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207 FORT AVE - BUILDING INSPECTION The Commonwealth of Massachusetts Department of Public Safety ^ ` Massachusetts State Building Code(780 CMR)Seventh Edition City of Salem I{�I Building Permit A !ica on for an Buildingother than a 1- or 2-FamilyDwelling vUA I (This Section For Official Use Only) Building Permit!dumber: Date Applied: Building Inspector. SECTION 1:LOCATION(Please indicate Block N and Lot# for locations for which a street address is not available) D� �o� k I ✓e SoAe-" 01970 ( Hobbs No.and Street City/Town Zip Code. Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑-(Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other M Specify: ROn� Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ _ Is-an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ � Brief Description of Proposed Work: S-�C- 2_Jc�5�•ne 5� r, nlo Tn8 11 1_ ,ts`r o� ��..� .� A � ` /z"� rs �, .r,e � z-r,o�r ce_ino• � wn �QL0.5 f1t202� SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR - CHANGE INIUSE 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): 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.) Ej noo"• ,'LOFT' SECTION 5:USE GROUP(Check as applicable) - A: Assembly A-1 ❑ A-2r ❑ A-2nc-13 A-3 ❑ .A-4❑ A-5 0 - - - B: Business ❑ - -I- Educational ❑ F: Facto F-1 ❑ F2❑ - H, Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H4 0 H-5❑ 1: Institutional 1-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ -R-3❑ R-4❑ - S: Storage S-1 0 S-2❑ - U: Utility❑ Special Use❑and please describe below: Special Use: - SECTION 6:CONSTRUCTION TYPE(Check as.applicable) - - IA.O IB ❑ IIA-❑ IIB ❑ IIIA ❑ IIIB-❑ IV ❑ 1 VA ❑ VB ❑ - SECf10N 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit: Debris Removal:. Water Supply: Flood Zone Information: Sewage Disposal: - - Public❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specif.% 1 rivate 0 or in.ienGA`Zone: or on site s(�atem ❑ permit is enclosed ❑ right-of-way: Hazards to Air Navigation: NIA I Ii,torir(•nmm�-ion R.,iv Pn•ri•,, Not Applicable❑ is titructure within airport approach area' Is their re%lew completed.' LRailroad onwnl la Budd enClo,ed ❑ Yes❑ or No❑ - Yes❑ . No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCYff .Lse Gmnup(s): Tcpe of Construction: l)ccupant Load per FlooCn an Sprinkler S.% T1 : Sptcial Stipulations: f SECTION 9: PROPERTY OWNER AUTHORIZATION -;- Name and Addresx of Property Owner C (Q r C 1,� 1 e's h�bb s 2 S /-o�� A•p JA Vr I : .' -_ Name(Print) No.and-Street Citv/Town II` .,, `:•, Zip PropertvChvner Con tact Information: C \v, ebbs Title Telephone phone No. (business) Telephone No. (cell) e-mail address ILapplicable,the property owner herebv authorizes Name Street Address City/T6%vn State Zip relative to work authorized by this building permit application- to act on the pro,rrh•owner's behalf, in all matter SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (If buildin•is lc�-than 35,0111)cu.ft.of enduscd s ace and/or not under Construction Control then check here D and ski Section I .0 10.1 Registered Professional Responsible for Construction Control o , 008 -735 0357 "Sm @ st�c3�a:l .c OG66e3 Name(Registrant) Telephone No. e-mail address Registration Number H Gross pr�a So.lcvn � O197o Street Address City/Town State Zip. - Discipline Expiration Date 10.2 General Contractor -- Company Name: Name of Per. n Responsible for Construction License No. and Type if Applicable _ Street Address - - City/Town _ State Zip ,. Telephone No.(business) �- Telephone No. (cell) e-mail address. SECTION 11:WORKERS.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 152. 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Departmentof 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 si ned Affidavit submitted with this application? - Yes O No,O. SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE - Estimated Costs:(Labor / TOO, o o Item - and Materials) Total Construction Cost(from Item 6)=$ 3 1. Building $ /3 ,5 00,oo Building Permit Fee=Total Construction Cost x_(insert here 2.Electrical - $ appropriate municipal factor)_$ 3.Plumbing $ Note:Minimum fee=$ -(contact municipality) ; 4. Mechanical (HVAC) - $ - - - 5. Mechanical-(Other)., --.. $ :,.._ - --- - Enclose-check.-payable _to 6.Total Cost $ /3 5b0 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT - Bv entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. 97b _735 03S-7 2/-A0 fo Please print and sign name Title Telep e No. ate � a ytrvet Addres City-/Tor.-n State Zip Municipal Inspector to fill out this section upon application approval: �� Name Date _ CITY of SMXUN NLASMCHUSET M i uLDDIG DPp►RT E iT 120 W.%iHINGwN STREET. Yo FLOOR TEL(978)14&9595 FAX(973) 740.96" wNi3EJtiEY DIUSCOLL IliobW ST.PaRas MAYOIt DIREcrOR of PL SLIC PROPERTY/RI:UMOIG CO%C4ml"%ER Workers ComP cnaatioa (muranca,\111darit: BuildcralCoatractora/ElectrlelaaalPtumbers Anallcant Informalloa Please Pr(rtt Lesibly Va�nCtBanne.rorVmration.trr6•�nl): '� �• � �V��2%�S �-l�c. . Address: L� CC-0 S 5 I city/stalc/zill: Q O f 9 7 Pitons iw (27 2 7 3 5 -03 5-7 Are Tor p empleW. Cheep the appropristo bow TYPO a/project(rcgrlr c-. - 1.® I am a employer with 2 4. Q I ara a ipnmal contractor and I 0. ❑NOW cowtruttioN employee(full and/or pne-tine:}e have Ailed Ltd . 2.Q I am a sale proprietor Or partner- listed an the asached ahem: 7. Q RemateGag ,hip and have no employee These sub-contr aemrs have tf. On alitiots .Orkin$ for an in any capacity. workers'camp.inwraaoa. 9. Q Building addition (No workers'comp.insurance S. Q We are a corporation and its 10.0 Electrital repairs or addition M.quu otlleaa have oaadaed their 7.Q 1 am a Iwrrtwwaw doing aU work risks of eatanI , P W IMOL I I,Q Plumbing repairs or*&"am myself.(No workers,comp. C. I A S 1(+),and via have no 12 Q Roof repairs insurancerequired.(r �trpkayea(Nostwrtmtt• 13.00dsar-2904c2 0 comp,insurance regtutl j _ -Aar appl=M*dr dM"boa at mur ale,to wr dw wmm ltrlwluaiq d►dr.or.w•mn�rasla PA&7 wAmun ton, - 'Ifim wanws dw reboil dds saldevir wkwiq I"a*&in$on-wk ale th"hlw awirmenafne Now'A"a cow al8i dioti�ri ie web ' c'.w.eVm rtrr•tore dikM nos arrserdaadaloww,h,w rbedriee fhft otrdrbtrtteasertadwa ad their.oboe•camp.Pdky' /raw an eerplayer lAw 6 prwvhfArE workers raapworrerw/wsrwfrnarft/my esphyam Bsiawhr*0PaMw ewdjaill s/dr . injornraftwa n� �-` n e1 insurance Company Vame: lreorrc'o�k ;``� / War kern - Corn,A. i'nlicy a or Self-ins.Lie.et Expiration Dam: Job sim Adds=: 1`j �_O 6 G �.� S k o 5 k City/Slatdzip: S a�Q-vv, MA 01970 ,%ttacb a copy of the wer era'compearaaoo Volley dsch"Uan pap(showing the pe ft Number sd erplrathm dW)6 Failure to sacure coverage as required under Satins 23A of MGL c. 132 can led to the imptrition of criminal-psnaltie Ora ring up to S 1,500.00 amUor one-year imprisonment.as we"as civil peaahie is the form Of a STOP WORK ORDER and a tine ,• of up to S230.00 a Jay a$ahw the violator. Ile advi:ad thus copy of this statement maybe fururarded to the Office of Invcsu$atiuns of the DIA for insurance coverage wYifKat�L - - /der hereby crMfy rrnlar fAm pains and prneldas alper/ary thartAa infdratethtw providW above is raw and t werK re. Dater P a' g �'735- 035. re 7 7 n/Jlrid/Y,ednlyL Do.ndwfila iw this dfeyfi De.Yrwp/Ilei/by riff a fawn o/Jhidd City or rwrn: Ycrmit/1.lcgnste__. I%suint Awhenty(circle une): -- 1. Ifwrd of lleattb. 2. Mudding Department I CiWrowa Clerk L Electrical pnspector S. Plumbing Inipeelor 6.01fttr l..dtact Ycnon: _ - ... Phone a•. ACOBD. CERTIFICATE OF LIABILITY INSURANCE 04i21/2 0 PRODUCER (781)942-2225 FAX (781)942-2226 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Gilbert InSurancd Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 137 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Reading, MA 01867-3922 INSURERS AFFORDING COVERAGE NAIC# INSURED IRE Builders Inc. INSURERn NORFOLK & DEDHAM INSURANCE 23965 4 Cross Ave. INSURERB: WORKERS COMP. INS. PLAN OF MA 0022 Salem, MA 01970 INSURERC: INSURER D: INSURER E: 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 D' TYPE OF INSURANCE POLICY NUMBER PoLIDY EFFECTNE POLICY EXPIRATION LIMITS Jill Nau DAM MMIDDIYO DATE(MMMDfY1Q GENERALUABILITY R1041917A 04/19/2010 04/19/2011 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 CLAIMS MADE OCCUR MED EXP(A,.person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,00 X POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea amdent) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per amclent) $ PROPERTY DAMAGE $ (Per amcfent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT If ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ FXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WWORKERS COMPERSATION AND TO THE BUREAU TO BE 04/20/2010 04/20/2011 X I WCsTATU- OTH- EMPLOYERS.UABILITY ASSIGNED E.L.EACH ACCIDENT $ 100,00 B ANY PROPRIETORIPARTNEWEXECUTIVE OFFICEI%MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ 100,00 If yes,describe UTMer SPECIAL PROVISIONS below E.L DISEASE-POLICY LIMIT $ SDD,OD OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I 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, David Bradwel l BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 14 Kosciusko OF ANY WIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES. Salem, MA 01970 AUTHORIZED REPRESENTATIVE Mark Gilbert ACORD 25(2001/08) ©ACORD CORPORATION 1988 CITY OF SALEM PUBLIC PROPRERTY • DEPARTMENT -\I .I"N I1Q�'•I+Ia\L:.LM It"atCT•�•\I I ft,�1.i+iN I11 J 1.•:1'/ _ - Tfl:•�.•t-:L49ylS •1�.�!f:Y7r•:IS•taM Construction Debris Disposal Aftid>tv It (reyu iced rut all demolition and renovation work) in accordance with the sixth edition of the State Building Code. 730 CMR section 111.5 nc Debris,and the provisions of MGL c 40.S 54. Building Permit q •_ 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: Q4woo� �5�3 'SO �r5) (name of hauler) The debris will be disposed of in : (n:ulne vl aci lty i I;Iddrese of lacllny/ Signature of pewit,Applicant 0 — o date