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17 HERITAGE DR - BUILDING INSPECTION ,, ;►: The Commonwealth of Massachusetts . , Department of Public Safety ' I G `+:,-,,.✓ \hi..arhusrtt.State Building Code(780 Ch1R)Se%enth Edition Itylo City of Salem Building Permit Application for any Building other than a 1- or 2-Family Dwell'(2" (This Section For Official Use Onlv) Building Permit Number: Date Applied: Building Inspector: SECTION 1: LOCATION (Please indicate Block M and Lot M for locations for which a street address is not available) a V�Ihr�J-mi / �U551h� No. and Street City /Town Zip Code Name of Building(if applicable) SECTION 2: PROPOSED WORK r -`�' - ' If New Construction check here❑or check all that apply in the two ruws below Existing Building lia'• Repair❑ Alteration ®--� Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: t Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineerin,Peer Review required? l ,,.," Yes ❑ No ❑ Brief Description of Proposed Work: 1VI A11 1, 5�A?-)00-�'5 Per wr/''N/V`r7(¢ 1'64. -'�Ir�w1r5 A'Ic Gr01n, I jogy. will 601,0 E 'ISXiK 0 eml y11te_.oAe-r s OcbYS vvoi be v( w S 00'f 100Y L04Y kV7d �F -6L L1s ,.✓I' / / ch v �✓a// do e h- ae M;47G Wl) /1J5 d'WY5 d H• 5-e-CZc�>5 wdl close- � I r� a 9fQf 1 d r tF 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) O 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 ap licable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑. H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ 1 M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4 ❑ INVN S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) "1011 IIA ❑ Ito ❑ [HA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0'for details on each item) Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: heck ifoutside Flood Zane•❑ Indicate municipal ❑ A trench will nut be Licensed Disposal Site Ur or indentita Zone: or on site system ❑ required O or trench or.pecily: permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: \I:� I I"timic(".,mmi»hsn Kock.. Pn,rr..: \ut :\p}+licable❑ I.}truclure mthin airport approodi area:' 6lheit'rrcirw completed.' or C mint to Budd enelo>e•d ❑ Ye,❑ or No❑ Yes ❑ \o ❑ SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY Lduinn of Cale: C.e Grnupl.l: Tcpe of Construction: Occupant Load per Floor: 1)nes the building contain an Sprinkler Scstem' Special Stipulations: Y �L r� SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Ow er Fleri-t►`y-e_D� SU �,m w►G Name(Print �— No.and Street City/Town Zip Property lhcner Contact Information: ywm11ue1wiilfd+MS yes- sly Ieob �1�_ �/3� 8700 . Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes Name Street Address City/Town Slate Zip to act on the an°pert 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 buildin•is less than 35,000 era.ft.of enclosed space and/or not under Construction Control then check here O and skip Section W.0 10.1 Registered Professional Responsible for Construction Control ayi G� "pV► 9?g31S-7,7qs Name Re�istmnt) Tellr�one No. e-mail address Re istration Number M28 `ifi -o- �� 1¢Yl Tell ,pry my 611"5" eorg5 st�,ar✓�,crt Street Address City/Town State Zip Disci 1' a Exptratio Date © ��ts 10.2 General Contractor b 6 (b oracl-i nq I o C_ Corpp�y i A7,d1r yqo 6- s Ar l/ Nam�\y>j/�UP'er� P Re"segble for Construction LiceTe No. and Type if Applicable N ,J—� /2(!�(f1 ( Gar` JO,"t,I/ Ki rIS Street Addrre�s�,,,, q)f City/Town State ap -�-`1YL�/ — �__6 _ 7>y5 1�l b'Vl��th9 ip q .,-U �� 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❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE ,.y} Estimated Costs: (Labor � � d,6 Item and Materials) Total Construction Cost(from Item 6) =$ / 1. Building $ 5 9 t '-0 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ '%00'06 appropriate municipal factor)_$ 3. Plumbing $ 4. Mechanical (HVAC) $ _ Note: Minimum fee=$ (contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6.Total Cost $ */ 7 7 �0 (contact municipality)and write check number here SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I herebv attest under the pains and penalties of perjury that all of the information contained in this application nte and accurate to the best of my knowledge and understanding.r r( h dw�� q?��is» sal u Please prii�nt�ani sign name i r I�(I Telephone 8o Date q — U IY�QCI�.ftY1�5 — ��lf�U MC4 D/ S titreet Address City/Town State Lip Municipal Inspector to fill out this section upon application approval: Name Date J CITY OF SM EM, ANLksS.kCHusEM BI:DMNG DEP.%Jtn NT 120 W.AsHNGTON STREET, Jae FLOOR TEL (978) 745-9S95 F.,Lx(978) 740-9846 Ip%BERIBY DRISC0f1. MAYOR THc& ASST.PIExM DI RECTOR OF PL BLIC PROPERTY/111V ILDNG COSMUSSION ER Workers' Compensation Insurance ,%Mdavit: Builders/Contractors/ElectrfclrnsiPlumbers A s licant Information IPrint r Vatnd (Busirwv.Organtrationlndsvddual): J 1'cU Address: V /,LW-V I Ulm 0 I—e& City/StateiZip: lit 0-0 ✓ U d' $�rilone N: 92� SlS >I y S' .ire you as employer'Check the appropriate box: Type or project(requlrcd): 1.Garet a anployer with —5 a. ❑ 1 am a gentxal contractor and 1 employees(full and/or pan-rim at:e).• have hired the stbcentrtors 6. ❑New construction2.❑ I am a sole proprietor Or partner- listed an the attached sheet: 7. ❑ Remodeling ,hip and have no employers Then sub-contactors have B. Q Demolition working rot me in any capacity. workers'comp.inwrneoa rfl 9. Q Building addition ng [No workers'comp insurance S. Q We am a corporation and its IO.Q BuildElectr repairs or additions nquired.] oan have exercised tidier 1.Q I am a homeowner doing all work right or exemption per MOL I I.Q Plumbing repairs or additions myself.[Na workers'comp. C. 152.410).and we have no 12.0 Roof mlinim insurance required.]t employeaa.LNG worksa' 13.0 Other comp insurance required.) -Any apparata dha chaos ears Of overt Am no ua The srniw below d', gentile oared'eenyanadat VaK'r inalar.tlen 'I banaownas who submit this anldvie indicting fry an doing all work Mad this Ain ateridr r'mntraresn nary alwak a dew alndovil indicting son► T.maraarn than rbvrk ibis boa mum anwhod am addti nsi dear showing raw now of sodb.ramllac,ssr and oboe woftesrI ramp.Policy inferwaea. I oar an entplryer that b prrriding markers'roarpeesodon Insenneejor arp earp/oyent QNaw b/be pNkp eadJel alas injornrmldxa In.urance Company Name: Q VV*aqV N J s`N_q( :J jn 6 CO O Policy M or Self-ins. Lie. p __ W 6�n z i'3 f 7 S Expiration Data: //�, Jab Site Address: 1? {A r i 9Q 2�` City/S1ate/Zip:_9&rq Mc .snack a copy of the workers'compensation pouey deeluallos pap(showing the policy number and expirstlaa date} Failure to secure coverage as required under Section 25A of MGL c. 152 Can lead to the imposition of criminal penalties of fine up to S 1.500.00 and/or one-year imprisonment,as wall as civil penalties in the form of TOP WORK ORDER and•flue of up to$250.00 a day agaime the violator. Ile advined that a copy of this statement may be rurwurded to the O17Ice of htv.arogationo ul'dte MA for insurance covcrago vcriticatioa /Jo hereby certify Under the it penalties ojper/uq 1Aon she inlormadow prorided above is true and tuned Phones• Offlctei use anly. Do non Write to this area`to be :u#npkrd by dry or town,,1fl,•iMJ i City or room: PcrmlN.lecnse M � i hsuing.bulhority (circle line): 1. "ourd of Ilvollh 1. Ruiiding Department J. Ciiytrorn Clerk b. Electrical Inspector 5. Plumbing In,pector 6. Ocher l..uttact Person:__ _ __ __ Phone e• 1 CITY OF SALEM PUBLIC PROPRERTY a' 4t DEPARTMENT 1111:: NI 1-11 Klw,'I I n1 1'O Vt'.\51]I\(.I i1N$rKLET •S•\I 1'%1. %`IAS'\l I❑ :I I I�:1'1 ILt: 9711-74a984e Construction Debris Disposal Affidavit (req uired uired for all demolition and renovation work) 1 In accurdwice 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c 1 t 1. S 150A. The debris will be transported by: CO- 1 name of hauler) The debris will be disposed of in nameuffacility) drhC "1dde ( act ss 4) signature of permit applicant Wo l0 l0 date 9/21/2009 10:12 AN PROM: MACDONALD PANGIONE MacDonald Pangione Insurance Agenry, Inc. PAGE: 001 OF 002 ACORD.- CERTIFICATE OF LIABILITY INSURANCE IR.TE(Mom rm 11/07/2008 PROD CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION MacDonald&Pangione Insuranc718 AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O.Box 428 DER THIS CERTIFICATE DOES NOT AMEND EXTEND OR R THE COVERAGE AFFORDED BY THE POLICIES BELOW. 104 Main Street North Andover,MA 01845INSURER AFFORDING COVERAGE NAIC 9 1N°D�O D G Contracting,Inc A Prefer ut In u nce om n428 Pleasant St B: Se Indemn Insurance Com nN Andover, MA 01845 a r' e mpany O INSURER E' COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ME ANY REQUIRENT,TERM OR CONDRION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY Be ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. T POLICl NUMBER POUCYEFFECINE POUCY YPIRATION LINTS A GENERALLMBIITY FAON OCCURRENCE S 1 O O wNNFRCNPL GENERAL UAaBm CPPDG001 07/18/09 07118l10 m mm oaw s p GENIIS RIME F. 00CUR NEO IMP(Am one P,,,,n) C 5 PERSONAL&ADVINAIRY C 1 GENERAL AGGREGATE E 2 pop OW GEMLAGGREGAIE LINITgpPLN:B PER' PNNa WLOOUCT3-CONPOPAGO S 2000000. POLICY r Loc B AUToMos"LIAMnY "Merr aNGLE UNrr s 1,000,DW. ANY AUTO 3116538 07/1=9 07/18/10 ALL OVMEO AUTOS SWEDULEDAUTOS BDOLV INJURY C (PIN PPIPLPI HIRED gUN6 NONONNED AUTOS BODILY INJURY $ (Pa Bantam) PROPERTY DAMAGE S (Px BcclBFnt) GARAGE UABRRY ALRO ONLY-EA AC E W C , ANY AUTO OTHER THAN E AUTO ONLY: AGS B EECESWIIMBRF11A LIABILITY EACH OCCIE2RENCE E OCCUR OWNS MADE AOOREGATE C I,...... DM FILE I R RETIXTOM S -. R `` NORIfiR&COI@ILITY IANp NCSTATLL OnR ENPLOYERM LIABILITY AMY PROPRIETORNARTNERMD<Fq 1M:OU35J-7475 U31J110`J OO(,r1/1D 100000 OFFILERMENMR E%ClUOFO? B yyaa..MIwDs uMs EL.DISEASE`EA EMPW C i pp SPECBY PRWIBION9 MNov/ OTHER EL.DISEASE-POLR WN(T S OCKRVIgM OF ORp1ATgR&/LOCATgMC/YCMK IOCLUC Ap OMCNDORe W/EPECALPROYIMWS Certificate holler as listed below CERTIFICATE HOLDER CANCELLATION SOUL)ANY OF TINE ABOVE 0 111861)POUM BE CANCELLED BEFORE THE 6ERAATgN :880 nacle OATM THEREOf,THE MNMNG INSURER WELL ENDEAVOR TO MAR. 10 DAYe RlarTaN Mai:MA01801 Unit G "°TICS M THE aRITITDArE MOLDER NAM®TO THE IEPT,BUT PNLURE TO 110 so exALL burn, wPou NO OBL""oR LNBRR'r W Ap HEID UPON WE NBUREN RB AGENTS DR REPREBFNTATNEB AUTHOR®RCPREBENTATNB ACORD 25(20011B8) 0 ACORD CORPORATION INS A D.G. Contracting Inc. Additions, Kitchens, Baths , Decks , Home repairs ,Excav,Mon work Commercial fit ups* finished basements* Dumpsters navi.d (q4f-Z41vf preswewt 428 Pleasant st_ N Andover Ma_ Office 978 689 4797 Home 978 683 0397 Fax 978 686 6337 Cell 97 3 815 7745 Ma. License # 001821 * Insured * Home improvement # 12( 199 Dgbuilding@aol. cam Princeton Properties Salem ma attention Dick 20 minute fire doors May 20, 09 Build 6 straight walls with a door within the wall to divide tie hall. Walls are estimated to be 4-6 feet long . Install a wood 20 minute rated door with a rated wood frame. Hardware to be spring hinges and lever door knob. Trim will be 2 1/2 inch colonial casing. Prep and paint 1he walls to match existing hall walls. Quoted price $990. 00 pf r doorway Price does not inc. architectural drawings , or any changes mad; to the scope of work, electrical/fire alarm work. This price assumes � 11 doors/walls can be done at one time. will �0 a �d a � ©� Y5 tql ID e,.S Piet (,Jc tg r r, OFFICE UP UP Sox 78 CLOSET 417 l�oo�i lAV-3bER Si SA IRS 36X $o �I S 3to x 80 36x g� 3�x 80 (2) 3[o x $o aooRs J CLOSET F76R SoL'gR �ReQoSEy 3=ohx 6�8 3z'/: 33 tJr�rNtiN(, 7-0 M1�J• ftA?Vbb660. To lRUIv�RK�'E�ecrR�e wi}{. 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