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315-317 ESSEX ST - BUILDING JACKET DATE: 17 S Citp of az�m, fAaE;5arbU5ett5 PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED Location of Building 1 S-31 "Sr Building Per wittApplication For: '(Circle whichever applies) Roof, Reroof, Install Siding, onstroc�ouijdatlon Shed, Pool Addition, Alteration, pair .p , Only, Wrecking Other. PLEASE FILL OUT LEGIBLY& COMPLETELY TO AVOID DELAYS IN PROCESSING To the Inspector of Buildings: I Tl:e undersigned hereby applies for a pern•,it to build according to the following spccificadons: Ownera Name 15 1 Contractor_ ; P Street 50% V LQ City Street-4 S 111 .e Ciry State Phone ff l�_M 7- y I i State Phone(9�(�) Architect: City of Solem Lick CSO73)93 Street City State Lic# o C HIP# ) l a 0(o I a/;t Q-6 7• State Pho ) Homeowners Exempt Form--yes ✓no Structure: (please circle) Single Family, Multi Family Y V Other Estimated Cost of job S 0 0�06 Witl•building confirm to law!__yes no G V Asbestos? es� no Description of work WIN-done: A 0 4 r r Drawings Submitted:J yes no Mail Permit to: St � ^ n St Sigoatu o c>�tio0,S ONED UNDER THE PENALTY OF PERJURY k� CONSTRUCTI N T OMPLETED WITHIN SIX MONTHS OF PERMIT O 0 st�� (� !I T ISSUED DATE Department use only; :Pemk(ll N Zonittg Maput Permit fee$ COMMENTS: > .; s u�+ _ V 1 } ar A . m.C�,'�'��.y��,3a��. ` �,J� '. 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IFIU(igl �,I�SI ., apftKf6`'1 Fh a` • 1 'a!`�t a��a�,�Fa;,.�J t P,t a.' .a isips� {�S:Sx: r, • , of 4:. fl;#,+fh+ ylP� a�,;i Gaya+wfn°lilAMk,`��i irk'° _>,rfi�Jr; .jlSilF, a,�„74 �IA'?!i I ,. �..tl';»iChf•RIySF ir�'.Y -r� `�T ..}it'•t,Uu..',V:` fMau".eY . ..S+v.v :;.r-,b .Ya..�:a, .++. .n_,:�. e.r aawkfi!v.ii Y1P4 '�iE4`k`P'�5131t r,, y , ts;i#�tiv)s"IS�II a(,.w �tPON�i4wG ;gtt�P " ' . ( y pp/�'yp ype,{� ,y4 �� "4X'; ' yyn PiP�pS/ ,.,+a, 5Pv• y� "`�i .. ,r In 1' �V,4r�H�1 PI"T'3�d `drf nSYf 7lalMSf't °i}i` 8?" ;' 1�{yfVY{ffi ?!1�ffi41"Y�Y}P*In!'<l4Rw'f1�0. `.'}' V _ @Fib r'i9�a c ;;eat4+.tr7;ai t4�¢ihE .; V O : tL Z o �+ L3 Lj Z a a z Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978) 745-9595 EXT. 311 FAX(978)740.0404 ! CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed: C1. Construction ❑ Moving ❑ Reconstruction Alteration ❑ Demolition ❑ Painting ❑ Signage ❑ Other work as described below will be appropriate to the preservation of said Historic District, as per the requirements sct forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property 115-317 Essex Street Name of Record Owner: Stephen& Linda Morris Description of Work Proposed: Main buildinz- Removal of synthetic siding and shutters. Repair/replace underlying wood clapboard siding, trim and watertuble in kind. Reconstruct window casing and window pediments on front, second floor to match photo on 1967 inventory form. Side windows to match window casing on abutting properties, including reconstruction of windows sills, t,(needed. Option to install Hood shutters on front fdgade (to be hung so as to be operable and, when closed, ofsize lo fill the window and hung to shed water"war from window). Existing synthetic fascia and soffit to remain. Paint colors-Pewter Gray clapboards, white trim. Rear addition-Installation of wood clapboards,fascia, cornerboards and water table to match main house. Construction of overhang per drawings submitted with roof to match existing. Remove existing steel staircase and install new wood staircase insane footprint and configuration(run, landing). Railing/baluster style per postcard submitted and to mew building code, baluster d",In center. Entire to be painted Pewter Gray, with treads to be painted Battleship Gray. Paint colors- Pewter Gray clapboards, whae trim. Application is continued to meeting of April6'"in order to address potential issues discovered in the Feld. Dated: March 23, 2005 SALEM HISTORICAL COMMISSION By. The homeowner has the option not to commence the work (unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date anless otherwise indicat.d. THIS IS NOT A BUILDING PERMIT, Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any,other necessary permits or approvals) prior to commencing work. i i The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building 0 Code, 780 CMR, T"edition OF SALEM� Revised January Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008 One-or rwo-Family Dwelling r This Section For Official Use Only vo Building Permit Numb Date Applied: Signature: Buildin Commiss' 1 peclor of Buildings Date SECTION 1:SITE INFORMATION I.t Property Address: 1.2 Assessors Map& Parcel Numbers �S 7 Jer Sk 1.1 a Is this an accepted street?yes 4-� no Map Number Pared Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed U Use Lot Area(sq It) Frontage(It) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Sypply:(M.G.L c.ao,§54) 1.7 Flood Zone Information: 1.8 Sewage Dis oral System: ; Zone: _ Outside Flood Zone?Public Private O Check if es❑ Municipal n site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2. Ownero Name(Print) Address for Service: A >/iL /`17�• '7�rs• /S7L / . JX`Cola� .y 0 O i u Telephone ' SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work': 4- .�.-. 7 I SECTION 4: ESTIMATED CONSTRUCTION COSTS aN4`%'4v Item Estimated Costs: Official Use Only Labor and Materials I. Building 1. Building Permit Fee: S Indicate how fee is determined: 2. Electrical S �Q� ❑Standard Cityrrown Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (fiVAC) S cjl)-U List: 5. Mechanical (Fire Suppression) S l!' Total All Fees: S 2 t955-- Check No. Check Amount: Cash Amount: 6.Total Project Cost: S D t �b ❑Paid in Full ❑Outstanding Balance Due: � 5'U 2�0+ 275 5� SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CJjR Qq / � _ c� Number I:spirutio Uuteof CSL- I lull 'rype Isee below) d o 13escri tion W Unrestricted u to 35,000 Cu.Ft.Restricted 1&2 Famil Dwellingnu ore Maso OnlResidential Roofin Coverinfcicphune Residential Window and SidinResidential Solid Fuel Bumin A fiance Installation Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) f I IC Company Name or I IIC Registrant Name Registration Number Address Expiration Date Signature 'telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 f the building permit. Signed Affidavit Attached? Yes.......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , ,/,� 11 it / � as Owner of the subject property hereby attothorilie to act on my behalf,in all matters relative to work authorized by this building permit application. C— Sianature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1 as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Signed under the Pains and penalties of 'u NOTES: I. An Owner who obtains 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 Soj have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS,respectively. ? When substantial work is pia ned,provide the information below: Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Habitable room count 12-/ Number of fireplaces oni� Number of bedrooms eL, Number of bathrooms e l Number ofhalt7baths C� Type of heating system r z-58- 4zt A_J Number of decks/porches Type of cooling system 4441 Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" SDA Schopf Design Associates Architecture. Interior Design. Documentation. Construction Administration One Cambridge Street Salem, Massachusetts 01970 978-741-0410 May 5, 2010 Construction Control Affidavit In accordance with Construction Control in 780 C'MR 116.2.2 of the Massachusetts State Building Code, I, Morris L. Schopf, being registered professional architect MA 5125, hereby certify that I prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Renovation of Existing Building 6-2 bedroom condominium residences 315-317 Essex Street, Salem, Massachusetts And that, to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, acceptable engineering practices and all applicable laws for the proposed project. I further certify that I will perform the necessary professional services and been present on the eonstru Ae from time to time as the demands of the project require; to determine roceeding in accordance wit the documents approv for the buildin �e Q\ tt .SC& C �F� rit!`°�� g125 cA S �D pr / Morris L. Schopf, RA Mass Archite 5 5 c 1 ORIGINAL SIGNATURE & SEAL SUBSCRIBED AND SWO TO BEFORE ME THIS DAY OF 2010 a, GIN NOT—WY— PUBLIC o Notary Public MY COMMISSION EXPIRES commonxreann o1 Massachusetts My Nov 10,2011 �pMIN6�� Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978) 745-9595 EXT. 311 FAX (978)740-0404 CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction Alteration ❑ Signage ❑ Moving ❑ Demolition ❑ Other work ❑ Reconstruction ❑ Painting as described below will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property- 315-317 Essex Street Name of Record Owner: Stephen Morris Name of Applicant: Raymond Young(Manager, 315-317 Essex Street Salem LLC under agreement to purchase) Description of Work Proposed: Reference: Plans dated 2110110, Schopf Design Associates Demolition of existing first floor store front. Replace with front door design as shown on page 4 including 2 decorative windows and side door design also shown on page 4. Install 4 shed dormers as shown on pages 5, 6 and 7. Enclose rear stairway as shown on pages 6 and 7. Install 4 new door openings on sides and back as shown on pages 5, 6 and 7. Doors to be wood, six panel with transom. New window configuration as shown on pages 4, 5, 6 and 7. Windows to be wood, 6 over 6 wood windows either: • Pella Architect Series Wood Double Hung Window with ILT's, 7/8"muntin; • LePage 7/8"SDL; or • J. B. Sash Proper Bostonian Where there is a wood choice, it should be cedar. When available, the.spacers between the glass should be bronze. Note: Applicant will applyfor fiberglass door option, chimney removal, vent installation,paint color,fence for east side and granite curb. Dated: March 4, 2010 SALEM ISTORICAL COMMISSION Y f&� /t,00 BThe homeowner has the option not to commence the work(unless it relates to resolving an outstandin v' I work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals)prior to commencing work. ' ONDIT�,�Q' CITY OF SALEM, MASSACHUSETTS BOARD OF APPEAL 120 WASHINGTON STREET. 3RD FLOOR SALEM, MASSACHUSETTS 01 970 TGr� t TELEPHONE: 978-745-9595 poi FAX: 97$f7r40-9846 KIMBERLEY DRISCOLL March 31, 2 -10 J 2pi0 NT ' P 3: MAYOR C Decision City of Salem Zoning Board of A-Cp,eals Petition of 315-317 ESSEX STREET SALEM LLC, see a Special Permit to change the current nonconforming uses in the building (13-room lodging house and office space) to another nonconforming use (six two-bedroom residential units), and seeking a Variance from height (number of stories) to constructftwo dormers on the property located at 315-317 ESSEX STREET, Salem, MA (R-2). A public hearing on the above Petition was opened on March 17, 261 I ursuant to Mass General Law Ch. 40A, § 11. The hearing was closed on March 17, 2010 with the following Zoning Board of Appeals members present: Robin Stein, Richard Dionne, Bonnie Belair, and Beth Debski. Petitioner seeks a Special Permit pursuant to Section 3.3.2 and a Variance pursuant to Section 4.1.1 of the City of Salem Zoning Ordinances. Statements of fact: 1. Attorney George Atkins represented the petitioner at the hearing. 2. Stephen Morris is the owner of the property. Raymond Young, Manager of 315- 317 Essex Street Salem LLC, has the property under agreement to purchase. 3. The property at 3 15-3 17 Essex Street currently contains thirteen (13) licensed rooming house rooms on the second and third floors and office space on the first floor. Both uses are nonconforming uses in the R-2 zoning district. 4. In a decision dated April 17, 2009, the Board granted petitioner's request for a Special Permit to convert the office space on the first floor to residential units (petitioner had requested five units; the Board granted the Special Permit for three). This decision was subsequently appealed and remains under appeal as of the writing of this decision. 5. In a petition dated February 26, 2010, petitioner requested a Special Permit to convert the entire building to six (6) residential units and a Variance for dimensional relief to construct dormers. 6. At the March 17, 2010 hearing, Attorney John Carr spoke in support of the petition, noting that he represented the abutters who had brought forward the appeal of the previous Special Permit. He stated that the abutters he represented had been working with Raymond Young, the property owner, and Attorney Atkins to work out an acceptable solution, and this petition was the result. He also stated his opinion that this project would be less detrimental to the neighborhood than the current use. Attorney Carr further stated that the appeal would be withdrawn if the current petition passed. 7. Also at the March 17 hearing, Ward 3 Councillor Jean Pelletier, 7 Lawrence Street, and resident Ted Richard, 10 Summer Street, spoke in support of the petition. No one spoke in opposition. The Board of Appeal, after careful consideration of the evidence presented at the public hearing, and after thorough review of the plans and petition submitted, makes the following findings: 1. Desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent or purpose of the zoning ordinance, as the residential density would be reduced from its current level, the non-conforming commercial uses currently allowed would be replaced by residential only, and sufficient parking is provided. 2. The applicant may vary the terms of the Residential Two-Family Zoning District to convert the lodging house and office space to six (6) residential units, and to construct the proposed dormers, all otwhich is consistent with the intent and purpose of the City of Salem Zoning Ordinance. 3. In permitting such change, the Board of Appeals requires certain appropriate conditions and safeguards as noted below. On the basis of the above findings of fact and all evidence presented at the public hearing including, but not limited to, the Plans, Documents and testimony, the Zoning Board of Appeals concludes: 1. A Special Permit is granted to allow for the change in use from a lodging house and office space to six (6) residential units. 2. A Variance is granted to allow for the construction of two dormers. In consideration of the above, the Salem Board of Appeals voted, four (4) in favor (Stein, Debski, Dionne and Belair) and none (0) opposed, to grant petitioner's requests for a Special Permit and a Variance subject to the following terms, conditions, and safeguards: I . Petitioner shall comply with all city and state statutes, ordinances, codes and regulations. 2. All construction shall be done as per the plans and dimensions submitted to and approved by the Building Commissioner. Submitted plan is titled, "315-317 Essex Street Condominium — Six 2 Bedroom Units," dated r - 3 2/10/10, and prepared by SDA/Schopf Design Associates, One Cambridge Street, Salem, MA 01970. 3. All requirements of the Salem Fire Department relative to smoke and fire safety shall be strictly adhered to. 4. Petitioner shall obtain a building permit prior to beginning any construction. 5. A Certificate of Occupancy is to be obtained. 6. Petitioner shall obtain street numbering from the City of Salem Assessor's Office and shall display said number so as to be visible from the street. 7. Petitioner is to obtain approval from any City Board or Commission having jurisdiction including, but not limited to the Planning Board. 8. Unless this Decision expressly provides otherwise, any zoning relief granted does not empower or authorize the Petitioner to demolish or reconstruct the structure(s) located on the subject property to an extent of more than fifty percent (50%) of its floor area of more than fifty percent (50%) of its replacement cost at the time of destruction. If the structure is demolished by any means to an extent of more than fifty percent (50%) of its replacement cost or more than fifty percent (50%) of its floor area at the time of destruction, it shall not be reconstructed except in conformity with the provisions of the Ordinance. 9. This decision takes precedence over any decisions previously granted by the Board of Appeals. G°t-o-Pi- r 1 �W /t9-)I' ( Robin Stcin, Chair Salem Board of Appeals A COPY OF THIS DECISION I-IAS BEEN FILED WITH I HE PLANNING BOARD AND THE CITY CLERK I!, Appeal from this decision, if any, shall be made pursuant to Section 17 of the Massachusetts General Laws Chapter 40A, and shall be filed within 20 days of filing of this decision in the office of the City Clerk. Pursuant to the Massachusetts General Laws Chapter 40A, Section 11, the Variance or Special Permit granted herein shall not take effect until a copy of the decision bearing the certificate of the City Clerk has been filed with the Essex South Registry of Deeds. I The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR, 7"edition OF SALEM ` Revised January Building Permit Application To Construct,Repa' Renovate Or De 74sh a I, 2008 One or Two Family ell g �Thts Sectron For` ffimal se^Only OYI Building Permit Numb i/� ate A hed: Signature: Building Commissioner/Inspector of Buildll'ings Dnm" ' _. SECTION'I $ INFORNLITION - 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers .31 5 - ?/ 7 S mil' l.la Is this an accepted street?yes_L,_�no_ Map Number Parcel Number 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 Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: -PROPERTY OWNERSHIP' 2.1 wner�of Record: _ 1 amc •i t �L�' Address for Service: ��-- Signa Telephone SE ION 3:D TION OF PROPOSED WOkW(check all that apply) New Construction❑ Existing B ing❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work 2: L 5ZZ SECTION 4: ESTIMATED CONSTRUCTION COSTS' Item Estimated Costs: - Labor and Materials Official Use Only 1.Building $ 'I. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ '❑Standard.`City/Tovvn Application Fee ❑TotaTProlect Cost'(Item 6)x multiplier x 3.Plumbing $ Z. Other.�Fees $ 4.Mechanical (HVAC) $ List - ,l 5.Mechanical (Fire Suppression) $ Total Alt Fees $ Check No Check Amount: Cash Amount: 6.Total Project Cost: $ (� 0 Paid,in Full ❑Outstanding Balance Due: r-SECTION,':5`CONSTRUCTION SERVICES . 5.1 Licensed Construction Supervisor(CSL) Y L Cll License Number Expiration Date Name of CSL-Holder /lh v Vl l.y DU cl �--I) �SGXeik` List CSL Type(see below) ` Address - '- ,Descri"tion U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 FamilyDwelling _ Signature - �/j M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Re ister H 7 e I tprovement Contra tor(HIC) HIC Co �jName or C Reg $ nt e LL.. v/1�� n Registration Number Adder c Expiration Date Signature / 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...........Cl SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED WHEN=i OWNER'S AGENT.OkCONTRACTOR APPLIE TOR BUILDING P.Ellm I, x4m6 /t C- V U!' '' as Owner of the subject property hereby authorize G Z to act on my behalf,in all matters relative to work authorized by this building permit app [cation. Sin tore of0 er Date SECTION ERA OR AUTHORIZED AGENT.DECLARATION q as Owner or Authorized Agent hereby declare that the statements and informative foregoing application are true and accurate,to the best of my knowledge and behalf. l Print Name Signature of Owner or Authorized Agem _ Date Si ned under the pains!and enatties of rJuryl NOTES: -� 1. An Owner who obtains 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" I �► The Commonwealth of Massachusetts Department of Public Safely \IaN.ichavus State Building(.', dr(7S0 CJIR)Srvvnlh Edition City of Salem U Building Permit Application for Any Building other than a I- or 2-Family (this Section For Official Use Only) 0udding Permit Number: Rite Applied: Building Inspector: SECTION 1: LOCATION (Please indicate Block a and Lot a for locations for which a street address is not available) .Nm and Street City /Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building O Repair O 1 Alteration ❑ 1 Addition 13 1 Demolition ❑ (Please fill out and submit Appendix 1) ChangvufUse ❑ lChangeofOccupancy ❑ 1Other ❑ Specify: Are building plans and/ur corutroctiun documents bring supplied as part of this permit application? Yes ❑ No ❑ Is an Indrliendent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O Existing Use Group(s): Proposed Use Group(s): t Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area (.sq.it.)and Total Height(ft.) SECTION Sz USE GROUP(Check as applicable) A: AssemblyA-1 ❑ A-2r O A-2ne❑ A-3 CIA4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 O F2❑ H: ILIgh Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-I O I-2 ❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-I❑ R-2❑ R-3❑ R4❑ S: Stora a SI ❑ S-I ❑ U. Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Is IIA ❑ 1180 IIIA ❑ 111813 1 IV ❑ 1 VA V8 ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Olsposal: Trench Permit: Debris Removal: Public ❑ C Iu•ik d uutsrdv PlasrJ Luny O Indicate municipal ❑ A trench will not be Lrce•n.rai Dispu..d Site❑ ur .rexa lV: I'nreh❑ ur mdantlh Lune: nr un.rtr sr.trm ❑ required❑or trench permit rs enclusrel O Railroad right•of-way: Hazards to Air.Navigation: xl\ I li•1 •rp t „...... "r It,a„,a I'n• .��: \r.l \)•i•I1c.1NV0 I.�Irui hue ac,lhm.urrurt arrntaih area' I.IhVo rea lva.iunt)•IVIVd.' •a l nt�cnl lu liu rlal rnclurd ❑ . l c•❑ nr No❑ 1'rs❑ \u ❑ SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY I diw n '-1 G-dV. _ Ltea•l.ruupl•1. ra rein lundnlcuun: lkcur.Inl Load pvr I lour i Ihr.rha•l'ud.hn�;innlatn.In til.nnklcr�a.la•tn` �pa•cial �hru Lthunv 2S� Z�_ 2ibl© 2(� SECTION 9: PROPERTY OWNER AUTHORIZATION .Name.wd ,lddre.,s of PrnF,crty Owner L t 3/E.- 31? �a�a mot, Y Rxae.�, C� ,� I._ Name(Print) .No.and 'Strad lily/Ri n Lip Vro +rrtc the net Contact Inlurmatwn: )f Ps (J Pt SA Ike, 5�- 3 U82 it0 Title Telephone No. (bus,nr s) Telephone No. (cell) r-matt ad.tns If applicably, the I•roi erty ,n•ner hrrrbv awhonzes � ; ,,/j*SA FA-oRRt-s Rk2:0s�tCJ4 R1 Ry 'v2n h1fl o /92 / .Name Street AddreNs City/Town tittle Lip to ac1,in the ,ru pert% owner'.behalf, m all matters rulahce to work authorized by this building +erm,t a + +bc.im, SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If bwldin is tars the l,ax c u. It.ul enclosed.+ace and/ur not under Coin fructiun Control then check hem O and Aup Sechun 10.11 10.1 Reitistonrcl Profes nal R onsible for Construction Control Iff 71(-q 5723— /Vft Telephone Nu. m.0 address R .K�strali n Number 5tb10� Ct /T 5 ite Zi Discipline Expiration Datr 10actor �*11Tl t Cump n Name• Je,0Y•eVj . `l�. l"� o ✓ r(s cSb?3"1-93 / Eao If� o � I Name of Person Resp,mviblr fur Cunstructiun tense No. and Type if Applicable 8( rz st&2 7 6 Qox�'v -d rl% A� of 5a ) Street,,9, dress City/Town State Zip 9�6 y . 77 "jPMCois liaa lern �Jz(, �ti . Com Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WO A V (M.G.L e. 1S2 2SC(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 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)-f 1. Building f . 000 Building Permit Fee a Total Construction Cost x_(Insert here 2. Electrical f 4 U• d A (3 appropriate municipal factor)-f 3. Plumbing f 44 0 . u60 3. Mechanical (H VAC) f p p O Note: Minimum fee.f (contact municipality) 5. Mechanical (Other) f '('1z O Enclose check payable to it A 6. Total Cost I f PS S• OOO (contact munici alit ).and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT lay entering my name below, I hrrrbv atlest under the pams and penalties of perjury that all of the information contained in this applic.,tnm is true and arcuratr to Ihr best of my11 knuwlrallir and understanding. S-Lepke N Moe art s yaln ��tMn 6Wrve 2 97� 77a� 7 2 I'Iva`a• int and .ry;n n.ime I Ie fclephonr\'u. Date Stic-el Addre" Cll i Tuw'n < fe Lip Sunicipal Inspectur to fill out this section upon application approval: !17 \amr Dot i Permit# Permit Date COMcheck Software Version 3.1 Release 1 Envelope Compliance Certificate Massachusetts Commercial Code Report Date:07122/10 Data filename:C:\Documenls and Settings\HP-AdministratoAMy Documents\Ray Young Projects\Steve Mortis Rooming House\GomCheck\Rl4 Rev 1 315-317 Essex Street Salem MA energy audit 6-16-10.cck Section 1: Project Information Project Title:315-317 Essex Street Condominium-6 Unit Condominium Renovation of Exsiting Structure Construction Site: Owner/Agent: Designer/Contractor: 315-317 Essex Street Raymond Young,Mgr Morris Schopf MA 5125 Salem,MA 01970 315-317 Condominium,LLC Schopf Design Associates Permit No.Salem 826-10 87 Federal Street 1 Cambridg Street Permit Date:May 11,2010 Salem,MA 01970-3208 Salem,MA 01267 (978)745-1572 978.741.0410 schopf@verizon.net Section 2: General Information Building Location(for weather data): Salem, Massachusetts Climate Zone: 13a Heating Degree Days(base 65 degrees F): 5641 Cooling Degree Days(base 65 degrees F): 678 Project Type: New Construction Glazing Area Percentage: 15% Buildlna Type Floor Area Multifamily 3500 Section 3: Requirements Checklist Envelope-PASSES: Design 190/'�better than code Climate-Specific Requirements: Component Name/Description Gross Area Cavity Cont. Proposed Budget or R-Value R-Value U-Factor U-Factor Perimeter Roof 1:All-Wood Joist/Rafler(fruss 3500 20.0 0.0 0.051 0.060 Exterior Wall 1:Wood Frame,Any Spacing 4508 12.0 0.0 0.096 0.091 Window 1:Wood Frame;Double Pane,Clear,SHGC 0.54 664 -- -- 0.350 0.603 Basement Wall 1:Solid Concrete or Masonry>8",Furring:Wood, 4236 5.0 0.0 0.159 0.115 Wall Ht 8.0,Depth B.G.8.0 (a)Budget U-factors are used for software baseline calculations ONLY,and are not code requirements. Air Leakage, Component Certification, and Vapor Retarder Requirements: ❑ 1. All joints and penetrations are caulked,gasketed,weather-stripped,or otherwise sealed. ❑ 2.- Windows,doors,and skylights certified as meeting leakage requirements. ❑ 3. Component R-values&U-factors labeled as certified. ❑ 4. Vapor retarder installed. 315317 Essex Street Condominium--6 Unit Condominium Renovation of Exalting Structure Page 1 of 2 Section 4: Compliance Statement Compliance Statement:The pmposed envelope design repr nt in this ovum nt i consistent th the building plans, specifications and other calculations submitted with this pe it ap licatio The p envel system has been designed to meet the Massachusetts Commercial Code requirements' COM he rsio .1 all ase a to comply with the mandatory requirements in the Requirements Checklist. mQu-lG Su�m�� a O/ g Principal En elope Design r-Name Signal Date Project Notes: Wood Frame Mulit-Family with partial basemen and crawl space 315-317 Essex Street Condominium--6 Unit Condominium Renovation of Exsiting Structure Page 2 of 2 Owens Corning PINK® Fiber Glass Insulation Product Line Cathedral Ceilings R-35 (9 7/811) R-31 (9 11411) R-28 (8 1121 Attic / Flat Ceilings Uninsulated Attic Adding to existing insulation R40 (10 3/80y) R-35 (9 7/8") R-31 (9 1/4") R35 (9 718") R-28 (8 1/2") R-22 (5 11201) Products R-31 (911411) R-20 (610) Exterior Walls R-22 (51/21 R-20 (6")* R-14 (3 112")** Systems R-13 (31/2") R-12 (311211) (*R-19 when compressed to 5 1/2") Floors Solutions R-28 (8 1/2") R-22 (5 1/2") R-20 (611 ) Crawlspace Walls R-22 (5 1l211 R-20 (6") R-13 (3 1/2") R-12 (3 1/2") Basement Walls R-20 (61 R-22 (5 1/2") R-12 (31/21)) R-13 (31/211) Interior Walls & Floors / Ceilings for Sound Control QuietZone (3 1/211) R-12 (3 1/21 R-13 (3112") o R-20 (6") R-22 (51/29y) e � INNOVATIONS FOR LIVING:" F CHOO & COMPANY ONEBILLINGS ROAD QUINCY , MA 02171 P14ONE ! 617 - 786 - 7727 FAX : 617 - 786 - 7115 FACSIMILE TRANSMITTAL SHEET TO: FROM: Mr,Thomas McGrath Ping Mandawe COMPANY: DATE: Salem Building Departrnent 7/16/10 PAX NUMBER: TOTAL.NO,OF PAGES INCLUDING COVE&i ()78) 740-98U 4 PHONENUMBRR: SENDER'S REF8R1°.NCe NUMBER: RE: YOUR REFERENCE NUMUEA: 315-317 Essex Street,Salem O URGENT X POR RBV1Fw ❑ PLEASE COMMENT O PLEASE REPLY © PLEASE RECYCI,F. NOTES/COMMENTS: L � ARTHUR CHOO ASSOCIATES INC., CONSULTING ENGINEERS ' ONE BILLINGS ROAD, QUINCY, MASSACHUSETTS 02171 OFFICE (617)328.3820 Fax (617) 786.7716 July 16, 2010 Tom McGrath, Asst. Building Inspector Public Properties Department 120 Washington St., 3rd Floor Salem,MA 01970 3408--Level.2 Structural Review -- Building Permit 4 825-10 315-317 Essex Street, Salem,MA This Report on Structural Investigation of the building code is submitted for compliance under section 3408.6.3. The current Building Code for this report --Mass 780 CM"R 7 h Edition of Base Code. A.3408.6.2.2.1 Foundation and Geo-technical Explorations --Level 2 Work, The scope of work for this Project does not involve an addition or include any increase in gravity loads. There are no new shear walls or vertical frames and there is no indication of settlement or lateral movement of basement wails or foundations. B.3408.6.2.3 Structural Evaluation of the Existing Building. I have examined the existing structural materials to determine their load bearing capacity and stiffness as required by_3408.6.2.3.1 and provide an opinion in accordance with 780 CMR 3408.9.2.3 and 3408.9.2.4. I have calculated the strength of existing structural members (drawings A400,.A401 Existing Framing Plans). All existing structural members meet the standards of the current building code except the following: A. 2"x10" @ 16" OC Floor Joists at the open areas on floor 1 and 2 described as Living/Dining/Kitchen" areas in Units 1,2 and 4 where the existing span is 21'-0" The maximum permitted span under the current code would be 18'-0" in this application. B. 2"x8"@ 16"OC Floor Joists at attic (floor 3) where the existing span is 1 T-0" The maximum pennitted span under the current code would be 14'-0" where the occupancy of floor 3 is bedrooms and related uses, 1 L. t ` ARTH-JR C1100 ASSOCIATES INC., CONSULTING ENGINEERS ONE BILLINGS ROAD, QUINCY, MASSACHUSETTS 02171 I OMCii (617) 928:3:3'30 fAX (617) 786-771 n C. Full 2x8 and 4x4 @ 24" OC existing rafters at the portion of the roof not being replaced by new construction where the existing maximum span of the hipped roof is 14'-0". The maximum permitted span under the current code would be 12'-0". C. 3402.1.3 Compliance option. All of the existing conditions (A, B, C above) where in compliance with the standards of construction and any building code requirements at the time the building was constructed and meet the test of section 3408.9.2.2 and 3408.9.2.3 for"compliance with the structural design codes, and standards in effect at the time of construction," <At-the-building-inspectors-option, their-continued use is_perrnitted as a 'c_ompliance�7 option" underSection 3400.2_of CH_34.--::� D. )hazardous Conditions. I have examined structurally any existing hazardous conditions to determine which existing structural elements or systems are in need of repair or other remedial action, and determine the character and extent of the repairs or remedial action. Except as noted,the existing structural members in sound structural condition may be reused as allowed by 3408.9.2.6 of the current building code. A. Storefront reconstruction The reconstruction of the front wall of floor I was previously permitted with drawing. A450 and letter dated May 19, 2010(Choo) and accepted in e-mail dated May 27, 2010 TM, B. Floor framing at rear of one story addition floor 1. Water damaged floor-framing members and membrane at the rear of the building can be replaced in kind by new members to the extent required to repair the damage. These `repairs" are shown on Drawing A402 Framing Plan floor 1. E. Additional Construction Where there are structural changes to floors or roofs, I have calculated the total service load capacity, and the net unreduced service live load capacity or the net service snow load capacity, as applicable, in the affected areas as required by 3408.6.2.3.3. I have reviewed the Drawings 402 and 403 —Framing Plans. The proposed new construction at floor 2 and 3 is in compliance with current codes and standards. 2 1.01 ARTHUR CHOO ASSOCIATES INC., CONSTTLTING ENGINEERS ' ONE BILLINGS ROAD, QUINCY, MASSACHUSETTS 02171 oFxrcr. rAx (617) 76(-7715 1 have reviewed the lateral load capacity of the existing building relative to the lateral load resistance required for the level of work to be performed as required by 3408.6.2.3.5 along with the sheathing of said walls as required by 3408.9.3. No additional construction is required to provide the required lateral load resistance. G. Site Visits and Periodic Reports During my periodic field visits I will examine the Connectivity of the structural elements as required by 3408.6.2.4 and condition of existing structural members as required by 3408.9.2.5. Any recommendations resulting from these field observations will be conveyed in a written notification to the building official. I will make periodic field visits during the progress of the construction work on the existing building in order to observe and verify the assumed conditions on which the structural design was based, and shall modify the design, as necessary, should the observed conditions differ in any significant manner from those on which the structural design was based and shall provide a written notification to the building official of changes to the contract documents submitted with the application for building permit. PEI" OF Arthur Choo Associates, Inc. caq �F D� ARrIiUR ��, Mao a aa- tares " Arthur Choo,PE "�F �o�s r s RE°e Fsf�Ok�t 3 Salem Historical Commission 120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970 (978) 745-9595 EXT. 311 FAX (978) 740.0404 CERTIFICATE OF APPROPRIATENESS It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction -3d- Alteration ❑ Signage ❑ Moving ❑ Demolition ❑ Other work ❑ Reconstruction ❑ Painting as described below will be appropriate to the preservation of said Historic District, as per the requirements set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property- 115-317 Essex Street Name of Record Owner: Stephen Morris Name of Applicant: Raymond Young(Manager, 315-317 Essex Street Salem LLC under agreement to purchase) Description of Work Proposed: Reference: Plans dated 2110/I0, Schopf Design Associates Demolition (?f existing first floor storefront. Replace with front door design as shown on page 4 including 2 decorative windows and side door design also shown on page 4. Install 4 shed dormers as shown on pages 5. 6 and 7. Enclose rear stairway as shown on pages 6 and 7. Install 4 new door openings on sides and back as shown on pages 5, 6 and 7. Doors to be wood, six panel with transom. New window configuration as shown on pages 4, 5, 6 and 7. Windows to be wood, 6 over 6 wond windows either: • Pella Architect Series Wood Double Hung Window with ILT's, 7/8"muntin; • LePage 7/8"SDL; or • .L B. Sash Proper Bostonian Where there is a wood choice. it should be cedar. When available, the spacers between the glass should be bronze. Note: Applicant will applY.forfiberglass door option, chimney removal, vent installation, paint crlor,fence for east side and granite curb. Dated: March 4, 2010 SALEM ISTORICAL COMMISSION By: `&� � / The homeowner has the option not to commence the work(unless it relates to resolving an outstandim v do0work commenced must be completed within one year from this date unless otherwise indicated. TI[IS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings(or any other necessary permits or approvals) prior to commencing work. , . - . - � The Commonwealth of Mass•rchusetts _ , I � , P<)R � � Board of Building Regul�tions and Swndards MUNIt'IP;V.I•fl � �� M•rssachusetts State Building Cocit. 780 CMR, 7 tJitiun USF: ,..� P. Rrri.crJ lunuw�r � Building Permit Application To Construct. Re �ir, Renovate Or Demulish � / rNl� One• orT«a-Fruriilv Dx�c�/ling This Sec�ion F fici•rl Use Only Building Permit Nufibec- Dat Applied: /� — � 3� �05� Signature: � . BuilJing Commissiu r/ Inspector uf Buil � D�te SECTION 1: SITE INFORMATION 1.1 Pr t ress: 11 Assessors Mup & Parcel Numbers I ?i��`5��C'a' ��-,., 1'1�.�. Ma Number P:�rccl Numt+cr L la Is this an accepted�sfreet'?yas_ ��— P 1.3 ning Informetlo� �r l.4 Property Dimensions: h�icv� Zuning District Proposed Uu L.ot Area(sq ft) Frontage IfU 1.5 Buildfng Setbacks(ft) - I � Front Yard � Side Yards Re:v Y:vJ Reyuired Provided Required �Provided Reyuired � PruviJcd � I 1.6 Water Supply:,(M.G.L c.40. §54) 1.7 Flood Zone Informatton: 1.8 Sewnge D/ispossl System: � Zone: _ Outside Flood Zone? Municip•rl �On sire Jispus�l system ❑ Public� ��«� �� Check if yesO SECTiON 2: PROPERTY OWNERSHIP� �2. wner'o[Record• e `�I � �� „�.,� �� S h e r.► c+��a r�� Na�nnt ress r5ervice: � o ; �.�.�;. �� G a�-� �� —� lephon Signamre SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all thet apply) NewConslruction�O� iExistingBuildingO Owner-Occupied ❑ Repairs(s) ❑ Alteration�s) Additiun ❑ Demolition ❑ Accessoty Bldg. ❑ Number of Units� Other ❑ Specify: Brief pescriptjon of Propose Work=: � � i SECTION 4: EST[MATED CONSTRUCTION COSTS i Es�imntcd Coscs: Otticlai Use Only I�em �L�y�r and Materials) I. Building r $�` °�.QO� �� Building Permit Fee: $ fndicate huw fee is Jetermined: ❑Slandard City/I'own Applicatian Fee � ?. Electrical $ (�� p Total Project Cost' (Irem 6) a multiplier x 3. Plumbing S a(�C� ?. Other Fees: E 4. Merhanical (HVAC) S b � �"�' 5. Mechanical IFire $ � �� O Totrl All Fees: S Su ression) f� � � Check No. Check Amuunt Caah Amnunt: 6. Total Project Cost: ��J � (� O Paid m Full O Outstanding Balunce Due: '�� -� �o �� 5 y _ � r . , � � SECTION 5: CONSTRUCTION SERVICES ' S.l Llcen Constructlon Supervisor(CSL) � � ��! � 3 i,� I ') � ' � ,� q Liccnse Numtxr Enpiraiiun Da�e N�ic��f C - HjVir� ) ) v . � List CSL Ty�x Isee hcluw) ��r� � T Dcxri lion ��y„r � O t. ti '2 (,7 U Unrestnc�rJ lu w}S.(q0 Cu. Fi.i R Reslrictcd INc_' Fumil DH�cllin � � �� '�3 ��.�` �1 Mnsun Onl RC RcsiJcntial Ruu�in Corcnn . Tclephon \VS RcsiJcntinl \Vindu�v �nJ SiJin � �M , SF Rcsideniial Suhd Fucl Bwnm :\ �hanrr In.�.illawin p ��'�Sti-•,.� D Residcniial Drnwhuun 5.2 Reg ter Ho p�ro�-ve�1 �t�ra� ctor(HIC) � � 20� 1 r ` `�"� HIC Co p:ui N•r� or H gislr�nt N . Registration um • � AJJress� U �� '�� V �� U �7�j � I ' � Ezpiration Date Signawr Telephone � � ' SECTI N 6: WORKERS' COMPENSATION INSURANCE AFFIDA VIT(M.G.L.c. 152. $ 25C(6)) Workers Compensation Insurance at'fidavi[ must be completed and submitted with this applicatiun. Failurc tu prueide this affid•rvit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... No........... ❑ � SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT [. , as Owner of[he subject property hereby authorize � to act on my beh•rlf, in all matters � relative to work authorized by this building permit application. � Si nature of Owner Date � . SECTION 76: OWNER�OR AUTHORIZED AGENT DECLARATION I, o<��.�-. , as Owner or�Authorized Agent hereby declare that the starem ts and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. _ ��i �tn.i D i� r Print Name _ ��a � I� Signawre of Owner or u[horizeJ Agent Dare (Si ned under ehe ains and nalties of r'u ) NOTES: I. An Owner who ubtains a building permit to do his/her own work,or�n owner who hires an unregismred cuntrac�or (no[regis[ered in the Home Improvement Contracror(HIC) Program), will ttot have access to the arbitratiun program or guaranry fund under M.G.L.c. 142A. Other import•rnt informa�ion on the HIC Program�nd Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and I IO.RS, respectively. 2. When subsrrntial work is planned, provide the information beluw: Tu�al Floors area(Sq. Ft.) (including grrage, finished basemenb•rttics, decks ur purchl Gross livmg rrea ISq. Ft) Habitrble ra�m ruun[ Number uf fireplaces � Number uf bedruoms I Number uf'bathrooms Number uf h�lf76aihs Type uf heating system Number uF decks/purches � Type uf cewling system Hnclused Opan � 3. 'Total Project Square Fuotage" m•ry be substituted fix"Tu�al Project Cust" , . , ''�� ' ° CITY OF SALEM 3 PUBLIC PROPRERTY �';��" ah DEP�RTIVIENT �,�.,��,��s��,��,K�„ ,,�� VL��K I':. A�f'.�;i�i>:�;rn�i i i<er.r � �.0 o-�i. AI.�•:.�rt u .r i :..;1'��J �Il�i: �)'8-i�1;.•�;7; � F��: ��;8-?+�'�tl�n �Vorkers' Comprnsatiun Insurance :�ftida�it: l3uilders/Contractors/Electrici•rns/Plumbers \ > >licant Infurmatiun Please Print Le ibl V;llll� i liusinc::.Ur�.mic�u.m Indrvi.lu.ill: ��lilres,: � `� � -7 �C (;� City;St:ite/Zip: J� Y�"'� �I�� Phune �: � 7 � / �� "��U \re m •rn emplu��er? Chrck�tA,he rpprupri•rte bua: T�'pe uf project(reyuired): I.��m a�mpluyer with 1 �. ❑ I am a general eontractur and I � � w eunstructiun I �in lo azs (full and/ur srt-time):` h�va hircd the sub-cuntructors p y P' 7. Remo�eling _',❑ I am a sole pruprictur ur partnar- listed un thc attached sheeL % - ship�nd huva no empluyees �I�hese sub-contractors have 3. ❑ Demolition working f�x mr in any capaciry. wvrkers' cump. insur�nce. y. � uilding addition I No workers' curo insurance 5. ❑ We are a curporatiun and its �. p� � IQ. � Flectrical repairs ur additions rryuired.� officers huve asercised their � ri ht of exem tion er MC;L I I. Plumbing rcpairs ur adJitions 3.❑ 1 am �homeowner doing all wurk 5 P P myselE [No wurkers' cump. c. 152, ,��'I(4), and we have no 12.0 Roof repairs insurance reyuired.J � cmployees. [No workers' �3.❑ Other comp. insurance reyuired.� •:\ny aVVlicant ihal checks box/tI must�Iso tiil uut the secliun below showing their wurkers'cumpensaliun policy inFormation. � I lumeowners who submit�his alTiduvi�indica�ing lhcy are duing olI work und�he�hire outside�tintracrors must submit a new a1liJavit indicating such. �Cuntraanrs�hm check this buz must altached an aJJilional sheet shuwing the name of�he sub-cunua<turs�nd their wurken'comp.puhcy infnrtna�ion. /uin �m employer dmt is providing �vorkers'compr�isution insurunce for my employres. Belaw is d�e policy und jab sile injon��ufirm. (� In;urunce C'ompany �Iame: ��'i�� Pulicy �ur Self-ins. Lic. N: w o oa 33 e� Expiratiun Date: � � � � _ Jub Site Address �� —� '� CiM/�0./� � City/State/Zip: �K�'_ '` � ' -"' :\ttrch a copy uf!he workers' cnmpensation pulicy decl•rr•rtion page (showing the policy number and expiration date). Failum tu,ecure cu��erage as royuired undzr Section 25:� uf�IGL c. I 52 wn lead to ihe impositiun uf criminal penalties of a i tine up to SI,SOU.UO;�nJ/or une-year imprisonment, as well as civil penaltics in the tiinn of a STOP �VORK ORDER and a tine „(up �o SZSO.UO a d8)' J1��1115[ (Ilf VIOI�[UL I)C �tIO'I�CII (Il�[:1 IUrY of ehis staicment may be fl�nvarded to the Office uf fnv�stiga�ion.of ihe UTA (or insurance �over;ige ��crilicatiun. /Ju hrrrby�cerrifi'uiulur d�e puins unJ prnul/ies aJ'perjury dmt rhe injurumtion provrded abore i.r rrue und correct � Date: U O �U �ien:uurc: ��:,,,,� � q�� - S�aB (IJ/ia ia(�ur ui+fy. Do nut n•rirr in d�is ureu. tr�br rumpluteJ hy city ur ton•n officiuL . Cih� ur�i'u�.n: ----------_---- Pcrmit/L.icrnse d --- . . Is�uing .1u�hurity I�ircle une): � I. 1loard u(Heal�h 1. IluilJing Deparhucnt J. Cih'i'Po��'n Clerk a. Electrical Inspector 5. Plumbing Inspector 6. Olher — - � Contrct Pcrson: ---- --- Phonr #:._. - � . Information and Inst'ructions \I:�ss:�.hu,cus Grnrr:�l La��s chap�rr I?_' rryuirr. ull emplu}rrs tn pro��ide �rorkers' �ontpcnsation tix�hcir cmpluyces. I'ursuant io this +tatute. :m �anp/urre is Jc�ine�l :u "._cc�ry person in th� xn�ier uf'sn��dmr und�r:my euntract uf hirt. r,c��rrss ur implirJ. ural or o�ritten.�. .\n .•�npLi��rr i; �IrlineJ as ':m indi�i.luaL p:irm�rship. :u;uciation. eorpor�eion ur ��dier Irgal rntity. ��r :my nvo or more ,�f ilir t�,rrguin� rn_agcd in a joint CI1IC1'�)f11C. :lI1tI inrluding thr Ir��l reprc,eneati�es uf a daceasrd��mployer. or ihe rr�cicrr or�nu�re �f an inJi��iJual. parmenhip. :u,ociation ur uther legal rntiry. rmploqin� �mplupee.. Fluwtver the ,��aner ot:i .hvrlling house ha��ing nut morc �h:m ihrce ap:irtmems and �.�h�� rcsiJes thcrcin. or�he uccup�nt of ihe il��•IIIIIR I1��UiC ot anuther ��ho cmpluys prnun, W iI0 I11:1tIllCil'JI7CC. CUIIiI(U14U11 Jf (C�:l1I N'UfIC Ufl iUlll lI\YOIIII7� FIUU52 ,rr ��n �he ;;rounils or huilJing appurtenant ihercto :hall not breause ol:u�h rmplu�m�ne ba �rrmed tu be an rmpluyer..• \I(.1L .h:ipt�r I�?, �_'�CI fi) alw ;tat�s �h�t "every state ur �ocal licensing agency shall withhuld the issu•rnce or � renew�l uf r �icense or permit to uperate •r business ur ro construct buildings in the common�re•rlth for any applicant �rho hrs not produced receptable evidence uf cumpliance ��ith the insur•rnce cuverage reyuired." :\�I�itiunally. M<iL �h:�pier 151. �_'iC1.7) ;tutes...Vrither�he cununumvealth nur any of its politieal subdivisiuns;hall � � riurr intu any coniract for the prrtimnanc� of public �vurk until �ccrptabla c��i�ence ot compliance with the insur�nce rryuirrmrnts uF this rhapter ha��e been presented w the:untra�tin5 authurity... . �pplicants Pk:�se fill uut the workrrs' compensation affidavit completely,by checking the boxes that apply to your situation and, if nrc�ssary, supply sub-cuntractor(s) name(s), address(�s) und phone number(s)alung with their certiticate(s)of insurance. Limited Liubility Cumpanies (LLC) ur Limited Liability Partnerships �LLP) with no employees other than the members or partners, are nut reyuircd to carry wurkers' compensation insurance. If an LLC or LLP dues have cmployees,a policy is required. Be advised that this a(fidavit may be submitred to the Department of Indusvial A�ci.lents for contirmation of insurance coverage. Also be sure to sign •rnd d•rte the affidavit. The aftidavit shoulJ be rctumeJ to the city or town thut the application for the permit ur license is being reyuested, not the Department of Industrial Accidents. Should you have any yuestions regarding the law or if you are required to ubtain a workers' cumpensation policy, please call the Department at the number listed below. Self-insured companies should enrer their self-insurance license number on the appropriate line. . .City or Town Officials , Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the botrom uF the uftidavit for yuu to fill out in the cvent the Office uf Investigations hus to contact you regarding the applican[. Pl�ase be sure to till in the pertniUlicense number which will be used as� ref'erence number. In addition,an applicant tha[ must submit multiple permidlicense applications in uny givan year, nred unly submit one attidavit indicating current policy infi�rtnation(if necessary) and under"Job Site Address"the appiicant should write "all locations in (city or �own)." A cupy of the aftidavit that has been ufticially stamped or marked by ihe ciry ur town may be provideJ ro the applicant as proof that a vulid aftidavit is on tile fbr future prrmits or licenses. A new aftidavit must be tilled out each }'C7f. WI1CfC �IlU1110 UWf7Cf Of CIIiLCI115 Uhf81010�8 IIi�I75C Uf PCCIIIII IIO[ �CI7[C(I[O�Ily b11S117C55 O�l'OITI7IC(CIBI VCOIUfB (i.e. a dug licen;e or pennit to burn Iro��es ctc.)said persun is \OT rcyuireJ to mmplete this affidavit. 'I'ha Ottice uF In��rstiga�ions would likz to th�nk yuu in advonce fix yuur eouperatiun and should you have:my yuestiuns, . plr:isc Jo not hesit�t� to give us a call. fhr 1)rpar�mrnt's ;idJress, telephun�:mJ fax number. � The Commonwealth of Massachusetts Department of Industrial Accidents Of}lce of Investigatlons 600 Washington Street Boston, MA 021 l 1 Tel. # 617-727-4900 ext 406 or l-877-MASSAFE it��.�� -,c,-u; Fax N 617-727-7749 www.mass.gov/dia , . . ,�:��""' �*\� � � CITY OF SALEM :( 1'� ;,, �, ;,=ji PUBLIC PROPRERTY :� � `.,r��;� DEPAKTMENT q ....�`4.'ArX ci:`�`% . nl\IU!.hl.l�.'i!'�IUSt:ItIJ. � .\I.'�,��'�I: 1?ON'A.iill\t:'1'ON$TRLI:T � ti.\IF�t, �i.\tii:\t]II.tiI�.Yi:iGl'�?� �(lii.: '/iS-7ii:);95 � I'.jS:9i8J�V':�74i6 Construction Debris Disposal Aftidavit (re��uire� ti�r all demolition und r�novatiwi work) In accordance wiUi the six[h edition ofthc Statc Building Code, 7S0 CI�1R scction 111.5 Debris, and the provisions of MGL c 40, S 54; � [3uilding Permit # _ ___ is issued �vith the coudition that the dcbris resultin� front this work shall be disposed of in a properly licensed waste disposal lacility as defined by MGL c I I 1 L S 150A. The debris H�iIJ be h-amsported by: CQ�o � tl�L, '�e►-,•o�e��C.�v,P (name of haulzr) � fhe debris will be disposed of'in : � �� 1'��_ (name uf facility)� �` l� (address nf' �cilityj � tign turc of permi[applican[ � � �� dare ��rb.i;�:t:,i�rc _ _ _ �- .. . . . � � d�1ERED�qC�' / .'I �. c`` p / . �,1 q � 3 �3. ya�i , r� �•� � . . . . � . . � ~�� N Y�SS�c� � . . . � � � � � � . __._.._.... __✓ • David� F. Jaqvith ��!__.O_Y�IIl,!}p4.trj_�_... _�... ___ � i �_. ... _._ ._. .. . _..._. �...� r _ ._... . -. _. _ _ __ I \`` . , .._.... � l�-----�_ _ ___ --� '' �'-" I �� .� � , � e�� J � I � �� , I � � - i ; �0 --�t�62�f__Itrt`_rJit�s-- ��w►� � ; <� I _ � �� _------ ._ ... ___ _ _ __ . . - (`�p ' - i ^ � .. 1 ' ► ' "� , �� . �rn- , �rn ' �i.• —�1� "��-- i _... .._�1w _:_ � N N �,"� � � -- _____. . , , I , � _ ._ �-_ � ` � < <v�dr1 f 1 �Pf-�� _-.._: - -�o�� _ _-- __ ___ I _ - _-�SOT SrGr1 ,. 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