10 GLOVER ST - BUILDING INSPECTION (3) t L
,. The Commonwealth of Massachusetts
Department of Public Safety
\lassdchusa•tts State Building Code(:80 CMR)Seventh Edition
Um' City of Salem
Building Permit A lication for any Building other than a I. or 2-Family Dwellin
(rhis Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block N and Lot 0 for locations for which a street address is not available)
to G Ioj s level M 70
No. and Street CitY /Town Zip Code Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below -
Existing Building❑ 1 Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Changeof Occupancy ❑ 1 Other Jp Specify: \qe Tocp\n
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: crL
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDMON,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing UseGroup(s): Proposed UseGroup(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SEMON 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicabie)
A: Assembly A-I ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E. Educational ❑
F: Facto F-I O F2❑ H: Hi Hazard H-I ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2 ❑ I-3❑ I-I ❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 ❑ R-4 ❑
S: Storage SI ❑ 5-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ III80 IV ❑ I 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:
Public ❑ Check if ouNde Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Dis)nrsal Site❑
required❑or trench ��r specifc:
Peirale❑ or mdenlilr Zunr: or un site scstrm❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air.Vavigation: \I:\ I li�i,•rn
\nl :\)•phcable❑ Is Struclurc tnlhut aopurt apprnach area.' Is their re% v%, onnplcted'
a lnt�cnt 6 RudJ cnd„v'd ❑ \res❑ or No❑ 1'rs Cl \o ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
I',htnm of Coale: -. L.r Grou)q'l: , ra I'c•ot C omtruclion: lkcupdnt Load per Hoof
I loc.(Jx•L'uildml;contain an Sprinkler S%,tem.': Spacial Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
`�cln bo�ecW I0 Glaer
Name(I'rint) Nu.and Street City/Town Lip
protu•rtc Owner(-on tact
�nnlormalion:
Title Telephone No. (business) Telephone No. (cell) a-mad address
If appbcablr, lher+nrper{h•owner hereby authorizes II �In/J ��` ��
c:1�.'C 1•�,�O d.QR J 1 G(OJ&r SA- �k-ehN l /I//�_SLL'=
Name Street Address City/Town State Zip
to act on the pro pert, ot%ner's behalf, in all matters relatta'e to work authortzed by this buildin • permit a p plicatiun.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is lass than 35,000 cu. It.of endoscd>lace and/or not under Construction Control then check here O and slup Sacttun I0.1)
10.1 Registered Professional Responsible for Construction Control
9'75' 73S- 0315-7 me-
SR3 U�iC��b3
N me(Registrant) Telephone No. a-mail address o Re istration Number
rt' Crvss OF+� 5aCef'✓7 Aid— d g s=8 -13
Street Address City/Town - State - -zip - Discipline Expiration Date
10.2 General Contractor
TtZo 'O: \&rn, -��C,
Company Name: n
`'S'Q wt P c R1
Na�nr of Person ftesut+iblr for Construction Q Ism License No. and Type if Applicable 70
1 C ro 55 ZZ 1 �-
Street Address City/Town State Zip
q9>—� �L-�3S- 03S� 1i rv1 S6 (9bvr'bei--5 ✓7
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor ) t_) 0,0 O
and Materials) Total Construction Cost(from Item 6)=ST_
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=5
3. Plumbing E
4. Mechanical (HVAC) $ Note:Minimum fee=5 (contact municipality)
5. Mechanical (Other) S Enclose check payable to
6. Total Cost S H (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 accuur/raate to/the/best of my knowledge and Understanding.
7�-&w,¢a l�-� .L !lam 6- =:- OG�n-e_r-- 17F. 7,�.� 7`7-3 a-1)
Plva,e print.end *ign pOxee �J � Title Telephu e.O. Date
c)7 �i
tilrcel Addres Cite/Town State Zip
.Mwricipal Inspector to fill out this section upon application approval: "r-"'h
Name VDate
CITY OF $AIY2%l, .NLvI.XSSACHUSETTS
BumDLNGDEP.mmWNT
• ' A• 120 W A.SHNGTON STREET.3iD FY.00R
Ta- (978)745-9595
FAX(978)740-9846
KMMRI t=Y D1tISCOII.
T
i1iL1YOR 1 omm ST.PtERRe
DIRECTOR OF PLBLic PROPEfay/BunziNG commsto., It
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 :
Tc,oSK-�
(name of(facility) t
S4J G^rr1 FPS CO� l`� . Scz`2Yt'�
(address of facilit )
signature of permit applicant
7. 3o _ H
date
JcbrivtF Jiw
CM OF SUE; 4 NLA SSACH S=
BL'1ID�1G DEPAa'I']tEv"[
j 120 W asuwGToN STREET,V0 FLOOR.
T L (Wg)745-9595
FAX Mg)740-9U6
KIMBERi FY DR1SCOLL
T
IbItiYOR t�ionlAs ST.PrF.aafi
DlRECioR OF Pt:BLiC PROPERTY/BL'1LD51G C01MMIONER
Yorkers' Compensation insurance Affidavit: Builders/Ctmtractors/Electricians/Plumbers
Annlicant Information t \ Please Print Legibly
NametBnaines gani nowir,h idmalY
Address. t_l Cra 5S Avg
City/State/zip:':-)c,\ex• M A O K17a Phony;#: 4 7'W 73 S -0 3 6-T
Arc oo an emphrya'f Check the appropriate boat: Type arprojecf(rmpdrem,
1.W1 am a.naplayer with 4. 0 1 am a general contractor and 1 6. []New construction
employees(full and/or part-tinmc)-s have hired the sub omn<anors
2.0 1 am a sole proprietor or parow- listed on the attached sheet.; 7. ❑Remodeling
ship and have no employees Them have & ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No warlcers camp,insurance 5. ❑ We are a corporation and its
requited.] officers have exercised their I0.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repaint or addition&
myself lNo workers'comp. c. 152,§1(4),and we have no 12.0 Roof�
insurance required.)t mploycn.[Noworkew I3.Q Otlrcr c� CZe�t rS
comp-insurance requized) v
•ratty appacmo mar dadno bo:al tom aka fin wr the aeaim tw;kvra6vwing t5dr wwlats•mmv�Imp;nfntmartoa
'llomeowom wtmsuhm0 this atlldavit indicting thgaadoing an work and the hi,,,w ide cua nuwa uaW a d,,b a ruw otildnit Ming sock
:Cen4xton dmt dusk dusbornmg atnched an,addatow dad showtog Me—,of the ad.epnlgam and their waybus.map ploy
l um an employer that is providing workers'compensation Insarmseefor my empioyeex Below it the policy andlab d&
infortiralien, .
lns, mncc Company Name: ��1
Policy g or Self-ins.Lic,q:\A/C r,- 3,S 3-7 7 SS'io2l Expiration Date: '7 �O -ii -Z
Job Sue Address: / G 1 o tier 5� CityiStateJZip: I e 7 /rt A O i m
Attach a copy of the workers'compensation policy declaration page(showing the Polley number and expiration bate).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine 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 fire
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage vcrifu:aGon- ,
I do hereby certify under the pabu and penalties ofperfury Drat the informallea provided above v pie and correct .
onc Ire,
Data: 7-`30
ayq-7 -
O - -735 a3S7
Official use only. Do oor write in this area,to be campfated by a7ty or town official
City or Town: PermitlLicense R
issuing Authority(circle one):
L Board of Health 2.Building Department 3.Cityffown Clerk 4.BlecWcal Inspector S.Plumbing Inspector
6.other _
Contact Person Plane fl
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE
POLICY Liberty
Mutual:
AR INFORMATION PACE
ugeerty Mutual Group
175 Berimay Street Boston,MA 02117
Issued by LIBERTY MUTUAL FIRE INSURANCE 16586
Policy Number WC2-31S-377255-021 Issuing Office 181
NEW BUSINESS NEW Issue Date 08-31-11
Account Number 1-377255 Sub Account 0000
1. Insured and Mailing Address FEIN 271976112
JRB BUILDERS INC
4 CROSS AVE
SALEM MA 01970 RISK ID 859092
Status 03 - CORPORATION
Other workplaces not shown above: SEE ITEM 4. PREMIUM-EXTENSION OF INFORMATION PAGE
2. Policy Period:The policy period is from 07-30-2011 to 07-30-2012 12:01 A.M. standard time at the
Insured's mailing address.
3. Coverage
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits
of our liability under Part Two are:
Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100, 000 .. each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE END WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required below is subject to verification and change by audit.
Code Premium Basis Total Rate per$100 Estimated Annual
Classifications Number Estimated Annual Remuneration of Remuneration Premium
See Extension of Information Page
Minimum Premium $ Soo (MA) Total Estimated Annual Premium $ 2, 523
Premium will be billed ANNUAL
Producer 0004-152882
GILBERT INSURANCE AGENCY INC
137 MAIN STREET (RTE 28)
READING MA 01867-3922
Sales Representative 3000
Sales Office Name WESTON
01987 National Council on Compensation Insurance,Inc. WC 00 00 01 A
All Rights Reserved Ed. 07/01/2011
Insured Copy