54 FORRESTER ST - BUILDING INSPECTION (4) The''Commonwealth{ of Massachusetts
� 4 / Department of Public Safety
n
' Massachusetts State Building COLIC(780 CMR)
Building Permit a\pplic5tion for any Building other than a One or fwo Fam' D II'
(This Section For Official Use Only)
Building Permit Number: Date Applied: Buildung Officia-•
SECTION 1: LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
611 fbh-eS{es- a flnit3 (mab�+ eA4 HA
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK
Edition of NIA State Code used_ if New Construction check here❑or,check all that apply in the two rows below
Existing Building❑ Ropn Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
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 19
Is an independent Structural Engineering Peer Review required? - Yes ❑ No Ea
Brief Description of Proposed Work: o, Q-X 15 l
1n�%W ear 6, m n lrn �( rnwL°In n vu re t tp-ka t n 11� t
UITpnY'1��1
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
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total r\rea(sy. ft.)and Total Fleigh[(ft.)
SECTION 5: USE GROUP(Check as ap Iicable)
A: Assembly A-1❑ :\-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ I If: Fli h Hazard El-l O•` H-2❑ H-3 ❑ H-d❑ 1-1-5❑
l: Institutional I-L ❑ I-2❑ 1-3❑ 14❑ NI: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-L ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
- Special Use
-.\ SECTION 6:CONSTRUCT[ON TYPE(Check asap Iicable) - -
L\ ❑ IB ❑ TEEA, ❑ 116 ❑ 111A ❑ II1613 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 Reunoval:
PP Y
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ reyu red O or trench - or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \tA I li t ri �. np71N,
vic�� f r�_ru; .
Not Applicable❑ Is Stricture within airport approach,.nrea? � �Is their revnpleted?ar Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code .Use Gnnip(s): Type of Construction: Occupant Load per Floor:
Dues the building contain en Sprinkler System?: Special Stipulations:
SECTION 9: 1,1201,Eft'FY OWNER AU'r1IORIZATION
Hanle and Address of Property Owner
-flto>ta�flandr� Ylo�rt. Sal F6w'ougt- ST U►ttt S pti� N
Name(Print) No.and Street City/Town Zip
Property Owner Contact information:
p� � 1C� .r��C�
L S� pVq F�o �'��o-�
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable, the property owner hereby authorizes
Nance Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit a Iication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) ,
If buiin is less than 35,000 cu.ft.of enclosed s ace and or not under Construction Control then check here O and ski Section IU.I
ld
10.1 Registered Professional Res orisible 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 .
RPM r
C)Ili panyJ'd�ame
N. �` 'JOt cs o�9ai�
Name of Person Responsible for Construction License Nu. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:l\(.N tie.I ti'COkO VN',\[ION INSUI'AN(.I. 411'11 i\\I\\ 'I M.G.L.C.152. 25C 6
A Workers'Connpensation 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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Il,m and Materials) Total Construction Cost(from Item 6)_:5
I. Building S Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ JggO042 appropriate municipal factor)=S
3. Plumbing $ l
Note: Minimum fee=3 (contact n 1 ni�' Deity
•1. Mechanical (FIVAC) S -
3. Mechanical Other S Enclose check payable to _ f
6. Total Cost $ (contact utlm ici polity)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering illy name below,I hereby attest under the pains and penalties of perjury that aft of the information contained in this
application is true and accurate to the best f niy knowledge and understanding.
Picase print and sign I lnle �1 Title Fefephone No. Date
Street Address Gty/Down State Zip
.Municipal Inspector to fill out this section upon application approval:
lame Dal,
CITY OF SAL&%%, MASSACHUSEM
BUILDING DEPARTM&NT
120 WASHIIGTON STREET, 3"FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KIJIBFRI RY DRISCOLL
YOA THOS(AS ST.PMM
DIRECTOR OF PUBLIC PROPERTY/BUILDIDIG COJL%IISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/ElectrlcianstPlumbers
4nplicant Infirrmation n', L Please Print Legibly
Name(Busitxs&orgjnixatiurvind/iviidual): lt(NA2J .,/ 7
Address:oZ Za&, d Gfi h��/�j /I/•IT •
City/State/Zip: (J3 S- S� Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 1 4. ❑ I am a general contractor and 1 6. ❑New construction
amployees(fltll-and/or part-time).* have hired the subcontractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. It Remodeling
ship and have no employees These sub-contractor have 8. ❑ Demolition
working.for me in an capacity. workers'comp.insurance.
Y P tY• 9. ❑ Building addition
(No workers'comp.insurance 5.'❑ We area corpomtion and its
rcyulred.):
officers have exercised their 10.0 Electrical repairs or additions
].❑ 1 am a homeowner doing all work right of exemption per MOL i 1.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152; 1(4),and we have no 12.❑ Roof repair
insurance required.]t - bmployees:[No workers IJ.O Other-
comp.insurance required.]
•Any applicard thin chuck,bax M I must also rill out IN action below showing their worken'cpmpensaloo policy information.
t Ihvncuwnens who submit this atAdavis indicating they am doing all work and then hit*outside corn reng must suhmit a near affidavit indicting such.
�Connxtom that chuck this box must attached an additional chat showing the name of the subaanuactort and that:workers`comp,put icy infaemation.
fain an employer chat b'pravfdlttg workers'compensation firsuranee for my employees; Below It the policy and fob slie
inforinadon.
Insurance Company Name.,
Policy 4 or Sel6ins. ,Liic. 0: Expiration Date: 6,,,,1
Job SiteAddress: 5'1 awS ST City/StateiZip: s rTL �r� Gi
,%ttaeh a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of,'YIGL e. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Ile advised that a copy Of this statement may bo rurwardcd to the Ofliee of
lnvestigulio s ul'the DiA fur insurance coverage veriticatiun.
l du hereby eer y rurder die pal alyd perlakles of pedury that tine iuformuNae provided a uve is true alsd correct
�tsn;�un� LAM _ I'�•� Data• 8' � 3
Phone A:
OJrcfal use only. Do not rvrire in Aria area,to be completed by city of town afficlat
City or Town: PermlU7.1eeme I
issuing Authority(circle one):
I. ❑oard of health 2. Building Department J.Cityfrown Clerk 4. Electrical inspector 5. Plumbing Inspector
6.Other_
Contact Person: - Phoned:
j
_._. A
CITY OF SALEM. ii LksSACHUSETTS
• Bt:ILDING DEPARTMENT
P 130 WASHINGTON STREET, 3" FLOOR
TEL (978) 745-9595
FA.K(978) 740-9846
KN{BFitt FY DRISCOLL
i`L�YOR THOM.+s Sr.PiERR&
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 c 40, 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 disposal 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
---zV --
(name of facility)
(address of facility) -
i
ignature of permit applicant
date
dcbris�if dux
Massachusetts
Board -9 Re Department of Public S Of Buildin ards
Construction Su pen,,,(,,
Regulations and Standards
pen,icor -
License: CS-079214 -"
JAMESRYAN _
2 Laura Lane -
dt v -
NewtOn N$ 03558
11 re d
Expiration
Commissioner
06/Oy2015
,Y
08/21/2013 12: 39 9785215127 COSTELLO INS PAGE 01/01
DATE I
;466RD CERTIFICATE OF LIABILITY INSI,RANCE 08/21/D2013)
I os/u/zo13
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE C ERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN HE ISSUINGINSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endors d. If SUBROGATION IS WAIVED,subject to
the terns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endomement(s).
PRODUCER ONTACT
NAME:
COSTELLO INSURANCE AGENCY ac Na,Ea-9HONE78.374.6$52 J(Ac Na);978.521.5127
TAr-
2 South Kimball St. MbIL -
ADOREse:
PO Box 5248 INENNER(G)AFFORDING COVERAGE NMCN
Bradford, MA 01835 wE1,1PERA: X.S. BR4IERS
INSURED Ryan Property Maintenance INSURERS: Liberty Mutual Fire Ins. -ARWC 16586
DBA: C/O James Ryan Jr. INSURERC:
2 Laura Lane INSURERD:
Newton, NH 03858 INSURER E
:
FINBURERFI
COVERAGES CERTIFICATE NUMBER: 2013 REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 WHICHTHIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID G IMS.
TYPE OF INSURANCE ADDC SUB
LT TYPE mSR WVD POLICY NUMBER IMMmDNYYY MM/D P LIMITS
GENERAL LIABILITY PAC701776 06/2212013 06/212014 EACH OCCURRENCE 4 11000,000
UN
X COMMERCIAL GENERAL LIABILITY PREMISES(E9O=%Unp ) S 50,00
cLgIMS.MADE L OCCUR
MED EXP(Any one person) g 5,00
A PERSONAL&ADVINJURY S 1,000100
GENERAL AGGREGATE Y 2,000,000
GENL AGGREGATE LIMIT APPLIES PER'. PRODUCTS-COMP/OP AGO g 2 D00,oO
POLICY PRO- PRODUCTS
LOG Y
AUTOMOBILE LIABILITY UUMBINED
Y
ANY AUTO BODILY INJURY(P¢r pemon) S
ALL OWNED SCHEDULED BODILY INJURY Psr eccdanp S
AUTOS AUTOS
NON-OWNED
HIRED AUTOS AUTOS Perarcldent g
Y
UMBRELLA LAB OCCUR EACH OCCURRENCE Y
EXCESS LIAR CLAIMS-MADE AGGREGATE Y
DED RETENTIONS g
WORKERS COMPENSATION WC STAT
AND EMPLOYERS'LIABILITY Y/N 00019342 08/2012013 08120/2014 TORY LIMITS ER _.
ANY PROPRIETORNARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ 1g0,ODD
B OFFICERVMEMBER EXCLUDED? N NIA _. ..._._
(Mandatary in NN) EA.DISEASE-EA EMPLOYEE Y 100 00
Ifyea,daecnbe under --- --
0ESCRIPTIONOF OPERATIONS Wj. E.L.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERILTIONS/LOCATIONS I VEHICLES (AMa¢A ACORU 1Ut,Adtllllonal Remarks Schedule,i(ma,e space Is mqu(no
CERTIFICATE HOLDER CANCELLATION
[ACCORDANCE
HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 9EFORE
HE EXPIRATION DATE THEIR Or,NonCE YBLL BE OELINTRED IN
WITH THE POLCY PROOISLONS,
TOWR of Salem REEDR RESENTATWE
93 Washington street
Salem, MA 01970
0 1988.2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD
I
54 FORRESTER STREET 193-14
Gis#:- :- 15500 COMMONWEALTH OF MASSACHUSETTS
Map:n-r 41
Block a' t' CITY OF SALEM
Lot. ,' 0223-803 -s ,
Category `"4x^REPAII2/REPLACE
Pern t# 193-14 - m BUILDING PERMIT
Project# JS-2014 000402.'
Est. Cost: , $17,750 00 =r',x
Fee Charged:'r` $148.00
Balance Due:', $00. c PERMISSION IS HEREBY GRANTED TO:
Const Class: =''Contractor: License: Expires:
z:
Use Group. �-. h -.._ °i�w' r �:==:�#m.`.'.Ryan Property Maintenance,lames Ryan. General Contractor-79214
Lot inge(s`q. ft.): 0 Owner: NOLAN THOMAS,NOLAN LINDA M
Zoning hEtii w� sr` E � ,:� .
Umts Gamed:E w i �ni a �--�8 Applicant: Ryan Property Maintenance,James Ryan.
Units Lost.L" ;,Y u AT: 54 FORRESTER STREET
Dig Safe#
ISSUED ON: 28-Aug-2013 AMENDED ON: EXPIRES ON. 28-Feb-2014
TO PERFORM THE FOLLOWING WORK:
REMODEL KITCHEN IN UNIT 3/2 L
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Bough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House# Smoke:
Water: Alarm:
Assessor Treasury:
Sewer: Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2014-000437 21-Aug-13 3604 $148.00
i.
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