24 GLENDALE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Department of Public Safety
➢u ? Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
� ' (This SectionFoK.,Official Use
Only},, �;`.,,,
Building.Permit Number: ' -Date Applied 'Building Official
SECTION 1:LOCATION(Please indicate Block#and Lot#fo'r locations for`which a`street address is not available)` `. .
ALI 6U-?d0At=a sr 0Al, I ` a-ALEM WN Ol9j HA wy-YR&Q (DNoot-BtstuM I2osr
No.and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK, Y
Edition of MA State Code used 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"I) ,
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review re tired? Yes ❑ No 2r'
Brief Description of Proposed Work: TL7 �AUT ��QLhMVA7F AW44 W 47e%
Y -
SECTION 1 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):
- SECTIONA.,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 a plfcable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: Hi h Hazard H-1 ❑ H-2❑ , H-3 ❑ H-4❑ H-5 ❑
I: Institutional 1-1 ❑ I-2❑ I-3❑ I-4 ClM. Mercantile❑ R: Residential R'-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6.CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION7:SITE INFORMATION (refer,to780 CMR 111:0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 0� Check if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site ❑
Private❑ or indentify Zone: or on site system❑ required ❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Pnx,ess:
Not Applicable❑ Is Structure within airport approach area? Is their review completed? -
or Consent to Build enclosed❑ 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 building contain an Sprinkler System?: Special Stipulations:
"SECTION.9:,PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
SNARc N PItJtSRUE•Ruzzli- t39 ATLl W06 All MAkRA C4-l1Aa0 M-A (019 '5
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: CI Ia
- si
-63% �S I. Q N00 `�--I—n—��- ��GgfNerlzon.ne,+
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes -
t 6//iY /1/ ✓!7,�W S+y — -50-4 j 'V�P. 0/9�V
Name 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 application.
SECTION 10.CONSTRUCTION CONTROL(Pleas'e fill ouhAppendix2);
if buildin is less than 3vCdcu:-ft:of enclosed s ace'and or not under.Constroctiou Control then check here O'and ski .Section 10.1'-
101 Re 'steredProfessional'Res onsible for Conshiiction 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
VISV K �iecemzAO
Name of Person Responsible for Construction License No. and Type if Applicable
3915 ✓ .� W-V. 47'10%V
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:FVORKERS'COMPENSATION.INSURANC:E AFF15AVIT 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❑ No ❑
SECTION'12,.CONSTRUCTION'COSTSAND PERMIT FEE
Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)
1. Building $ _�V Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ /two appropriate municipal factor)=$
3. Plumbing $ ,j qJ
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ (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 is true and accurate to the bestof my knowledge and understanding.
vOHM N /t�ytirlto ON>V1L �w--3L-Or1c_3 ,�L3
Please print and sign name Title Telephone No. Date
.345 e/EiFZYSss� 9r� -Ss' J /A9. G/
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
° CITY OF Sm-F-mll lAksSACHUSETTS
yy ) BUILDING DEPAIMLEINT
120 WASHIINGTON STREET, 3""FWD.%
r TEL (978) 745-9595
Ria(978) 140-9844
iU3(BFRI EY DRISCOu T
-
,1�j.�YOR HOJtAs ST.PiE.¢lis
DIRELTOR OF PUBLIC PROPERTY/HI:ILDL`1G CONalISSIONER
Workers' Compensation insuranceAfiidavit: Builders/Contractors/Electricians/Piumbers
Apolleant information /� Please Print Legibly
Nairic tUUlIth59UfsdniraflaNlndlvidaal): _ r/ N. /�('mpAge le
Address: f 4 /3/S
City/State/Zip:[f t:.et3 *-Alt- --f/f•9S Phone* 9a% 43/-03/0
Are you an employer?Check the appropriate boss 'typo of project(required):
I.(�'rm a employer with_/D 4• ❑ 1 am a general contractor and 1 6. ❑Now construction ,T►
employees(full and/or part-Lima).• have hired the sub•uontractors
2.❑ 1 am a sale proprictar or partner. listed on the attached.sheuL t 7• ellf—em odeling
.ship and have no employees These subcontractors have it. 0 Demolition
working for me In any capacity. workers'camp.Insurance. 9. 013vailding addition
(No workers'camp. insurance 5. ❑ We are a corporation and its
re officers have exorcised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL I I.❑Plumbing repairs or additions
myself.(No workers'camp. C. 152,Q 1(4),and we have no 12.❑Raof repairs
insurance required.J t employees.(No workers'
camp.insurance rcquirad.J l).❑Other
•Any applicum nW chute brat e l mutt AW fill out the Venice bcleW ahowine IhaLr warkrm'eotnpnradun Pulley inaunnotiot�
'I l.vnuuwnew who,uhmil Wit arn4vil indicaing they an doing all watt m+d thee him oalridecantraetae must miunk a titre aMJaril indfatne tuck
:Cumnelars lhal chat lhie box court mtachol m addillumd,hal showing the nama of lee rubavntnctan and thalr worttare'manµ policy inrwmadae.
l airs an employer that Is prov/din f workers'compenraden h/surance for my employees Below Is rho pollay and fob sire
inforiiradan.
insurance Company Name:—/.rle.9
Policy 4 or Seli-itts. Lic.t1: Expiration Onto: //-AT
Job Site Address: zr 4w/r- 10/ City/Statr/Zip: .
Attach a copy of the worker'campensatloe pulley deelaratlan page(showing the policy number and expiration date).
Failure to sccuro coverage as required under.Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 untVar one-year imprisonment,as well as civil penalties in the farm of it STOP WORK ORDER and it Tine
of up to $230.00 a Jay against ere violator. Ile advised that a copy of this stalumunt may ba forwarded to the Off ice of
In,vii igui ium of eta OIA ror insurance coverage veri ficaliun.
/du bit renlf uder the pains cud puoahles of perfury 1huf the lnfurinadon provided abuve is true mid conreR
"PRI1nure: , Data: 3/.4
11
one
011f iul use an/y: Ott nar 1-ile ire th/s urea, to be cunrpleled by city ar lawn off slut
ICity or town: Purml0.1ceme,9
--Iewing Aulhurily(circla one):
I. Iluurd of Ilealth 2. Building Uepurtutent 3.Cityffown Clerk 1. Veetrical inspector 5. Plumbing Inspector �
5.Onhcr
Contact Person: .._ __ Phone U•
Harborview Condominium Trust
20-24 Glendale Street
Salem,-MA 01970
March 30, 2013
To whom this may concern;
We Sharon Pingree-Russell of Marblehead;MA,Judi Jackson and Cynthia Shapiro of
Salem, MA owners of the premises located at 24 Glendale St, Salem, MA and trustees of
the Harborview Condominium Trust, agree that
Sharon Pingree-Russell Trustee of the Periwinkle Realty Trust has our permission to
renovate the bathroom located in unit 1 of the Harborview Condominium Trust.
Sharon Pingreec*- ussell; Unit l Date
6, G'ItrcP 31 i 1_
Cynthia Shapiro; Unit 2 Date
Judi Jackson; Unit 3 - Date
Harborview Condominium Trust
20-24 Glendale Street
Salem,MA 01970
March 30, 2013
To whom this may concern;
We Sharon Pingree-Russell of Marblehead, MA, Judi Jackson and Cynthia Shapiro of
Salem, MA owners of the premises located at 24 Glendale St, Salem, MA and trustees of
the Harborview Condominium Trust, agree that
Sharon Pingree-Russell Trustee of the Periwinkle Realty Trust has our permission to
renovate the bathroom located in unit 1 of the Harborview Condominium Trust.
Sharon Pingree-Russell; Unit 1 Date
Cynthia Shapiro; Unit 2 Date
uui Jacks Unit 3 Date
A • . I
t'
Y
CITY OF &U ENfti i. 1SSACHUSETI'S
j. 81:MDENGDEPARTM&N
1 10 W:1SHNGTON STREET, 310 FLOOtt
TFL (978) 745-9595
IU.NtBERL.EY DRISCOLL FAX(978) 740-9346
A UYOR TFIOAU ST.PIERM
Dime-rOROF PCDLIC PROPERTY/81:1LDLNG CC-NNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 1 11.5
Debris, and the provisions of tMGL c 40, S 54;
Building Permit !k 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 NfGL c
111, S 150A.
The debris will be transportcd by:
.7 e#ri s)/n CV
(oumc of hauler)
The debris will be disposed of in
(name of facility)
�.41
(address of r'acility)
signature of permit applicant
3 Z-J�IZ3
late --
'I
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE04/2013
04/ 4/2013
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 958
Salem MA 01970— INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:Merchants Insurance
J. N. PICARIELLO COMPANY INSURER B:Guard
P.O. BOX 1315 INSURER C:
INSURER D:
MARBLEHEAD MA 01945-5315 1 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 ADO'L TYPE OF INSURANCE POLICY NUMBER POLICY
(EFFECTIVE
b DD YY) PDATE M DD TON LIMITS
LTR INSRD
A GENERAL LIABILITY / / / / EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES To occurrence s 100,000
CLAIMS MADE aOCCUR BOP9097993 09/19/2012 09/19/2013 MED EXP Anyoneperson) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE a 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY PROT- 71 LOC
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) 5
ALL OWNED AUTOS / / / / BODILY INJURY
SCHEDULED AUTOS (Per person) S
HIRED AUTOS / / / / BODILY INJURY
NON-OWNEDAUTOS (Per accident) 6
PROPERTY DAMAGE
(Per accident) s
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO / / / / OTHERTHAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE S
5
DEDUCTIBLE
RETENTION $ b
B WORKERS COMPENSATION AND 4569099 08/23/2012 08/23/2013 X I
TORVLIMITS DER
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000
OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE& 100,000
If yes,d escnbe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000
OTHER
DESCRIPTION OF OPERATIONSILOCATONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Additional insured listed below
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
CITY OF SALEM FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
BUILDING DEPARTMENT INSURER ITS AGENTS OR REPRESENTATIVES.
AU HORIZED REPRESENTAT
ACORD 25(2001/08) O ACORD CORPORATION 1988
INS025(010e).06 Page 1 of 2