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27R HARDY ST - BUILDING INSPECTION gq•.0110 The Commonwealth of Massachusetts u Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is pot availab No.and Street City/Town Zip Code Name of Building(if app ble) �1 SECTION 2:PROPOSED WORK 5 � Edition of MA State Co used If New Construction check here❑or check all that apply �1 the tw67ows m m Existing Building e I Repair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit end' O Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: $ < Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ IQ Is an Independent Structural Engineering Peer Review required?/J Yes ❑ R, od Brief Descr lion of Prop Work: kk r(iI/• E 6 e . z .'h 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): 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(R) t9���! �41 /- - SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑ R Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ 1-2❑ I-3❑ 1-4❑ M: 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 ❑ 1111313 1 IV ❑ 1 VA El VB ❑ SECTION 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: Licensed Disposal Site❑ Public C3 Check if outside Flood Zone❑ Indicate municipal A trench willyerbe isp Private❑ permit is enccll or indentify Zone: or on site system❑ required trench or specify: osed❑ Railroad right-of-way Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable Is Structure within airport appr area? Is they revie pleted? or Consent to Build enclosed❑ Yes❑ or No Yes ❑ 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: 5"------ The Commonwealth of Massachusetts Department of Public Safety t Massachusetts State Building Code (780 CMR) J`ssyw_ �;mcD Building Permit Application to Construct,Repair,Renovate or Demolish any Building other than a One-or Two-Family Dwelling i r= a Code and Other Requirements for Building Permits Tlie Department of Public Safety has issued these building permit application forms so that municipalities ,-across the state can move toward use of a single permit form and consistent permit application process. The MA'State Building Code specifies the requirements of building permits and the applicant is advised to review and be familiar with these requirements in order to avoid some of the common permit application problems.Likewise the applicant should be aware that some municipalities require that the owner confirm, even prior to acceptance of the building permit application, that no outstanding property taxes,water fees, etc:exist,' Filing Instructions 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be reviewed if construction documents, specifications, fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a check for the Building Permit fee. The fee may be calculated using the information to be supplied in section 12 of the Building Permit Application. The check is to be made payable to the local city or town where the work will be done. L . o r Zk Salem Historical Commission 120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970 (978)619-5885 FAX(978)740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving ❑O Reconstruction ❑ Alteration ❑ Demolition G Painting y t„ ❑ Signage ❑ Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: Derby Street Address of Property: 54R Turner Street (Hooper-Hathaway House) Name of Record Owner: House of the Seven Gables Settlement Association Description of Work Proposed: Repair and replacement of deteriorated clapboards and broken windows. There will be no changes to design, color, or material. Non-applicability due to work being in-kind repair and/or replacement. Dated: June 2, 2014 SALEM HISTORICAL COMMISSION By: Z J The homeowner has the option not to commence the work (unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of Buildings (or any other necessary permits or approvals) prior to commencing work. SECTION 9: PROPERTY OWNER AUTHORIZATION Na a and Address of Prop rty wner Name(Print) No.and Street City/Town Zip Pro erty Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail addrels If a iiplicable,the prop rty owner hereby authorizes Ke✓,�r/ CJ�i,yP //J �e%�!i s J J d ftii ✓%u o ll7d 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(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction 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 Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip j 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 and Materials) Total Construction Cost(from Item 6)_$ / colpat 1.Building $ Building Permit Fee=Total Construction Cost x_"(Insert here 2.Electrical $ appropriate municipal factor) - 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ Q // (contact municipality) 5.Mechanical Other $ r Enclose check payable to �- f Y � J¢�All 6.Total Cost $ / 'Poo r `— (contact municipality)and write check here 12,4141 SECTIO 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the parns and penalties of perjury that all of the information contained in this application is true and accurat .to If best of y kn ledge and understanding. Please print and si name ,^ Title Tele hone o Date //s �erb Al B/ Street Address City/Towne State Zip Q Municipal Inspector to fill out this section upon application approval: t� Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot#for locations for which a street address is not available) No. and Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark'Y'where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) . .. _6.." - .MAC -... .. __ .. _. . . 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other Sec' 22 Other S ec' *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address Ci Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town Town State Zi Discipline Expiration Date ' The Commonwealth of Massachusetts - -. DepartinentoflndacctrialAccidenis Office of Investigations I Congress Street,Suite 100 ' Boston,ALL 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ;� ' ( �l Please Print Legibly Name (Business/Organization/Individual): I r V Ltl Q- OI { ��- �� �Gt.Y�IQS Address: I low aya+ City/State/Zip: Sg �ryirn 0l9 Phone#: 6?_7 M u Q- (A(q Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheeL 7. ❑Remodeling shipand have no employees These sub-contractors have g and have workers' ❑Demolition employees working forme in any capacity. 9. ❑Building addition [No workers' comp. insurance comp.insurance? required-] 5. ❑ We are a corporation and its ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] •Any applicant that checks box#]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. lContmctors that check this box must attached an additional sheet showing the time of the sub-contractors and state whether or not Nose 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 jab site information. Insurance Company Name: Policy#or Self-ins. Lie.#:_ vim-- (�( �y Expiration Date:: illI Job Site Address: I l� I�l/6q car rQ� City/State/Zip: �1��I ( TID Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 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$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. Be advised that 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 penalties of perjury that the information provided above is true and correct Signature,Aoqok Date: Phone#: 1 �( LI — q I e- { 1 I 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.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r s NOTICE , _ NOTICE TO 1 TO EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we)have provided for payment to our injured employees under the above-mentioned chapter by insuring with: ISCC NAME OF INSURANCE COMPANY 10 New England Business Center, Suite 303 Andover, MA 01810-1024 ADDRESS OF INSURANCE COMPANY WC 000547-14 01/01/2014 to 01/01/2015 POLICY NUMBER EFFECTIVE DATES HUB International New England 600 Longwater Drive Norwell, MA (781) 792-3200 LLC NAME OF INSURANCE AGENT ADDRESS PHONE# House of Seven Gables Settlement H 5 Derby Street Salem, MA EMPLOYER ADDRESS MP_IiS5p RpAnolds 9-�-V�gg - on kilt IhP4 EMPLOYER'S WORKERS' C PENSATION OFFICER (IF ANY) LJATE1 MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hosptial attention, employees are hereby notified that the insurer has arranged for such attention at the �Iyytl� gore MP&(&1 Ccn[f y- Bl lioland )ite �n�m NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER