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20 FEDERAL ST - BUILDING INSPECTION (3) -ECEIVED The Commonwealth of assacWLl s sS RV10E5 Department of Public SafMassachusetts Stale Building Code G —1 P � 32kuv) Building Permit Application for any Building other than a One-or'Fwo-Family Dwelling .(This Section For Official 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 not available) M & a No.and Street City/Town Zip Code Name of Building(if applicable) l SECTION 2:PROPOSED WORK Edition of NIA State COLIC used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair V1 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: IAre building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 8� 1lr Is an Independent 5tructurat Engineerm Peer Review required? Yes ❑ No 01' Brief Description of Pro o ed V rrk: u w u� 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)&Area Per Floor(sq. ft.) Total Area(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a Iicabie) A: Assembly A-1❑ A-2 ElNightclub ❑ A-3 ❑ A4❑ A-5❑TJ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ ft: High Hazard H-1❑ H-2❑ H-3 ❑ H-d❑ H-5❑ 1: Institutional [-1 O 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-I❑ S-2 Cl U: Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) IA ❑ lB ❑ Ile\ ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Hood 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: Ilazards to Air Navigation: MA I,Ii t ,is i_,mmn w n u ,i.... 1.r t;.,<: Not Applicable❑ Is Stn¢lur,within airport approach area? Is their review completed? OF Consent to Build enclosed❑ Yes O or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): type of Construction:. Occupant Load per Hooe Does the building contain.m Sprinkler System?: __ Special Stipulations: l�Sf�p NcEp 105 CDoc.)O LTR VC) W k . Q . L —VTtl �2 SECTION 9: PROPERTY OWNER AUTHORIZATION ; Name and AJdmss f[?roperty.Owner Name(Print) No.and Street City/Town Zip Property Owner Con'tact'fnfo7matigri; Mir Title Telephone No. (business) Telephone No. (cell) a-mail: idress IfaP the proper y owner hereby authorizes Name Street Address City/To n 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 than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professio al! agponsible for Construction Control Nante Rc pis t Telc ho re o. e-mail address s a gistration Number Street Address City/To4A State Zip Discipline Expiration Date 10.2 General Contractor - - - ili [IJOO �/J Company Name Name of Person Respons ble fo Construe wn License No. and Type ti Applicable a�tior�fc��J ��1r� Street Address City/ own State ip Telephone No. business Telephone No. cell a-mail address SECTION 11:1VORKER.S'COMIIFNSAI ION INBURA:NICE AFFIDAVIT 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 Item Estunated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Budding $ — Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ d. Mechanical (HVAC) S Note:Minimum fee=$ (contact municipality) 5. hlechanieil Other $ Enclose check payable to 6.Total Cost $ D > I (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 Ime an�curate t best of my k wled and understanding. fiPfn�� J w �r/�/�/ 9� -1-2= lease print<utign nine/ , ! �l Title Telep�ne NoD Date dcdZ�1?�' l0 64Ac�1�/�IZL\� ,yl�. Street Address City Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date CrrY OF SALEM mASSACHUSE M BUILDING DEPARTMENT .,.?S 120 WASHINGTON STREET,3"D FLOOR nL.(978)745-9595 KIMBERLEY DRISCOU FAX(978)740-9846 MAYOR THOMAS STYIERRE DIRECTOR OF PUBLICPROPERTYIBUII.DING COMNIISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature of applicant Date Y , New Salem @ Cohdbminium Association 20 Federal Street Salem,MA 01970 January 7,2415 City of Salem Inspectional Services s, 120 Washington St;3rd Floor Salem, VIA03970 To Whom !t May Concern: The New Saiein I Condominium Association is aware of the work that is being done by Sinclair Hardwood In Unit 2 owned by Jane Dickson and Joseph Pickett. Please let me know if you have any question_or requite any further information. Sincerely, a ;. Barry loner Condo Association Treasurer 508-847-7582 Am li t �r� ' x.• 1 .e 01/08/2015 11 :20 FAX 9787741411 HOWEMANNING (a 001/001 i AzbeUa Protection Tn302wice Compan A,R $E L LA 1100 Crown C)Ioony Drive COMMERCIAL GENERAL L I AB I L I TY Quincy,MA 02269-9174 RENEWAL DECLARAT IONS , DIRECT BILL - INSURED 10 Py ,( '! � oa/oe/aosa oe/oa/ao iar01 Iles SRAtaDAxn TIttM 9 1. SINCLAIR HARDWOOD FLOORS PHIL RICHARD INS INC THOMAS SINCLAIR DBA 27 GARDEN ST 23 FULLER RD UNIT 18 MIDDLETON, MA 01949 DANVERS, MA 01923 116 ANNUAL PREMIUM: $1,366 FORM OF BUSINESS. INDIVIDUAL BUSINESS DESCRIPTION: CARPENTER DESCRIBED PREMISES: LOCATION: 1 23 FULLER RD MIDDLETON, MA 01949 SUBJECT TO ALL THE TERMS OF THIS POLICY, INSURANCE IS PROVIDED AS SHOWN . LIMITS OF INSURANCE GENERAL AGGREGATE LIMIT (OTHER THAN PRODUCTS/COMPLETED OPERATIONS) $1 .000,000 PRODUCTS - COMPLETED OPERATIONS AGGREGATE LIM $1 ,0.00,000 PERSONAL & ADVERTISING INJURY LIMIT $500,000 EACH OCCURRENCE LIMIT $600.000 FIRE DAMAGE LIMIT $100 ,000 PER FIRE MEDICAL EXPENSE LIMIT $5,000 PER PERSON PREMIUM CLASSIFICATION CLASS PREN PREM/ PROD/ LOC# BLDG# DESCRIPTION CODE BASIS ID OPS COMP OPS 1 1 Carpentry-interior 91341 $28,600 (P] $993 1 1 Carpentry-interior 91341 S29,800 (P) $172 1 1 Contractors-Sudcntrct work 91585 $30,000 (C) $179 1 1 Contractors-Suhcontrect-Can 91585 $30,000 (C) S32 ID DEFINITION: (P) = Payroll Per $ 1,000 ID DEFINITION: (C) = Total Cost Per $1,000 CCI-Y OF S'u.Em, NWSACHCSETTS 4 BL'ILDI.C,DEPARTNIE-NT 120 WASHLNGTON STREET, 3'°FLOOR .. ` TEL (978) 745-9595 Ria(978) 7,40-9846 K1%I8ER.LHY DRISCOLL "-,q-1YOR THOhtAS ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BCBDr\G CONNISMONER %Vorkers" Cornpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A a ilicant Informatino P lease Print Leg7ibly Naina IllminussOrganiraliun,'Individual): G ✓© lily Address: City/State/Zip: l Phone n: 9Z Are you an employer!Check the appropriate box: Type of project(required): I.❑ I am a employer with 4, ❑ I am a general contractor and 1 6. ❑New construction iployees(full and/or pan-time).' have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. t .7. Remodeling ship and have no employees _ These sub-contractors have a. ❑Demolition \vurking for me in any capacity. workers'comp: insurance. 9. Building additiun - 1 No workers'comp. insurance 5. ❑ We are a corporation and its reiluiri:d.) - officers have exercised their 10.❑Electrical repairs or additions 3. 1 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing.repairs or additions myself.(No workers'comp.. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) }, - employees. [No workers' 13.❑Other camp.insurance required.) -Any applieyn not chucks box/t most also fill out Ihu seeriun below showing their worked compensation polity iornmwdon. 'I lumuuwnsn who submit this amdwit indicating Ihry an doing all work and then hire uunido contnctsm most suhmil a new amdavit indicting such $.,o~un thus chsvk Ibis box most amchd an addiliuswl Awl showing IN none of the asbavmnctnn and their wnhen'comp.puliry infutmation. fain on enrpluyer that is pruvidfng Ivorkers'conlpensailun fnsurmicerfor my earpluyees. Below is the policy and Job site information- Insurance Company Name: Policy 4 or Self-ins. Lic.0: Expiration Date: Job Site Address:.7oF� s� Ql City/Starr/Zip: /® Atlach a copy of the worltere'compensatlou pulley declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can Icad to the imposition oferiminal penalties ofa tine up to SI,500.00 und/ar rote-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and u tine of up to S23000 a day against the violator. Ile advised that a copy or this statement may be furwarded to the Office of Invesogaiimm ol'the MA for insurance coverage verification. - Ida hereb re 'y under the pairs and peenn�lr e,ffx v1perjury that the infunaaflaa provides/ubuvr is true and rurrecY P 1 ,d cYil n/liraar ass only. no ,at lrr6t hr this area,to be conry7ef¢d by city tar to run n/Jfria[ Ciry ne I'nwn: issuing Aut hurily (circle one): --- --- -- I. Board of Ileallh 2. Building Deparnacut .i.Citylrnwn Clerk J. Electrical Llspectur 5. Plnnlbing Inspector 6, Other Contact Iverson:..___. .. .. Phone 1t: {� Masshusetts`Oepartment of Public Safe 11SS// Board of Building Regulations anc(StandarBs'.' 66struc on Supers psor - ' License:'"e5`078g7fi 'y ° THOMAS R SINC 23 FULLER RD MI DLF%N MA 01 c` Expiration Commissioner 05/17/2016 L •"'A`wT i' ryq tVM/JEgL(ry,O�l✓�[q�� 4EC� �- r � Office f Consumer A?fav$&Bu'smess Regola'non ; OME MPROY N TCONTRACTOR � . u egisra tion! 38363 Type'' � v.,iExpiratwn -�3/27/ZO?5' _ OBA S; �v.SINCLAIRHAROWODpDC�I''4„I�RS � I' -. '°"J z THOMAS SINCIAIRY`' 23 FIJLLER D. 1 g MIDDLETON,MA 019f}9 ' .. Undersecretary