2D FLETCHER WAY - BUILDING INSPECTION (2) ad
The Commonwealth of Massachusetts
W
Department of Public Safety
Massachusetts State Budding Code(780 CMR)
ti Building Permit Application for any Building other than a One-or Two-Family Dwelling
^ IC (This.Section For Official Use Only)
(V Budding Permit Number: Date.Applied: Building Official: ._..
rn
N SECTTION 1.LOCATION(Please indicate Block p and Lott H,for locations for which a street address is not abl
f No.and Street City/Town Zip Code Name of Building(if appliMle)
l /) - - SECTION 2 PROPOSED WORK, - D �'o
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two ia_ws belo:i_v
1 Existing Building Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Ap dix V,
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 fry
Is an Independent Structural Engineering Peer Review required? Yes ❑ No Er—
Brief Description of Proposed Work: l
L ewe ,
22
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
PFa
Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
rea(sq.ft.)and Total Height(ft.)
SECTIONS:USE GROUP(Check as a pJicable) - - - -
embly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ -
o F-I❑ F2❑ H: High Hazard H-1 ❑ H-2❑. H-3 ❑ H-4❑ H-5❑
tutional l-1❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ - R: Residential. R-10 R-2 W-YR-3❑ R4❑
age S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IB ❑ IIA ❑ IIB ❑ 1[IA ❑ - IIIB ❑ IVY VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Supply:/ Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal:
lic G Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
ate❑ or indentity Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: %1,%Historic Commission 1te,ww�'nxt_ss:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed Cl I 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 buildhrg contain an Sprinkler System?: Special Stipulations:
G-1 g - Cl -7 Cl - 7 I Z)
Crh,L .L- t1 / I $ ' 15 � CAcA1L—Ia�� I-t, Ey ,
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name a,n/ *14 v d�Address of Property Owner / _
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
2 - 9 /2/ -
Tt a Telephone No.(business) Telephone No. (ce6) e-mail address
If a plicable,the,property owner hereby authorizes no (W 112t/r?�L /7�1d1on�sr m*�y��eko /1-,f Q'22�0
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 buddingis less than 35,000 cu.ft.of enclosed s ce and or not under Construction Control then check here Bandski pSection 10.1
10.1 Registered Professional Responsible for Constriction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
_nwo 102�;eyt_e
None of Person Responsible for Construction License No. and Type if Applicable
!? 139l3To& J-f Ae Fte/O M eme
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:W0I7 KEKS'CONtPLNSA'I'IC.N INSURANCE AFF'IUAVrr 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
Estimated Costs:(Labor pd
Item and Materials) Total Construction Cost(from Item 6)=$��
1.Building $ Q o
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (FIVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 3 a-D do (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' rue and ac r. o the best of my knowledge and understanding.
Please print and sign name Titl Telephone No. Date
Street Address City/Town /Ile,f State Zip
9
Municipal Inspector to fill out this section upon application approval: �5-
Name Date
11/06/2015 11:33 17812895289 RM CATALDO INSURANCE PAGE 01/02
P,M. a4TAL D0 /NSGCRANG%E,44ENC�'
COMPLETE INSURANCE SERVICE
230 SQUIRE ROAD REVERE, MA 02151
Phone (781) 289-5286
Fax (78.1)-289�5289
DATE: November 6, 2015
FROM.• June Macdonald
TO: City of Salem .Inspectional Services
FAX.• 978-740-9846
RE: Dino Persia dba Fasciani Development
MESSAGE: Attached is a liability certificate for the
above insured.
June
NUMBER OF PAGES INCLUDING COVER 2
.� {fiee of CNaume�r�vmaoP,���hr°JG�o ,c
1,0
Affi�re&B r
1NEIMPROVEMENT "81°�sa+l4n■■
# istraLon ""82172 CONTRACTOlk
90
FASCIA{VI DE _ " PBA
VEtjpENy. a� r
-r Ni PERSIA,-
4
f78ABSON
WAKEFIELD
2 zMA,'1f 1880
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i,Uudersecreta
Mas achusgtfs¢pepargneni of POWfo Safety
Board of Building Regulations and.Standards-
r (;;Construction 5apen isnr
- + a.1 License:.G"55513= r
. �MNORPERS7A
17` BAB$ON ST&)LET a
F Wakefield MA O, SO ` P • •.
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e%p�t19!y.
®1" Co Issioner` ' '
CITY OF SALEA A ASSACHUSETIS
' BE DINGDEPAR7MENr
110 WAMCMNS7MMET,3IDFLooR
UL(978)745.9593
FAX(978)740-9846
RiMRRRi FYDRIS�LL
MAYOR TrioiM STY MRE
DIRECTOR OPPUBLiCFAMERWAtUUDnd OOMOssioNER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit 8 is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 156A.
The debris /will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
The Commonwealth ofMassrtchusetts
Depardnen- t oflndusiria1,4s i'ents
1 Congress Street,Suite 100
Boston,M402114-2017
www.masxgov/din
Wworkers'COMPeR52tion Insurance Affidavit:Builders/Coi&actors/Elecbicians/Plumbers.
TO BE FL=WITH THE PERMITTING AUTHORITY
ApplicantInformation Please Print Ledbly
Name(Business/(igr®zetio lndiv000):_ �L.�(-"i.�'{I//. l/1 —,42ICI]2�
Address: !7 gL61A1 Sfi
City/State/Zip,: Alt Phone 0: 19
Are you m employer?Chesk the apProprlase 60::
Type of Project(reiluired):
].01 m a employer with .empkmyees(fall and/mpmt-t®e).� ' 7. Q N mchUn !i
2. e.aole proprietors partnership epdlmve no employees workhtg lot meio
my capacity.[No wiukeis'a*-hemlines reguirval 9. 0 Demolition:
3.01 m a homeowner doing all work myself.[No workers'comV�iosmance required.)t
10 Q Bm7diog addition.
4.p 1 em a homeowner and will be hiring cmuactws to conduct all work on my pmpeM. 1 will
emme that all conuaams afberhave workers'compeomoon in$manee or are We 11.0 Electrical repairs or additions
poprietms with memployms. 12.[]Plpmbing'tapers of additions
5.01m a g,mmal cormadur and l heve hued the submnaaaae listed on theat�ed$beet. 0.0 Roofrepairs.
lbew mb-contracma have employees and have wor)cge cGmFL HIMMEMMi
6.D We are a con met mend its officersheve exercised then right of exemption per MGL c. 14.0 Other ..
152,§1(4),end we have no employees.(No wmkm'wmp iosmanu:ngwrcd.l
'Any applictut that cbeelrsDoa sl must elm fill out the section below showing therw'wkas amp�im policy6 tom:
t Homawma who sulmtit this dGdavitindiaang they ere deieg all wmK and tbeu bne outside contractors most submit a new a%devit mdiwneg such-
tcmtrsctm that check this box mast ausched on additional Awsbowiog an name of the sub-commadms end state wtieBiv or out those cmipa beve
employees Ifthe sobconeactma here emOcyces,they must pawidetheir K'mkaa=oomAPolicymmtiq
lam an employer that is providing tporkers'competraation msurmrcefor my employees. Below is thepoHmy ant[job site
infonnadon. _ '�1 I/�e/F
Insurance Company Nam: K /"r �l&00 )U(/t?1zP— ✓l// s-s - —
Policy#or Self-ins.Lic:M 77T-- _<2K u03 f _ Expiration Date: �/ O,
lob Site Address: r City/State/Zip: W&R r/DLY/ vl,rI
97v
Attack a copy of the workers'compensation poW declaration page(showing the policy number and expiration date).
Failure to secure coverage as inquired under MOL C. 152,§25A is a uavi»na]violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties'io the farm of a STOP WORK ORDER and a fine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage veriticatitm.
I do hereby ce&under the pains/an�d penaftm ofperjury that the information jompideed above is lose and correct
Signer `/,>��/f.�LIL�,.�-� 9 Date,
Phone M
Official use only. Do not write in this area,to be colapided by pry or town offWal
City or Town' PensdoLicense#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#'
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuanee or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states'Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting autbority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-conlractw(s)narne(s),addresses)and phone number(s)along with their certificate(s)of
insurance. Linated liability Companies(LLCM or Limited Liability Partnerships(LLP)with no employees other then the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured'companies should enter 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 bottom
of the affidavit for you to fill out the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that nnut submit multiple permit/licanse applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town):'A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dqg license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
De)artment of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017;
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www,.mass.gov/dia
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