Group: Murrary Masonry&More,Corporation BrGeneral Contractor- 104223
LotSize(sq. ft) 0
Zoning: , O1v71G'r: Mary Mabel Murphy�..
Units Gamed.' Applicant: Murrary Masonry&More, Corporation Brian Beote
IUmts Lost: AT: 11 CHURCH STREET
[Dig Safe#:
ISSUED ON. 09-Jan-2014 AMENDED ON. EXPIRES ON. 09-Jul-2014
IV PERFORM THE FOLLOWING WORK:
Y7NIT 807 -ESSEX CONDOS -REMOVE/REPLACE ONE(1)EXTERIOR DOOR WITH SAME SPEC&DIMENSIONS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas PlumbinE Building
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rough: Rough Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House# Smoke
'Water: Alarm: Assessor
_Scsver:. Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
Fee Type; Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2014-001135 09-.Ian-14 CASH S25.00
,GeoTMS@ 2014 Des Lauriers Municipal Solutions,Inc.
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