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15 FRONT ST - BUILDING INSPECTION (2) " ► The Commonwealth of Massachusetts Department of Public Safety •r .\I,issachusetls Slate Building Code(780 CMR)Seventh Edition City of Salem Building Permit Application for an Building other than a 1- or amil Dw Ilin (This Section For Official Use Onlv) 1 Building Permit Number: Date Applied: Building Inspector SECTION 1: LOCATION (Please indicate Block # and Lot# for locations for which a street address is not available) 15 -Front S+- Sal et Iva of j`1 ^ ^ \o. .1nd ',tree[ CitY /Tov,'n Zip Code Name of Building (if opplicA le) SECTION 2: PROPOSED WORK If New Construction check here❑or check.ill that apply in the two rows below Existing Building Repair Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change u(Ocaipancy ❑ Other ❑ Specify: Are building plans and/ur construction documents being supplied as part of this permit applicati=NoIs an Independent Structural Engineeringr-Peer Review required? Briut Description of Proposed Work: 11P le brIC CJQL'>Jt a✓,�'+n Stdo Et- Ttt b (.tea J 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 ❑ B.- Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2 ❑ H: High Hazard H-1 ❑ H-2 ❑ H-3 ❑ H-4 ❑ H-5❑ 1: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 1-4 ❑ M: Mercantile❑ R: Residential R-10 R-2 ❑ R-3 ❑ R-4 ❑ S: Storage 5-1 ❑ S-2 ❑ U: Utility Cl Special-MWO and please describe below: Special Use: SECTION 6: CONSTRUCTION TYPE (Check as applicable) IA ❑ IB ❑ IIA ❑ 1111 ❑ IIIA Cl 11111 ❑ IV ❑ 1 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: Pukht ❑ Check if outside Flo„d Zone ❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site ❑ required ❑or trench or +pecifc: P1 n.,1e ❑ .,r indent0% Zone:_ or un site"stem ❑ permit is cncluseii ❑ _ Railroad right-of-way: Hazards toAir.Navigation: \I:\ list„rn c ,nnmi.�bm H, ,��", 14. \rl ,\l,l, iiobe ❑ I.tit nictu ru ,�shin airport apprn.ich area' I. their re, Iv,c r, m pcicd' r l , nwnl !n liuil,l rnelo.r,i ❑ Yc, ❑ �v \o ❑ Ye. ❑ \n ❑ SECTION 8: CONTENT OF CERTIFICAFE OF OCCUPANCY I .hunn 1 (- nir: ___ l+c•( roupl a: fcpe of C,met nicunn: l.)aup.uu Load per IIn,ir: ____ : I) r, the bwldinl;umlam an Sprinkler ti�.lcm': Special Stipulaliuns: . - ' SECTION 9: PROPERTY OWNER AUTHORIZATION Namr an. Address of Pruperty Owner CG�I vr� 6 Lip Name (I rinU No. and Street City/Town Property l)w ner Contact Information: e-mail address Title Telephone :No. (business) Telephone No. (cell) . If applicable, the property owner hereby authorizes — Street Address City/Town State Zip Name ,erm it a , ,lication. Iu act tin the ,no �erly o,v ner's behalf, in all matters relative to work authorized by this buildin SECTION I0: CONSTRUCTION CONTROL(Please fill out Appendix 2) (I I buildin•is less Ilwn.15,1111U ru. it.of enclosed s nice and/or nut under Construction Control then check here and slti,S�'d ion 10.1 Re istered Professional Res orisible for Construction Control Name (Registrant) s Registration Number Telephone No. e-mail addres State Zip Discipline Expiration Date Street Address City/Town 10.2 General Contractor �5A'l rel.�+�ls Co '3 � any Name: S r -'t 4 ��. ��- 3x License No. and Type if Applicable _� _ Nam of Person Responsible fur Construction `�al `4� _091_ t t �� t\A A City/Town State Zip treet Address �� ) tf aa _ �5 3�`� e-mail address Telephone Na. (business) Tele hone No. (cell) SECTION 11:WORKERS'COMPENSATION QJSURANCE AFFIDAVIT (M.G.L.c. 152. 25CVe A Workers'Compensation Insurance Affidavit from the MA-Department bf Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuances No e of the building permit. Is a signed Affidavit submitted with this a lication? Y SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor Total Construction Cost(from Item 6) _ $_----- Item and Materials) 1. Building $ $ 00 Building Permit Fee=Total Construction Cost z _(Insert here $ appropriate municipal factor)_$ 2. Electrical 3. Plumbing $ Note: Minimum fee =$ (contact municipality) 4. Mechanical (HVAC) $ 5, Mechanical (Other) $ Enclose check payable to 6. Total Cost $ 500 (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 7� application is true and accurate to the bee tt my k�ledge and aA-ez L`CAYr�T )i lY///J �� . I�� /-s C `��— Tcic ,hu ne Nu. Dale title b�_�� I'Ira; ,nn! and >i •n na ne � p C��t�wLQ city;T„ State Zip wn - hlrrrl :lddre�s i Municipal Inspector to fill out this section upon application approval: Name 1)ate I Ylassachusetts - Department of Public S:dit� Board of Buildin-, Rel ulation:s and Standards Construction Supervisor License License: CS 53693 Restricted to: 00 ROGER A TREMBLAY JR 29 HATHAWAY AVE BEVERLY, MA 01915, 6—L f' Expiration: 5/92011 (lnnmisi.n ivi Trfi: 14698 ti �t DPS-CAI 0 4010-0atQ84D8SUFORMCA108212008 ....__._.___- --------- --..-...._ 12 tiv Board of Building Regulations and Standards _ HOME IMPROVEMENT CONTRACTOR Registra pn: 145375 - tra - .3/2011 Tr# 282954 —_ e Corporation ROGER A.THE -Q ORS, INC. ROGER TREMBL 10 COLONIAL RD -= t�y„�„ SALEM,MA 01970 N4. Administrator I s" I � t 1 1; The Commonwealth of Massachusetts zz � Department oflndastrialAccidents y gfffce itlhueI III 600 lYashington Street Boston, Alass. 01111 Workers' Compensation Insurance Affidavit R 1 : O A T yt err o'Ic - ry 311 AAA 0 1 1-7 0 � I am a homeowner performing all work myself. h 9 I am a sole proprietor and have no one working in any capacity ��*-arcmerr�=mom. I am an employcr ro Idmg workers compensation for my employees working on this fob insurance co 0 1 am a sole proprietor, general contractor, or homeowner(circle one) and have h red the conRactors listed below who have the following workers' compensation polices: Company n1m add ress' ' a msurnnce co ' t; D I. Y�: x a d di_t'r tiiv: hti q". meurince.to -no li rW' tto<h aJa nonakth h < Fallurt In sscur< ury cruet as required undo Section 25A or NIGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or unc You" Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.DO a day against me. I understand chat u copy of Ihls statement may be fu,. arded to the Omec of Investigations of the DIA for coverage verification. . l do hereby crrii v under the paint and penanirs of perjury that the information provided above is truce and correct Q signature_ A 6 . ' Date b1 ` (. -) —zj 1 r _ , Print name ' F-Q. �1C Phone k �YI 3—,1 (� ofrl1 use onty do not write in this area to be<omplele0 by city or town omcial ary ur man: permitnicensc a nUuilding Depummcnt It S7 ❑LI,e.,mg Board 4k,5 Q check if 1mnledlulc respunse is required - Q$d I ectr Office QHeunh Department t connct person' phone a; rl Other r.N lAf>1�1 ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE 08/20 9' PRODUCER (508)651-7700 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC - Commercial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 West Central Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Natick, MA 01760 INSURERS AFFORDING COVERAGE NAIC# INSURED Roger A. Tremblay Contractors, Inc. INSURERA: Selective Insurance Co of SC 19259 10 Colonial Road INSURERB: National Union Fire Ins Co PA Suite 4 INSURER C: Salem, MA 01970 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. i16 DD' TYPE OFINSURANCE POLICY NUMBER IMMDIYYI POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY S 1842342 04/15/2009 04/15/2010 EACH OCCURRENCE $ 1,000,000 X I COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 CLAIMS MADE M OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL&AOV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 POLICY MJE LOC AUTOMOBILE LIABILITY A 9091419 04/15/2009 04/15/2010 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ A X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) X $500. DEDCUTIBLE PROPERTY DAMAGE COMP./COLL. (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY S 1842342 04/15/2009 04/15/2010 EACH OCCURRENCE $ 2,000,000 win n Ov.,,.m rv..uAGGREGATE A $ DEDUCTIBLE $ hX RETENTION $ C $ WORKERS COMPENSATION AND WC3531587 07/01/2009 07/01/2010 X 1, WCSTATU- OTH- m EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECVTIVE E.L.EACH ACCIDENT $ SOO,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDOR$EMENTI 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 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Y_ ""'�'— / Rosemary Fulham/PMA ACORD 25(2001108) FAX: (781)586-8120 ©ACORD CORPORATION 1988