33 HARBOR ST - BUILDING INSPECTION 2 CX_S34
f REGEtVER
The Commonwealth of Massach e s
Department of Public Safety A 3; 1
(1 Massachusetts State Building Code(780 CMR) lOIS APR b
LJ Building Permit Application for any Building other than a One-or Two-Family Dwelling
l v - (This Section For Official Use Only)
Building Permit Number: Date.Applied: Building Official:
J� pofMA
SECTION II:LOCATION(Please indicate Block#and Lot#for locations for which a street address is notavailable)
f �1 SG4,w G/974
^ City/Town Zip Code Name of Building(if applicable)
l SECTION 2-PROPOSED WORK.
ate Code used If New Construction cheek here❑or check all that apply in the two rows below
❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition O (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ I 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
Brief Description of Proposed Work: 1 aC n 1,6_4 %if _9 44,4 9 '�a 4,e 7,C/ 2yr
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): I 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 Area(sq.ft.)and Total Height(ft.)
SECTIONS:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-I❑ F2❑ 1 H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5 El
I: Institutional I-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ - R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable) -
IA ❑ Ill ❑ 1[A ❑ IIB ❑ IRA ❑ IIIB ❑ IV ❑ 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:
I
Public❑ 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 I tl_t me C nmissi>n No6w,,_.Prxc.s:
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:
z
SECTION 90 PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owners
}
Name(Print) No.and Street City/Town Zip
Property Owner ContacBlnfonnatioon: G —�
0.j_ r Q _ 11 U - 9L QPi Z p "-1 �_ (oN-i2_
Title - Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Mune Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please Iill out Appendix 2). -
f budding is less than 35,000cu.ft:of enclosed space and/or/ not under Construction Control Then check here O and skip Section 10.1
10.1 Registered Professional
�jResponsible for Construction Control - - -
Sev� `�2r / J � SC��s�co�/
Name(Registrant) Tele h9ne No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - - - - -
Company Name
SVe. - / Ol.e, ,, /.1.5
None of Person Responsible for Constniction License No. and Type if Applicable
1 -/ 2L
Street A� dress City/Town State Zip
/la✓�-r �4G� _= C'�3���i �lres7GG.C� /12'f'
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WOKKERS'COAIPENSA'I ION WMUKIANCF!AFFIDAVfl' M.G.L..c.152.§25C6
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 I2:.CONSTRUCTION COSTS.AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
P
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ Z ll'/i'� -� (contact municipality)and write check number here
SECTIO 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 best ol�jnx knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: - 116 t
Name Date
A� CERTIFICATE ®F LIABILITY INSURANCE DATEIMN 6 D )15
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 COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING MURFR(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: N the certificate holder is an ADDITIONAL I URED,the policypes) must be endorsed. If SUBROGATION IS WAIVED,suhjscf to
the terms and Conditions ofths policy,certain policies may mgMlre an enclomemeni A statelllent on this eerfificats does not caller rights to the
certificate holder in lieu of such endorasmen
PRODUCER COME: T I(ri8tin Linname
M.P. Roberts Insurance Agency PHONE g78 683-8073 �N
1060 Osgood Street a D)R6, kriatin@ probertainsurance com
North AndgVerr, D1845 NSUPE AFFORDWO COV9tA4E NArDn
...... .........___.._____ ______ INSUR6rA: auta.lUs Insurance CO, .
IMURED INSURER B,:Mercha_nts Mutual Insurance Co
STEVE HADLEY nNSURmc:Liberty Mutual
DBA STEVE HADLEY CONTRACTING ...... _._._...._.... ,...,...._
INSURER D:
239 JEFFERSON AVENI7E _._._ _.._...... ......:..._..._...__._._
IN9UREB F:E:
sALram1, MA 01970
INSURER
COVERAGES CERTIFICATE NUMBER. REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO 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 PERTAN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
FXCLUS10N5 AND CONDITIONS OF SUCH R POLICIES.LMII.l.SUM P EFF PGLILY EItP _......_,.__—__--_._—_...__—.._.........
TYpeormisuRmar Am
Ing. Pg1CY MINDER MDn RMmurym LUaIS
A GE"QlnLtdAenlTr NN473420 6/19/14 6/18/15 EACHOCCURRENCE
X CCMMERCIALGENERALLIABILITY DAMAGETORENTED
I' r REMISES(F.A.raunencW._... s 100 000
CLAM ISMADE ilOCCUR NEOFJ�NMa�?P r) $ 5 .000
—.__...._._...__ FEM!4LSAOVINAJRY t 1 000�000
_.............. GENERAL AGGREGATE S _2 COO.,900 _
GEN'LAGGREGATE UMITAPPLIES PER _PRODUCTS-ODM°,OP AGG S 2,000,000
POLICY P LOC e
8 AUTOMOeILEUASILITY MCA7014084 10/29/14 10/28/SS If, ll N
l__...,_, a 300<000
ANYAUiO EODILYeLIURY(Pv Penon) S
AI-1-0 eO SCHEDULED -
AUTOS AUTOS BODILY BUURY(Per eccWmt) $
X HIREOAUTOS I( NON-OWNED PERIY DAANGE •.. .•_.�—
ALROS per
— S
UREIRFLA LI49 OCCUR
EXCESS LWB _EACH OCCURRENCE S ....._....
.,_ CLM1 W'Sde1DE AGGREGATE
D RETEHTIOry _._... 5
C VIORNE MCCMMNSARON WC531S32906403 7/8/14 7/8/15 WC STATU, DTH-
MO EMPLOYERS'.LIABDITY Y M r TORY.LM _......
ANY MOPRIETCIWARITIER1Eli UMvE
OFFICE RMIEIRFR MLLDED7 NIA E;L,.E?cti!_AoaL>Frvr ._500,000
(Mandawy In NH) EL.DISEASE-EA ET.sLPY.EE $ 5n0,000
IIyea tleAtllbO,mdar
DESCRIPTION OFOPERATIONS below EL.DISEASE-POLICYLMrr S 500 000
ASCRIPTION OF DAERA710NS I LOrAT10N$1VEFIC9FS(APAetI ACORD 10T,AddNonel Re11eAu Sermdub,N Alan epees Ia,egJrod) I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY Or THE A13OVE BESrMBED PCUCES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INCITY OF SALIC+t ACCORDANCE WITH THE POLICY PROVISIONS.
INSPECTIONAL SERVICES
220 WASHING$ON STREET AUTxOFQED aENNESERTATNE
SALEM, Ma 01970
M]:CHAEL P- ROBE S
0)1938-NIO ACORD CORPORATION. All rights reserved.
ACORD 25(201 DIOS) The ACORD name and logo are registered marks of ACORD
Phone: Far: (978) 740-9846 E-Mail:
The Commonwealth ofMassaehusetts
Wr
Department ofIndustrial Accidents
1 Congress Street, Suite 100
Boston,MA,02114-2017.www.mass.gov/dia
ke'rs Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibly
Name (Business/Organization/Individual): S' ��( , MG Ven 6/5 TEE 6
Address: q ) 19 ROL, I (�-i.,q 7
City/State/Zip: )t,U h Gt Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
L❑I am a employer with employees(full and/or part-time)." 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in $. FKemodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.F-]I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.= 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
`Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. �"
Insurance Company Name: G t�Gr)-y/ /`�✓u %'"7j�1
Policy#or Self-ins.Lic.#: l,U C /, J rT% j7 q / dl Expiration Date: %tM e-
Job Site Address: -� /& i City/State/Zip: � JCJ
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penallt�ties((//n�l/�[/f'p//erjury that the information provided above is true and correct.
Signature' ✓t- M.�// Date:
Phone#:
official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every Person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self'insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
required to complete this affidavit.
i e.a do license or permit to burn leaves etc. said person is NOT re p
( g P ) P q
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
CITY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
t 120 WASHINGTON STREET,37 D ROoR
�- nL.(978)745-9595
KIMBERLEYDRISOOLL FAX(978)7400846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING ODW&SSIONER
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 c40, 5 54; Building Permit# is with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit 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:
e �n
(name of facility)
(address of facility)
Signature of appli nt
Date
• i