195 DERBY STREET - BUILDING PERMIT APP JACKET C IJI VJ GO Cte, 1(,OLM
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r>� The Commonwealtfd�'F1ggMh yjRES
11 Department of Public Safe p1
/V \�Iassuehriptts State Build INVA41,1A Rr 40
kqR Building Permit Application for any Building other than a One-or Two4amily Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Zo Buildngofficial:
SECTION 1: LOCATION(Please indicate Block H and Lot q for locations for which a street address is not available)
M Stifle,-, /her- o<f 76
No.and Street City/'Fawn Zip Code Name of Milding(if applicable)
SECTION2.PROPOSED WORK
Edition of ib1A State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building KI
Repair Pr' Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use - ❑ 1 Change of Occupancy ❑ Other ❑ Specify: ife.A- 4_� '
Are building plans and/or construction documents being.supplied as part of this permit application? Yes ❑ No
a Is an Independent Structural Engineering Peer Review require ? Yes ❑ No
Brief Description of Proposed Work: /4,oue��_ .�.Q
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 CNIR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)q 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-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business M' E: Educational ❑
F: Facto F-I ❑ F2❑ ll: High Hazard F1-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-l ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-l❑ R-2❑ R-3❑ R11❑
S: Storage S-1 ❑ S-2❑ U; Utility❑ Special Use❑and please describe below:
Special Use:
SECTION G:CONSTRUCTION'I-YPE(Check as a licable)
fA ❑ Ill ❑ IIA ❑ I18 ❑ ILIA ❑ IIIB ❑ 1 IV ❑ I 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:Licensed Disposal Site ErPublic d Check if outside Flood"Lune❑ Indicate municipal t Ef A trench will not be required❑or trench or specify: Sole...
Private❑ or indentify'Lone: or on site sysystem❑ permit is enclosed❑
Railroad right-of-wa ` liatanls to Air Navigation: �L\! I n ynnry si n 11•r� I res:
Not Applicable Is Slru[ture within airport ap roach area? Is them review completed?
or Consent to Build enclosed❑ Yes❑ or No(S� Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY /11 ,-
Edition of Code: Use Group(s): Type of Constriction: Occupant Load per Floor:_
Uoos the building can Lein an Sprinkler Systum?: Special Stipul:lions ___
7 SFEVEtJ LS� I1" r° Vlwac�� CONsi - 03
L
a
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Otvqnen_„�
olqz
Name(Print) No.and S 19et City/'Gown Zip
PIr/t�pfe�{1 Owner C) I et liyifo�in.)fi`on:E(I J/) 111�
V• 1 �f��-b � ,30?a =— �iCX�/ r--r rMa'C @�/�oo .
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 property owner's behalf, in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less thin 35,000 cu.ft.of enclosed s ace anJ or not under Constmction Control then check here Mind skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address _ Registration Number
Street Address City/'Gown State Zip Discipline Expiration Date
10.2 General Contractor
Ur (7a�,_ Cft �-vc�i
Company Namof
Nam•of Persot Responsible
for Construction ,1 License No. and Type if Applicable
/1� 0`F�. c �V /vlgl A/ (N I M�t Q/9Ys
Street Address City/Town State Zip
V.. 7� Iff-617rEck ` eVA601DAG ih
Tete hone No. business Telephone No, cell e-mail address
SECTION 11:W01,'Kh724 COAiPFN5A"IION INSURANCti Al-TIDAVff 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
Item clod Materials) Total Construction Cost(from Item 6)_$ ' ,
1. Budding $ Building Permit Fee-Total Construction Cost x (Insert here
2. Electrical 5 appropriate municipal factor)_$
3. Plumbing
At. Mechanical (HVAC) 5 Note:I'dininnum fee=S (contact municipality)
S. Mechanical Other 5 Enclose check payable to /'.•H d M
6.Total Cost 5 ) �/\ 1 (contact municipality)and write check umber hero
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 cs tru and accurate to the best of my k 1•dge mderstan m
Please print andd name t C�e /9 /{ / A Telephone No Dote
/�/1 O /�tS/l�`' ill, GtQ r/ /�r_/ '
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. WCC-500-5001342-2014A
PRIOR NO. WCC-500-5001342-2013A
ITEM
1. The Insured: Village Construction Inc
DBA:
Mailing address: Mr Michael Rockett FEIN:"'"'1709
190 Pleasant Street
Marblehead, MA 01945
Legal Entity Type: Corporation
Other workplaces not shown above: See Location
2. The policy period is from 03/11/2014 to 03/11/2015 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 A
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTEA 137531
INTER SEE CLASS CODE SCHEDU E
Minimum Premium $550 Total Estimated Annual Premium $550
GOV GOV Deposit Premium $138
STATE CLASS
MA 42 MA Assessment Chg.
$9.00 x 3.4000% $
This policy, including all endorsements, is hereby countersigned by 63!ej' 5?,& -.Cry 01/15/2014
Authorized Signature Date
Service Office: Boston Insurance Brokerage Inc
54 Third Avenue
Burlington
24 Federal Street, 4th Floor
Burlington MA 01803 Boston, MA 02110
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
The Commonwealth of Massachusetts ECEI EO
k Board of Building Regulations and Standards "NSPECTIONAL SERV OF
WMassachusetts State Building Code,780 CMR S
1 Ib JRW e��dOMOarzorr
Building Pemtit Application To Construct,Repair,Renovate Or mo t
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number. I Date Applied:
� l.S I•w-Il�
Building Official(Print Name) Signature Date
' SECTION 1:SITE INFORMATION
1.1 Property A dress. u� 1.2 Assessors Map&Parcel Numbers
l q -� J)P rL � ��� �1' Y1 �I l� �
-- l.la Is this an accepted street?yes_ no Map Number Parcel Number
'ryI 1.3 Zoning Information: 1.4 Property Dimensions:
►�-+ Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requved Provided Required Provided
1.6 Water Supply:(MG.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHW
2.1 Owner- of Record:
A4rmr G uzoWSkl G1Ni7'� S/Yl Pm l�A
Name(Print) City,State,zip-
if
&fz h h S4- -7Sr1—a
No.and Sheet ITelephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORD'(check all that apply)
New Construction❑ Existing Building M Owner-Occupied JM Repairs(s) ❑ 1 Aheration(s) M Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': l-2;v x Tu. m 6f l-a y-S � J P w
�Ov�l rj c/i G,� ��G.. Cfi/t-�I I=e�fC L�aei sn 7'r2
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Cow: Official Use Only
r and Materials
1.Building $ /a a 00_ ego 1. Building Permit Fee:$ Indicate how fee is determined:
2 Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cose(Item 6)x multiplier x
3.Plumbing ) $ 2. Other Fees: $
(�AC 4.Mechanical $ List
5.Mechanical (Fire $
S cession Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ %2 Odd, v� ❑Paid in Full ❑Outstanding Balance Due:
fY\AiL- 50 I !21 (1 (�
°�i Olt 06/6 fttl�_
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) J o- s _ 01 1 -7 Og ao I
n'11 c N-R c C_ M� w, k 1 R-M License Number Expiration Date
Name of CSL Holder
'/
1'/'vC e- List CSL Type(see below)_ (/ _
N .o and Street Type Description
,n n A r �� U Unrestricted s to 35,000 ca ft
YU I k _ �l7 R Restricted 1&2 Family
City own,State,ZIP M Masonry
(, d t n 7 K Tj RC Roofing Covering
WS Window and Siding
G Q '/ SF Solid Fuel Burning Appliances
`]p - 6,3 - / �7 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No.and Street Email address
Cilyfrown,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152.§ 25C(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes .......... ❑ No...........13
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR
nBUILDING T
I PERMI
I,as Owner of the subject property,hereby authorize rM I L (�l G L y 1 ,A-G L(/l
to act on my behalf,in all matters relative to work authorized by this building permit application
kh& l (2,?O a2S 4,1
Punt Owner's Name(ElectronicSignature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest ureter the pains and penalties of perjury that all of the information
co in this apph 'on is d accurate to the best of my knowledge and understanding.
-lam
's or AuthoragA s N (F.lectrnaic Signature) Date
NOTES:
1. An Owner who obtairs a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will nor have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
w-w,v.mass.Rov/oca Information on the Construction Supervisor License can be found at www.mass.Qov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemegUattics,decks or porch)
Gross living area(sq.it) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halffoat s
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Squaie Footage"may be stibstituted for"Total Project Cost"
PICKERING.WHARF CONDOMINIUM ASSOCIATION
57,WHARF STREET,SUITE,2E'
SALEM, MA 01970
January 29, 2016. `
City of Salem
Building Inspector
120 Washington street
Salem, MA 01970
RE: Karen Guzowski
195B Wharf Street, Unit F-4
Salem; MA 01970
Dear Building Inspector,
The Pickering Wharf Condominium Association has been contacted by Karen Guzowski regarding
her property at 195B Wharf St, Unit F-A,Salem, MA 01970. Ms.Guzowski will be completing interior
repairs/renovations to her premises at 195B Wharf Street. Ms.Guzowski will need to have her
contractors name the Pickering Wharf Condominium Association;Pickering Wharf'Complex, LLC and:MR:
Beckett Management Co. Inc.as second insured. The noise level must be kept down in order sotto
disrupt other commercial and residential tenants and owners. Any and all debris/trash from the
repairs/renovations must be deposed of by all contractors and removed from the premises in a time
manner. No debri/trash can be disposed of in the Pickering Wharf Condominium trash room(s). All
contractor,subcontractor; repair men or service technicians are not permitted to park in Pickering
Wharf during the renovation, all vehicles will need to be parked on Derby Street. Thank you for your
attention to this matter.
Sincerely/
T. Michael Ruckert
Trustee„Pickering'Wharf
Condominium