0005 CRESSEY AVENUE - BPA-16-1288 The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CNIR)
Building Permit Application for any Building other than a One-or Two-Family Dwel-lirig
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official: 3 1 „
SECTION 1:LOCATION (Please indicate Block#and Lottt#�ffor locations for which a street address is notlI aila.
D PC
No.and Street City/Town Zip Code Name of Building(if appMble) ')]
i SECTION 2:PROPOSED WORK t;y1 �-p
w Edition of MA Sta Code used If New Construction check here�`or check all that apply in the two taws bE26w
Existing Building❑ Repair Alteration ❑ Addition❑ Demolition ❑ (Please fill Out and submit Appendix 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 )ij
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
\e Brief Description of Proposed Work:
I
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): Pr posed Use Groups):
SECTION 4:I3 ILDING HEIGHT AN R£A�
\ Existing Proposed
No. of Floors/Stories (include basement levels)8r Area Per Flo6r,(sq. 6.)
Total Area(sq. ft.) and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ElA-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑
I: Institutional I-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 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 ❑ Ill IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
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:
Public Cl Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑ or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: %1:1 t-ii_rtori( Corns_,si,)n Rcviin} Pr_rtvs; :
Not Applicable❑ Is Structure within airport approach area? Is their review conipleted?
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 anSpiinklerSystenr?: Special Stipulations:
�� o wh-
SECTION 9: PROPERTY OWNER AUTHORIZATION
Namg mclA,Idre 6.P_rnnnrl n...,ip__
Nan e4l?rint) No.and Street City/Town Zip
Property Owner Contact Information:
M�;Cfr P&tL
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the pro erty owner hereby authorizes
1'I 1 �5" rulV�iy4uF� ow fj j
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 Cl and skip Section 10.1) ,
10.1 Registered Professional Responsible for Construction Control
i
Name2(Ref$7istrant le hon No e-mail a 11 ss ReRe tshah�—
Kn� A M � � t l U9—;Fti oI g
Street .Address City/Town State Zip DisciP!ine Expiration Date
10.2 General Contractor
ltmll
Company Name
Name of P17on Responsible for Construction License No. ancI T)pe i 1pplicable
Street Address City/Ton n Zip
ZL
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11:4VORKEP.S'COhIPENSA"110N INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C 6 )
A Workers'Compensation Insurance Affidavit from the iMA Department of Industrial Accidents must be completed and
Submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(prom Item 6)_$
1. Building $ a5 Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
.4. blechanical (FIVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)arid write check number here
SECTION IS: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 to th best of m nowledge and understanding.
Please print and sign name Title n/�n nTelephone No. Date
�C(1N �7r E)�1✓�Zn3 I l'lp 0 i
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
✓ �\ Office of Consumer Affairs&Business Regulation
OME IMPROVEMENT CONTRACTOR
t egistration QW(39 Type:
UW'Expiration,_-'--t-t49720l7 DBA
JAMES F. NEUMANN,
JAMES NEUMANN
3 PUTNAM ST - a;
i DANVERS,MA 01923
Undersecretary
1� Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Suner-isor
License: CS-066533
ck T 1'.ti
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JAMES F NEUMAjbN 4L'
P.O.BOX p8191< IMF
SALEM MA 0197 (�)
3\r1I�/
'r,e'a Expiration
Commissioner 03/23/2017
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AYE(MMIDNYYYIT4500_R_D CERTIFICATE OF LIABILITY INSURAN11 03/2016Ducat (978) 745-6464 1L11SCERTIFICATE IS ITER OF INFORMATIONONLY 0.N000NFERS 00
ON THE CERTIFICEXTENDATEse Insurance ALTER TM CIOVERAGE E POLICIES BELOW.8 CERTIFICATE DOES NOT AMEND, EXTEND ORToning Avon-aQ
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iE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
EQUIREMENT,TERM CR CONDITION of CONTRACT OR OYNER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MA7 BE ISSUED OR MAY PERYPJN,
1E INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
GOREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. PDMY EFFECTIVE LACY EP PIRATroN
R DDY POUCY NUMBER DATE(NmUDOlYY1 DATE URATS
y TYPEDFRssuRANCE 500000
Oa+LEIALLIAELOY POP1057582 05/11/2016 05/11/2017 EACH OCCURRENCETORRENCE $
DAMAGE ORB`fIED s 50000
x COMNERCIALGENERN-11ANUTY PREMISES eccte+erbe
MFD EXP An 5000
CLAWS MADE QOpGUR 500000
PERSONAL S ADV INJURY 6
GEN2RALAGGREGATE s 1000000
GENL AGGR2rATEIPJgMOIT APPLIES PER; / / / /
PRODUCTS-OOWMPAGG 6500000
p UCy JECT 7 LOG
AUIOMOBLLELMBdRY / / / / COMBINEDSINGLELIMIT B
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SCHFAURED AUTOS BODILY INJURY
HIREDAUTOS IF&sw)deN) 8
NON.OWNEEDAUTOS
PROPERTY DAMAGE S
(Pet sxd.N)
AUTO ONLY-EA ACCIDENT 6
GARAGEL [Lrry OTHER THAN EA ACC S
ANY AUTO AUTO OWN.
AGG s
EXCt35WMBRELLA LMBUIY / / EACH OCCURRENCE 6
OCCUR F—ICLAIM MADE AGGREGATE 6
6
DEDUCTIBLE
6
RETENTION s
g WORKERS COMPENSATOR AND 438a2i4 11/19/2015 11/19/201fi 7L W RT% O
EMPLOYERS'LIABILITY EI,PACK ACCIDENT 6 100000
ANY PROPRIET0R/PARTNEWE)Q5CURVE 100000
OFFICERRAEMSER EXCUIOFP? EL DISEASE-EA@AFIA 6
ff e .deeafce under E.LDISEASE-POUCYLIMIT q 500000
SPECIAL PROVISIONS belw+ / / / /
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CERTIFICATE HOLDER CANCELLATION
(978) 740-9846 ( ) — SHOULD ANY OF THE DROVE D69(YtIB® POLICIES BE CAHCELI ED 9EFORE THE
H'�PDR/LTION DATE THERB]F, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
L_�
.30 GAYS WRITTEN NOTICE TO THE CERTIFICATE HOLLER NAMED YO THE LEFT,6UT
City OP Salem FAILURE TO DO SO SHALLIMP03E NO OBLIGATION OR UAIELITY OF ANY WHO UPON THE
IN5URER,rMAOEITS OR R6PRESFNTATNEB-
AIRHDR12ED REPRESENT /1
0 ACOND CORPORATION 1988
ACORD 26(20011081 Pepe 1 d 2
CY7YOPSALFJ14 MASSWAwl
BUZaMDEPACNW
snrar,3'°xoox
>fi 7�99RS.
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MAIM DXMISSrJUM
D9Ma Rc'Rxw AwmEwcawwm
Construct/on Debris Disposes/Af�dovit
(required forall demolition andrenovation work)
M aowrdnoe with dw sbA edjWn of the State Bugg Code,7B a^Secdon 111.50ebri
and drc P OMWIs of MGL 000,S54;Jk"W ftm*Jt Ishww wlth the
oondidon dwt the debris msukkW from dris ww*sMB be d<Wmd ofin a properly Bcensed
waste depM feci *as dethwdby M6L c 111,S 15k
The debris win be transported by:
of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
n ture of applicant
----------------
Date