11A FIRST - BUILDING INSPECTION f a [•
;► ' The Commonwealth of Massachusetts
Iy Department of Public Safety
Ma...sochuNells Stale Budding Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
(This Section For Official Use Only)
Building Permit Number. Date Applied: Building Inspector:
^� SECTION 1: LOCATION (Please indicate Block 0 and Lot 0 for locations for which a street addm is not aavvailable)
\'o. and Street City /Town ZipGxle Name of Building(itapplicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Changeof Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
to—
Isan Independent Structural Engineering Peer Review required? Yes ❑ No-�L—
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) ❑
Existing Use Group(s): Proposed Use Group(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ T B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 O
I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 14❑ 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 a Ilcable)
IA ❑ too IIA ❑ 1100 IIIA ❑• III8 O 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❑ Check if out>ide(good Zone❑ Indicate municipal ❑ A trench will not be Lice•n.ed Di.pusal Site❑
I
required Our trench or,pecav:ricaty❑ or mdcnlife Zone: or un ate.c.trm❑ permit is cnclnsed O
Railroad right-of-way: Hazards to Air.Navigation: yL\ I li.tnn; it....... I'n
\ d :\I'plicable❑ 1.Structure%crthm airport approach area' 1, their review completed.`
"n )e,❑ or No❑ 1'e,❑ \n ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Fdiuon ,,I Cede: __ L,v Gi,Mpl.i: r:peo,Construction: OCCLIpant Load per hour:
I hoc.tile'buddmt;contain an Sprinkler S%,tem': Special Supulauun*:
SECTION 9: PROPERTY OWNER AUTHORIZATION
e and Addr of Properly U wner
f1-�iI�.rl/9/yo 6
Name(Print) No.and Street City/ruwn /Zip
I' pa•rtylhynrr 'untactlnlormauon �� n_,'� C//s yJ1/O,�V
munlar)
itIe Telephone No. (business) Telephone No. (cell) a-mad address
If 1.4 iQe, the property its ner hereby authorizes —
(JJ'7M'1Y1(� Name Sleet Address City/Town State Zip
to act on the .ro erly owner's behalf, in all matters relative to work authorized by this building permit a >plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(It buildin•is less than 35,000 cu.it.of endavJ s pace and/or not under Cumtruction Control then check here O and sJup SLrtiun IU.I)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor n y� y�,,,' /
C anyN 911 �� `s lym AtliylJ
ame of Person Respxmsible for Construction License No. and Type if Applicable
City/Town State Zip
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE 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 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
1. Building S Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=S
3. Plumbing S
4. Mechanical (HVAC) $ Note:Minimum fee=S (,S)ntact municipality)�5. Mechanical (Other) $ '
Enclose check payable to C�
6. Total Cost S , (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereb attest and the pains and penalties of perjury that all of the information contained in this
,4 licatiun is true and accurate t best of kno ledge and understanding.
1 r G YN
PI -AW Vnnt 1 sttin name - / � / ride ' TclephuneNat
dv
Date
�u'cel Address �Il/ Cityi Town State Zip
Municipal Inspector to fill out this section upon application approval:
ame Date
i 4\
CITY OF SALEM
PUBLIC PROPRERTY
�• DEPARTMENT
I'Ji: M111 ' Mlr 1'II
I'C R',+I IL\L.,!V 51 N kr i 0)•111)1,St.\K 11 111 .1 I,•.I', .
1'rl:'071.70-)I y! I°,t:'ll/•TJS'IAJA
Construction Debris Disposal Allidavit
(required lur all demolition alld renovation work)
in accurdime with the sing],edition of the State Building Code, 780 CMR section 11 I.S
Debris,and the provisions of MGL c 40. S 54;
Building ilermit N . _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 130A.
The debris will be transported by:
name of twuled
The debris will be disposed of in
(name ul? aci I Ity
Iadtl s of I•acJityl
,I�Ilalure II , ppliQnt
hate
f
WORKERS COMPENSATION AND EMPLOYERS'LIABILITY
INSURANCE POLICY-INFORMATION PAGE
INSURER: POLICY NO: 2 010 01-12-3 9-03-7
PENNSYLVANIA MANUFACTURERS'
ASSOCIATION INSURANCE RENEWAL OF: 200901-12-39-03-7
NCCI Company No: 11916
Account No: 1239037
ITEM 1. NAMED INSURED AND MAILING ADDRESS: PRODUCER NAME AND ADDRESS:
CLOISTER CONDOMINIUM I COMMUNITY ASSOC. UNDERWRITERS
(SEE SCH OF NAMED INSURED (S) ) OF AMERICA, INC.
C/O EAST COAST PROP 2 CAUFIELD PLACE
400 HIGHLAND AVE STE 11 NEWTOWN PA 18940
SALEM MA 01970
PRODUCER NO: 0181
LEGALENTITY: ASSOC. , LABOR UNION, RELIGIOUS ORG.
OTHER WORKPLACES NOT SHOWN ABOVE: (See Extension Of Information Page)
ITEM 2. POLICY PERIOD: From: 04-22-2010 To: 04-22-2011
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
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: Part Three of the policy applies to the.states, if any, listed here:
All states except North Dakota, Ohio, Washington and Wyoming.
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verifica-
tion and change by audit.
Total Estimated
Minimum Premium: $ 282 Annual Premium: $ 332
Audit Period: ANNUAL
Issued At: 25 MOUNT LAUREL
Date: 03-01-10 Countersigned by
WC 00 00 01 A Copyright 1987 National Council on Compensation Insurance
INSURED COPY
CITY OF S.U.E.NIt NlaksS.XCHUSEM
BLODLNG DEP.\RT%1L%T
120 W.%SHLVGTON STRM. 3"FLOOR
Tim (979)743•9595
'a F.kX(971A 7J49&W
KINCBEAIEY DRISCOLL
MAYOR THosus ST.PIERIte
DIUCTOR OP PL/LIC PtOPt itTY/K DLVG COhOrtSSIO-ER
Workers' Compenaatloa Insurance Alfldavit: guilders/Contractor/EltretrlclanslPlumben
%nalleant InformaHos Please Print Leeibler
r
//��
V'atnt:ItluutanaOrtartuatiorbIndivtdualY• t / J /( /�) /
Address:
cilyistate/zilt:
.%ro Yoe as employe!Ckaek the approprlata box: Type of project(required/:
1.❑ 1 am is csnpkeye wilt e. Q I an a peternl caetaete moo I & Q Now construction
employs"(IWl and/or pan-time).• have hired the mbcon&wwn
2.Elnea 1 ate a sole pmpriale tw Peri listed an the adsched shed:
y. Cl RemaltlinR
:hip and have no employes Thee sub•eomeeatme haw e. Q Demolition
wortlns far me in any capacity. workers'comp instunae s, 9. Q Building addition
I No workers'comp insurance S. Q We am a corperedou atd is
rcgtdreL(
otlkms have atmteised their I O.Q Elacrriwl repair a additioru
3.Cl I am a homeowner Join/all wort right Of a omprice Per MGt. I I.Q Plumbing repairs or ad iMmus
myself.(No worka o'comp. e. 1 JZ 11(4).and we haw no 12.13 Roorrepaies p
insurartce required.)► cmPloyeea.LNoworkera'
comp inssuanoa required j
'Any appaor ter dowse 10111 Of ntttw Am no uw tlw mrim aAM abewiy to* a oor"Pum ua Paley inamomim.
'❑.r.AArwrae ohm"A"Ahis Atadsvt indledN toot an dens All Moak 2"dtm him atr"coom es New Admit a owe a11hMi1 44ke is
t'.wtr.eAtAe that cbwb tW M nnea atlehea as 2M*AWl Amid dewiq rti roan 8111/vaeereAme MA that warhae'ran7.pd4y iabeWa
f me an rmpbya►that trpavJding nwAers'costa rw I wcr fm q emy/oyeus salon fa 1110011147 awd so
in�Ntwa1lNa 99 '�n 1/ `/ �7yJ�I�j // lL7 ///'
In.urance Company Nama: V/W i/ r��� � � 1/��7L"7[/�Iy/�✓ �1//t1 �lV/Ll/
Policy e or Self-ins. Lia.e l,�i /�� J —� �_ Eapiratioo Date:
Jub Site Address: ���/�/ L� CityislaWzip ll;`�
.\nark a copy of the workers'eomponsatles policy dmlarstloa pap(stewlog Me palk7 semtte and esplrselora dste).
Failure to shun coverage as required under Section 23A of MOL e. 132 can lead to the imposition of ritninal psnaltin ofa
fine up to S 1.500.00 and/or one-yew imprisoning,as well as civil penalties is the form if es STOP WORK ORDER and a flu
Of up to S230.00 a day atlsinss the violator. Ile adviad that m copy of this statement maybe forwarded to the 0171ce of
Invcanyatiune of die MA for insurance coverage v%witieatios.
f Ja hrrrbr r y under rAe ills wa PrweArfe e/Perlary that Me in/erweelow provided aubaw is true and ca rotes
O/Jrcid sae r,dy. nil not wriq in this arrq to be,etwp/erd by airy of fawn n//fcie{
City or futrn: ecrmialcensel__
Awing.\uthurtty(circle unep
I. Iluard u(Ilrutlb 2. Rudding 0epartmene 1. cirytrown Clerk b. Electrical laspwor S. Plumbing Impeaor
6. Other
/•,,hart Pcrton: _ . _ .. Phone m'
From:978 745 9684 04/20/2010 20:36 #771 P.001/003
EAST COAST PROPERTIES
400 HIGHLAND AVENUE, STE 11
SALEM MA 01970
(978) 741-2003; Fax(978) 74S-9684
acsimile transmittal
To: City of Salem— Building Department Fax: 978-740-9846
From: Cyndy Anselmo Date: 4/20/2010
Re: 11A First Street,Salem MA 01970 Pages: 3
Cloister Condominium Trust
Cc:
i.7 Urgent i-I For review 171 Please comment i Please reply 0 Please recycle
.-______._ _......___.........,..-
Notes:
Attached Is t he completed workers camp Insurance for Cloister and a copy of the declaration page of the
insurance. I will be by tomorrow to bring in the $93 check for the building permit
From:978 745 9684 04/20/2010 20:37 #771 P.002/003
c 1
CITY OF S.0 E.`f, NLiss xcHL•sET B
0LamLNG DEPAVMEiT
120\V.%sHwGTON STRW,3m FLOOR
TEL(978)143.9593
FAx(975)14499"
KI►BEALBY DRISCOLL Iw"UST.PRRRi
MAYOR DIRecZon oir F eLlc rROrVRTY/KI DaG CONMOSSIONER
Wurktn'Compenaatloa Insurance AMdavit: Builders/Conlracton/Eledric)anslPlum ben
aunlle2nt In(nrmadon Plante Print Lealb(ft
Valnl:lau"MniOrsanuatienlnJmduYl' � JL �/�f 7i'�� i.-/j// �����//Li/Lij7� /✓C Lei C�
F1/l
Address: 41 (J
CIfy/StawZip _J Z L//Y Ptmrw
Are yos so empleyer7 Cbaeb the appropriate toss 'ryps of project(nquirele
1.❑ I am a employer wit! e. Cl I an a Small casae.4 awl a ❑New construction
employees(IWI andor pan-timsj.e have hired eke su►carettcon
2.❑ 1 am a stab pnpries or partner- listed an the attacked#^IGL 1 7. Q Remodeling
.,hip and have no amployces new st►contraaon have S. Q Demolition
wotklna rot me is say Capaeiry. workero'comp.inatusacL 9. Q Building addititm
INo workers'comp.insurance S. ❑ Wa sew a capandart and id
regtdrtaLj often haw exercised their I0.❑Ekactrical repair a atfdiritma
).❑ I am a homeowner doing all work right ofaaomption par MOL 1 I.Q Wumbini repairs or addkions
myself.(No workers'comp. C. 152.f 1(4),and we haw no 12.13 Poormpain
insurance required.)r rployn rsL�wNG maolbv
j
•A•r appbma iti du M bm n mare ester nor wt nw.eem ear. I I tksk.ak..•mnrrar+e wtlay hrna.Aa.
'If.wtuwwm who su6am"dedwe i Akwies my s Joins to"*sea din hfw.tatila eeersdan eras mane a raw ottWwe ieakwiet■rA
i'.vesvn ttm.+sues tail W inua snarW as elstiw.l J.r rr.liy tlr ern.art tea ar+ertstrete W ta.k -coal,patsy tefrwWr
f Use as ratpkyer that bPn1Wd1sjr Work#Pr'ceespewardso A elafor e p eaWaywa OiNre b the pe/k�nerd alb.
i n�wtwarAW� �
In.urrnce Company Name: .Mel��i/)l�).�%�� /17��i i <///%y/��.'J��°�L��i`%;l Sf(�7.. I)J C,I/(_. l
Policy a or Self ins.Li
e,M* Expiration
lob SireAddivu: /� -��11(/ yx(l City/Slate/Zip:
.►neck a copy of tbo workan'tespearadee pally declarative pap(Allowley Ike pe ft seabw sad eaplratloe dwe),
h'oilure to uxm covenp as required unJrr.Sectlon 2!A a(MOL e. 152 can lead to the imp sition oferimind ponstliett of■
f ne up to S 1,500.00 and/or one-year imprisrmm e K as wall As civil penalties is tits fam of a STOP WORK ORDER and a 6ae
or up to S270.00 x Jay uyainu the violator. IN advia+d thus cupy urthis stak'maa maybe ruwurded to the Ot1lcs of
In.c.usniuna ul'the DIA far insurance coverages witkatwa,
/ds hereby • y"Mier she par"n pease/r/rr rf perfaq shot rAa information pnridd above is it"turd ewrrea
�,..�/,IlL
7
QJJrcia/"ore✓.Jja Oe nor wrin ie this+era6 to be'ump/rted ey city"tewo m/fAridt71nipector
Ciry or fuwn: evrmicn.Itrnu.elasing.►uthenby lcircle uneltI. tfuarJ uIIleullb 1. Rudding tleputment 1.City/rows Clerk t. Eletlriul Inspect
6.01her
1."nlact Pcnont _ .. Pho 'a s•
From:978 745 9684 04/20/2010 20:37 #771 P.0031003
WORKERS COMPENSATION AND EMPLOYERS'LIABILITY
INSURANCE POLICY-INFORMATION PAGE
INSURER: POLICY NO: 2 01001-12-3 9-03-7
PENNSYLVANIA MANUFACTURERS'
ASSOCIATION INSURANCE RENEWAL OF: 200901-12-39-03-7
NCCI Company No: 11916
Account No: 1239037
ITEM 1. NAMED INSURED AND MAILING ADDRESS: PRODUCER NAME AND ADDRESS:
CLOISTER CONDOMINIUM COMMUNITY ASSOC. UNDERWRITERS
(SEE SCH OF NAMED INSURED(S) ) OF AMERICA, INC.
C/O EAST COAST PROP 2 CAUFIELD PLACE
400 HIGHLAND AVE STE 11 NEWTOWN PA 18940
SALEM MA 01970
PRODUCER NO: 0181
LEGALENTITY: ASSOC. , LABOR UNION, RELIGIOUS ORG.
OTHER WORKPLACES NOT SHOWN ABOVE: (See Extension Of Information Page)
ITEM2 POLICY PERIOD: From: 04-22-2010 To: 04-22-2011
Effective 12:01 A.M. Standard Time at the Insured's mailing address.
ITEM 3. COVERAGE:
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 liabilityunder
de 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: Part Three of the policy applies to the.states, if any, listed here:
All states except North Dakota, Ohio, Washington and Wyoming.
D. This Policy includes these Endorsements and Schedules:
See Schedule of Forms and Endorsements.
ITEM 4. PREMIUM: The premium for this Policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required on the Workers Compensation Classification Schedule is subject to verifica-
tion and change by audit.
Total Estimated
Minimum Premium: $ 282 Annual Premium: $ 332
Audit Period: ANNUAL
Issued At 25 MOUNT LAUREL
Date: 03-01-10 Countersigned by
WC 00 0001 A Copyright 1987 National Council on Compensation Insurance
INSURED COPY