276 ESSEX ST - BUILDING PERMIT JACKET ' Commonwealth of iNlussachusetts
1 Sheet Metal Permit
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Fstimaled Job Cost: $ ���� Permit fee: S _
I'Lms Snbmitled: YES NO ✓ flans Reviewed: I ES NO
Business License k S'W/�'4� T 7dwAJ WQ1, Applicant License #
Business hlntbrmation: Property Owner/Job Location Information:
Name: 1� �'j�0�� Iv✓./�� Name: >n 2'ne�UG �G�Qcs / -
Slrect:Z�S� l�5 vim • Select: 77t �Ss�aC rz�`
City/Town: J'✓OSC City/Town: Cmµ
Telephone: 7f7 `J7�, —•7ydZ Telephone:
Photo I.D. required/Copy of Photo I.D. attached: YES NO
si�rr udu:d
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I- ,restricted license
J-2 / M-2-restricted to dwellings 3-stories or Icss and commercial up to 10,0P0 sq. It. / 2-stories or less
Residential: 1-2 family_ Multi-tamily_ Condo/ Townhouses_ Other_
Commercial: Office `1 Retail_ industrial_ Educational
Institutional _ Other_
Square Footage: Under 10,000 sq. tt. over 10,000 sq. tt. _ Number of Stories: r
Sheet metal work to be completed: New Work: Rullovation:
IIVAC ✓ Metal Watershed Roofing_ Kitchen Exhaust Systen,
Metal Chimney/ Vents_ Air Balancing
Provide detailed description/of%work to be donee::
INSURANCE COVERAGE:
a current liability lit Insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes No
I have ❑
_
If you have checked Yes, indicate the type of coverage by checking the appropriate box below:
A liability Insurance policy type Other t e of Indemnity [IBond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this box I hereby certify that all of the details and Information I have submitted(of entered)regarding this application are true and
Iacurate to the best of my nc compliance with all pertinent provision of the lMassachusetts Building Code and Chapter 112 of he Gener l shoat metal work and installations performed under the prmit Issued for this application will be
al Laws.
Duct inspection required prior to insulation Installation: YES_ NO
Progress Inspections
Date Comments
Final lusucction
Date Continents
Type of License:
By kMaster
title _ ❑ Master-Restricted
i
❑Journeyparson Signature of Licensee
pen"I At__-- ❑Journeyperson-Restricted
License Number:
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PLANS MUST BE FILED AND APPROVED BY THE
INSPECTOR PRIOR TO A PERMIT BEING GRANTED
Location of Building a29b Z&-SkX ko2A1b F2409
Building Permit Application Fo
'(Circle whichever applies) R ]teroof nstall Siding, Construct Deck, Shed, Pool
Addition, Alteration, Repair/Replace, Foundation Only, Wrecking
Other. '
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
To the Inspector of Buildings:
The undersigned hereby applies for a permit to build according to the following specifications:
Owners Name: 22/IEN Contractors `r "44ng '
Streetx,& S - I�IVPA City EALEY street
State Phone (q�&_2 /y 09l/ state Phone(79/ ) &a t-9099
Architect: City of Salem Licit
c
Street City State ID& O290 I Co HIP#
State Phone ( ) _ Homeowners Exempt Form_yes no
Structure: (please circle) Single Family. Multi Family# Other /A/
Estimated Cost of job S/6,-000-� 7/5S.'"
Will building confirm to no law?X,_yes
Asbestos?_des no /�,�
k to Description of wor be done:lC. AQ� t eCSr/�i a(16 FLQ7/2 P4*,S'rR?
S A65ZE ANY LI M em AP As
ROOT IJA/OMHI� 946T i /TfP IVO IfANr P 6J012& 8
PF2�02Gr�7D
Drawings Submitted:__ycs no Mail Permit to:
X
Sigoatu of Application,SIG D UNDER THE PENALTY OF PERJURY
;X
CONSTR ION TO BE;COMPLETED WITHIN SIX(6)MONTHS OF PERMIT ISSUED DATE
Department use only: Pernik# V nt9g Map/L of
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Permit fee$
COMI ENTS:
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\V The Commonwealth of Massachusetts
® Department of
ui Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
('Phis Section Fo fti 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 no available)
276 Essex Street Salem 01970
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 apply in the two rows below
Existing Building O Repair❑ Alteration ❑ 1 Addition❑ 1 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 ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:Renovation of existing office space with new bathrooms
tom. 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): 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-2❑ Nightclub ❑- A-3 ❑ A-4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M. Mercantile❑ R: Residential R-1❑ 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 ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
sl` 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❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
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:
7
SECTION 9; PROPERTY OWNER AUTHORIZATION "
Name and Address of Property Owner -
Steven Haley 45 Mason Street Salem 01970
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Owner 978 744 0911 781 258 7895 steveheabs@verizon.net
Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes
Glenn Kennedy 108 Leach Street Salem MA 10970
Name Street Address City/Town State Zip
to act on the property owners behalf,in all matters relative to work authorized by this building permit appEcation.
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 0 and skip Section 10.1
:.10.1 Registered Professional Responsible for Construction Control
Jones Architecture 978 744 5200 rick@jonesarch.com •Zp I `3l q
Name(Registrant) Telephone No. e-mail address Registrabop Number 10 Derby Square 3R Salem MA 01970 AjY.M.M;,H c '
t
3
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Double D Construction
Company Name
Doug Dubin
Name of Person Responsible for Construction License No. and Type if Applicable
21 Elm Place Swampscot MA 01907
Street Address City/Town State Zip
781 598 8810 781 844 8758 dougdubin3@aol.com
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPLNSAHON INSURANCE AFTIDAVrr 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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $58,600.00 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $12,000.00 appropriate municipal factor)_$
3.Plumbing $11, 500.00
4.Mechanical (HVAC) $12,000.00 Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $94,100.00 (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 to the best of my knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: - -
-;., ;.: Name -Date . . ..::