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24 FLYING CLOUD LN - BUILDING INSPECTION
i l • "►�' The Commonwealth of Massachusetts Department of Public Safety \las.echusa•Its?lair tlmlalmg Ctrdr l%BOC:\IR)tirarnth Editwn City of Salem �\ Building Permit Application for any Buildinn other than a I.or 2-Family Dwellin 1 _ (this Srrtiun For Official Use Only) Budding Prrmel Number: D.rtr Applied: Building Inspector. q SECTION t: LOCATION IPfease indicate Block a and Lot If for locations for which a street address is not available) l Nu. and Start Cily /Town Zip Carde Name of Budding(il applicable) SECTION 2:PROPOSED WORK ` If New Construction check here❑or check all that apply in the two rows below Exiling Building Repair O Alteration O Addition O Demolition O (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy O 1 Other ❑ Specify: Are building plans and/ur constructiun documents bring supplied as part of this permit application? Yes ❑ Na-0 �p Is an Independent Structural Engineering Peer Review required? Yet O No r Brie( Description o/f preposed Work: SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,Olt 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): P Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed No.of Fluurs/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area (.sq.ft.)and Total Height(ft.) SECTION Se USE GROUP(Check as applicable) A: Assembl A-1 O A-2r ❑ A-2nc❑ A-3 O A4❑ A-50 1 B: Business O E: Educational O F: Facto F-I O F2 O H: High Hazard H-1 ❑ H-2 O H-3 ❑ H-4 O H-5 O 1: Institutional I-1 O 1.2❑ 1-3 O 14 O M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4 O S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describer below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ le O I►A ❑ lie O IIIA O file O IV O VA ❑ VB O SECTION 7:SITE INFORMATION (refer to 7II0 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: public ❑ C heck el out>rdr FLwrJ Luna•❑ Indicate municipal ❑ A trench will not be Licensed Dispee.rl ;lie O rcqurrtd❑or trench or,pa il.%,: I'neaty❑ or inda•ntd\ Zuni: ur un.tie sc.trm❑ permit rs enclos d ❑ Railroad right•of-way: Hazards to Ai r.Naviga lion: \1to 1 b�dnr ( •nnnn••nn I<r.o w Pn \\•I \pidre.ddv0 1,'�Iructuru tcnhm.urpurt dppnarch area' I.their rrc iew complewd.+ .,r(',.n..•nt t,, Iitnld cncl„v,I ❑ )v,O nr No❑ l rs ❑ ❑ SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY Iditwn ,-l (',nla•. L,r rt pe o, C.-intruchun: (kcupanl Lod lvr ll,s,r Il,y.the buil.bnr;:,uV.un.in tit+ru+A ter tit.Icm^ �lvrral?lipuleu/ns� SECTION 9: PROPERTY OWNER AUTHORIZATION .V, m .end •\.LI s/ r (�rnl•er t•Owner Z` / � - //' /` �J� a Name l 'rint) .No.and Strut �— CiH/ rown r Z4?, 1'ro +erty th)ner Concoct Inhurmauon: Title relephone Nu. (busmess) relephune No. (cell) a-mad address If.tpyhcable, Ihr pro•erly uc%ner her ly a�unc� r/+__ LK c�F � J'�o Y��i � ✓V��r.� � O> SZ .Name Street Addr . City/Town State Zip. act on the +ro rrrl% .ncner's behalf, in ell matters relative to work authorized by this building mrmd a r rlication. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) tit t•urWin is lax than 37,UW cu. it.of vnckwst. ace and/ur nut under Comtruction Control then check hen O and alu Smiaun 111.1) 10.1 Re istemd Professional Responsible for Construction Control sr�U p�09az Nem J�(,,Re�•,,.Ir.ynt) Trlrphun u. rmaH, rrss Registration Number 'tYv �c O�Jrw � - Street Address City/Town State Zip Discipline ExpiratonDate 10.2 General Contractor Comp amq.2 U Y6`IdZ v / 3� (p(pr Name of Prtwn RResponsible for Construction dicense No. and Type if Applicable it'7 /t✓he �_ 6Z r'Z Street Add City/Town State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:W0RKE&aQKVENSATl0N INSURANCEAFFIQAVIT(M.G.L.e. 1SL I 23C(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 O SECTION 1L•CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6) =f 1. Building f jeloo ' �zlBuilding Permit Fee-Total Construction Cost x_(Insert here 2. Electrical1 5 appropriate municipal factor)-f 3. Plumbing f 4. Mechanical (H VAC) f Note:Minimum fee>•f (contact municipality) 5. Mechanical (Other) f Enclose check payable to 6. Total Cost f �r ' 60 (contact munici alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below. 1 herebv all"I under the pains and penalties of perjury that all of the information cunt.uned in this .tpplicalwn is true and accurate to the b"I of my knowleclgeand understanding. PIv.1'e print and .ig name /// ale roephone\u. Datc Q.��' 8 _ U.11 /t(P.,. r�r2 Street Addr,— Cth/Timn State Zip i %funicipal Inspector to fill out this section upon application approval: \'omr Date CROWNINSHIELD MEN MANAGEMENT CORPORATION AMOS May 6, 2010 Ms. Kelly Gifford 24 Flying Cloud Lane Salem, MA 01970 RE: Replacement Sliders—Sanctuary Condominiums Dear Kelly: Thank you for your inquiry regarding the replacement of your sliding doors. Please be advised that the Board of Trustees for the Sanctuary Condominiums does not object to the replacement of these doors providing that they match in appearance from the existing, they must slide and not open like a French door, and they must fit in the existing opening. They will not allow grids etc. We also require the permits be pulled in advance, and that a copy of the final approved permit once completed is also submitted to our office. We also require that you hire only a licensed contractor, with adequate insurance. You will most likely need to show a copy of this letter to the Building Department in order to obtain your permit. Should you have any questions or require additional information, please feel free to call me directly at (978)532-4800 ext#232. Sinc rely, J. ama, CMCA P perty Manager Crowninshield Management Corp. Managing Agent for the Sanctuary Condominiums cc: File 18 CROWNINSHIELD ST. • PEABODY, MA • 01960 • TEL (978)532-4800 • FAX (978)532-6023 • WWW.CROWNINSHIELD.COM CITY OF SALEM ;,. i PUBLIC PROPRERTY R. DEPARTMENT '..I\II;:RLrY URI1CULl. l2C WA\HING I OK STRGL•-r • S,LLEM,MASSACI n l.sii'f is 01970 978-745-9595 0 Fsx: 978-7449846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ihly Vamt (13usincss/OrBaniratinNlndividu/all: h�af/ �K JGL "�° Address: City,''State,Zip: (2 )1 et-6Zt3-Z-Phoncll: 7kr/6 6//-6 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 g ❑ New construction e to -ces full and/or art-time).` have hired the sub-contractors y ( P' 7. ❑ Remodeling � ❑m a sole proprietor or partner- listed on the attuchcd sheet. ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition [No workers' cons insurance 5. ❑ We are a corporation and its I P• 10.❑ Electrical repairs or additions required] officers have exercised their 3.❑ I um a homeowner doing all work S P P' on exem ti right of per MGL 1 I.❑ Plumbing repairs or additions myself. [No workari comp. c. 152, gl(4),and we have no 12.❑ Roof repairs d t employees. [I�o workers' e insurance re wre 13. - Other 1 . q 1 ❑ comp. insurance required.] x-clion buluw showing their workurs'cumpensution policy infurntation. 'Nry applicant tlmI checks box bl must also till caw the 'I lomeuwm:rs who submit this affidavit indicating they are doing all work and then hire outside contractors must euhmit a new arCdavit indicating such. Commcturs that chuck this box maul attached an additional sheet showing thu name of the subcontractors and their workers'comp.policy information. l urn cut employer that is providing Ivorkers'c•ontpensatinm insurance fo•uty employees. Below is floe policy and job site information. Insurance.Con,pany Vmne: -_..-__. . _- _ _-..----._--.._._..-------- Policy A or Self-ins. Lic.t;: —_.....-..._ .. _..;......___ Expiration Dace: Job Site Address: CitytState/Zip: attach it copy of the workers' compensation policy declaration pulse (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ur`1GL c. 152 can lead to the imposition of criminal penalties of a tint up to 51.500 00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 it day against 0 violator. 13c advised that a copy of this statement may be forwarded to the Office of Ill\"CSIhaIIUIU uI the IA r i . ranee coverage verification. /du herrhy certi t nr r coins ant!penukiex of perjury that the information provided buve - true and correct. Sienaune: Date' �// 7 /16 _ __ CPt7 !P I h r i official use only. Do nor ivrofte in this area,to be cunipleted by city or town official. City or Town: .. Permit/License x—__.-- -- _ --_.... .. _ . Issuing Authority(circle one): I. Iloard of Health 2. Building Department 3.City/rows Clerk 4. Electrical Inspector 5. Plumbing Inspector G. Other ------- Contact Person: _.---- Phone H: Information and Instructions ;Massachusetts Gcneral 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:u 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." SIGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance 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, bIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perfomtance of public work until acceptable evidence of compliance with the insurance - requirements of this chapter have been presented to the contracting authority." Applicants Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s) namc(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than 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 Ifas provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to till in the permidlicense number which will be used as a reference number. In addition,an applicant that must submit multiple pennitilicen-se 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 proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled 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 dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The 01lice of lovestigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Fax #617-727-7749 ac -is d 5-,6-us www.mass.gov/dia t ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 08/17/2010 PRODUCER (617) 846-8600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION John M. Bi io Ins A enc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE gg - g y HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 399 Winthrop Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. WinthropMA 02152- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Nautilus Insurance Lighthouse Construction INSURER B:Travelers Insurance 47 Bates Ave. INSURERG NSURER D' Winthro MA 02152- INSURERe COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS A GENERAL LIABILITY / / / / EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES ERENTED nce $ 100,000 CLAIMS MADE OCCUR NC 933141 07/07/2010 07/07/2011 MED EXP(Any one person) $ 51000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 17 POLICY JECOT LOC B AUTOMOBILE LIABILITY 920821808 04/01/2010 04/01/2011 COMBINED SINGLE LIMIT ANY AUTO (Ea accdent) $ ALL OWNED AUTOS / / / / BODILY INJURY X SCHEDULED AUTOS (Per person) $ 100,000 HIRED AUTOS / / / / BODILY INJURY NON-OWNEDAUTOS (Per accident) $ 300,000 PROPERTY DAMAGE (Per accident) $ 100,000 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR F—ICLAIMS MADE AGGREGATE $ DEDUCTIBLE / / / / $ RETENTION $ $ WORKERS COMPENSATION AND / / / / TORV LIMITS ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE$ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Kelly Gifford FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE 24 Flying Cloud Lane INSUR ITS&GENTS OR REPRESENTATIVES. AUTHO R NTA Salem MA 01970- A{�C, ORD 25(2001108) ©ACORD CORPORATION 1988 P6.�INS025(0108).05 ELECTRONIC LASER FORMS,INC.-(800)327-05 5 Page 1 of 2 CITY OF SALEM PUBLIC PROPRERTY DEI'ART'.�tENT t. • • .• �,�I•F i 1': 11:4 Cr r r tiA[I \I. \1\1;a • I'\s:•r8.74:'Is4:• Construction Debris Disposal Affidavit (required lily all demolition and renovation work) Ilt accordance \\ith (he sixth edition of the State Building Code, 780 Ch1R section 1 1 1.5 Debris, and the provisions of'1v1GL c 40, S 54; Building Permit 0 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 t I l: S 150A. The debris will be transported by: (name of hauler) I he debris will be disposed of in (name of facility) (address of Iucility) \ uauuc of permit applicant