1 HIBERNIA LN - BUILDING INSPECTION ; ���' '_ ' ' ' The Commonwealth of Massachusetts
Q�� �', i•`-� ,� Department of Public Safefy
VJ � �v� � \la.c�cbu.�ll>Slatr tlwlding('udr 1:!lUC�IN)��•rnth Edil�un/� M�\
City o(Salem ��o�"� C� _
Buildin Permit A licatian for an 8uildin other than a 1- or 2-Famil Dwellin
(ihis Srttiun Fur Uf(iciol U�r Ch+lv) . .
Uuddinµ Prrmd Uumbrr: Data Appliad: Bu�lding In.pactor.
SECTION l: LOCATION IPie�x iadicate Block I and Lot� for Iocallons for which a slrcet addrefs is not avaifable)
#i �d�gr��►iA 4�i� sACF�y,^�� o/�70
V��..uu1 tilrret " : • Cilq/T.+a•n ZipQ�dr Namruf Building(il apE�licablr)
SECiION L•PROPOSED WORK
, . If Nrw Cun.tructiun check hrrc O ut chrck all that appty in thr Iwu ruwy bek�w �
Eti.tin Building O - Rrpair O Altrratiun� Ai�dition O Drmolitiun O (Plrasr fili uut and submit Apprndix 1)
. .GNnngrufUer � Changru(Occupancy O Uthrr O Sprci(y:
Are building plaar an.1/ur curutruction Aocumen�s bring�upplird as part uf�hi�prrmit applicatiun? Yrs� Nu ❑
- Is:irt Indrpnndrnt Slructural Enginrrring Perr Rrvirw reyuircd? �, / . Ye� D • Nu j�'
Brief Dr.cripti.���(Prupo�.xi Wurk:_1QF!`�/00�7 /-�lTCfi�rN
SECTION 3:COMPLETE THIS SECIION IF EXISTING BUILDING UNDERGOING-RENOYATION,ADDITION,OR
CHANGE IN USE OR OCCUPANQY
Check here i(an Exi�Nns Sullding EvaluaHon is eneloyed(See Z80-C-MR"3902.0) O �
Fxisting Use Group(s): P'opased Use Croup(s): F
' Existing Harard Index 7&1 CMR 34: Proposed Hazerd lnd�780 CMR 34:
SECf10N-4r8UILDINC HEIGHT AND AREA
� � � -t .., � . . Exiadng - Proposed
. IVu.of Ft.wrs/Storiea(indude ba�ement levels)&Area Per Floor(sq.ft.)
Total Area(.+y.ft.)and Total Height((t.)
SECfION x USE GROUP(Cheek a�a Ileable)
A: Asrembiy A-1'0 A•2t O� A-2ne O A-3 O A-4 O A-5 O B: Busines� �. E Edueadonal O
F: Facto F-I O F2 O H: HI Havcd H-1 O H-2 O H-3 O H-0 O H-5 O
� L• [eeHtuHonal-(d ❑ 1-2 O I-3� f-t O M: MeecanNie O R: ResidenNal R-10 R4 O R-3❑ R-1 O
S: Stonge SI O SI� U: Utilitr O Speeial Use�and Irasr dr�cribn brluw:
$prcial U.e:
SECTION 6:CONSTRUCftON 7YPE lCheck a a Itcablel
� IAO IBO I►AD 1190 . IIIAO � IIIBp ' IVO VAO , V80. .
� SECTI(�IN 7:SITE INFORMATION In(erlo 780 CA1R l ll.O for detaits oa.each iteml
LYater Supply: Flaod Zone In(omiafion: Sewsge Dispoaal: Trcnch Permil: Debrif Removal:
� PubLc❑ C hiYk ii�n�t>idr FkH�d Lunr O Indicalr mumcipal p �\ trcnch wJI nut br Licrn.atl Di.F�n.il�itr❑
Pn��ate O ��r mdcntih'Zunr: �a�m.rtr>c.trm 0 rryu�nw!O ur tnnch ur.p.tiii��:
. . .. . prrmit i+en.I��.nl �
Railroadrighbof•way: HazardstoAirVavigation: �b� lb.n.r�. i�,�,,,�ni..�..,��t.�.���.. 1'n���•,.
\ut :\�•F�hc.ible0 - � - 1.5ttua:ltac�cith�n.urEheet.iF•�•rn.�ch.irr.i.' .. ` .h lh�i�rrc�v�c o�mF�lclatil.'
\ ��r l',�n.cnl l�� Hud.l vniL.val�� Ya�� ur X��❑ 1'r>❑ \�u ❑ �
5ECI'ION B:CONTENT OF CEHT1fICAIE OF OCCUP.kNCY
I�dtu.m ��1 (��.dc: __� l�e(;r��upl.l: (��•c.�t l�m.lruiUun: lkcupanl Lu.�.l F.cr hlnue
, Ih�.•.Ihel�udJin�;..�n�.un.intiF,nnAler?�.tein.': <paKialtil�E•ul,tti��n.: �
`��cu:Q � �'c���c
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Addressor 11nopvrty Owner � .4/qA9
:7 1--.44 / -/4r/ °F/i� -
Name(Print) No.and Street City/Town Lip
' operh•0% ner •}/Q}acC9 t�lnfidmalwn:�
Ti Telephone No. (bustne-s) '- Telephone No. (cell) r-mad address
If applicable.the property owner hereby authorizes
Name. Street Address City/Tuwn State f , Lip
' ki act on the propertv Owner's behalf, mail matters relative to work authorized by this budding permit a + plication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) .
ilf budding is less than 15.trW cu.11.of enCkwJ s cr and/ur not under Comtntctiun Contmt than check here Gandkip Section 10.0
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) - Telephone No. e-mail address Registration Number
5ttete7 Address - City/Town - State •Zip :Discipline Expiration Date
10.2 General Contractor
Culp Name: S ( JS Z
Name of Person Responsible for Construction License No. and Type if Applicable
S- L'Cl/vA tFT IZO.417 i//h"/I�CCs/�ts7�4 L/1/i' 019/V6
Street Address i City/Town State Zip
/-��+ " 9093 7�/ -�- S`S`O9_s' F .4�5°[J/✓OSCLi/SGC?�X['JYE, Cd/•?
Telephone No.(business) Telephone No. cell - e-mail address -
SECTION 11:WO R9400 EA (M.G.L.x•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 a liaationt Yes No O
SECTION 12..CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=E
1.Building f a0�r7 1.r70 ... Building.Permit Fee,-Total Construction Cost x"_(Insert here
2. Electricalf , / X00.0-0 appropriate municipal factor)-f.
3.Plumbing f 0.00 + '+
4.Mechanical (HVAC) f Note:Minimum fee=f. ( n act R)_t on lity)
5. Mechanical (Other) •f Enclose check payable to G'- -
6.Total Cost S A2 2iS219.00 - (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Hv entering my name blow, I hereby attest under the pains and penalties of perjury that all of the informath,nxontamed in this
application is true and accurate to the best of my knowledge and understanding. _ -
mE5 uo �tQQQ 178 _`?44: uS 9 1 16
I'I •a.r rent and,i1;n name lith -ielrphoneu, rte
o ( 70
';trcel Addrr.. C rtyi Tuu:n to �.. tp
i
Municipal Inspector to fill out this section upon applicationapproval: '
IL
C3 o p CROWMNSMELD
O G 13 MANAGEMENT CORPORATION AMO®
September 1, 2010
Mi. James Fallon
1 Hibernia Lane
Salem,MA 01970
RE: Kitchen Remodeling
Dear Mr. Fallon,
Reference is made to your request concerning permission to remodel your kitchen.
Please be advised that there are no objections to your remodeling the interior portions of
your unit providing the following is adhered to:
• Your contractor must be licensed and insured
• The certificate of insurance must name the Sanctuary Condominiums as an
additional insured.
• A building permit must be obtained and a signed copy forwarded to my office for
your unit file.
• No changes that affect the exterior of the building will be permitted.
You will most likely need to show a copy of this letter to the Building Department.
Should you have any questions or require additional information,please feel free to call
me directly at(978)532-4800 Ext., #232.
SinFerely,
1 ama, CMCA
roperty Manager
Crowninshield Management Corp.
Managing Agent for the Sanctuary Condominiums
cc: Unit File
18 CROWNINSHIELD $T. • PEABODY, MA • 01960 • TEL (978)532-4800 • FAX (978)532-6023 WWW.CROWNINSHIELD.COM
n_ w
CITYOF SALEM
rt ' PUBLIC PROPRERTY
DEPARTMENT
,1%W;aLl°Y Ual1(:UI.1-
�t�Yrin M�WASHIwrONSTSEE•r SALEst,MASSMAu %Li'iS0f97^
Tel.:978-745.9595 • FAX:978-740--9946
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .
Applicant Information Please Print Legibly
Name(tusinesstorganizationtinrlividual):
Address: CO//iaV'i ��r7��
City/State:%ip:
:;t you an employer'Check the appropriate box: "type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and t G. ❑ New construction
~`gni)lo ces full and/or art-tine).• have hired the sub-contractors
I Y ( P' 7. E] Remodeling
2. 1:un a sole proprietor or partner- lilted on the attached sheet.
ship and have no employees These sub-contractors have 8. El Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition -.
'No workers'cum insurance 5.-❑ We are a corporation and its
r P- 10.❑ Electrical repairs or additions
required.) officers have exercised their
3. 1 am a homeowner doing all work S exemption tion P'
right of per MGL I LE] Plumbing repairs or additions -
❑
myself. (No workers'ctnnp. c. 152, y 1(4),and we have no 12.❑ Roof repairs ,
insurance required.]t employees. LNo workers' 13.❑ Otter -
comp. insurance required.]
•Ally ai)plicaat ttatt checksbo%itt rilaS1 also till out lhe.wctlnn blow jmwing their workeo compensation policy information.
'I lomeownen who submit this affidavit indicating they are doing all work and then hire oulside cottnetors maul auhmit a new affidavit indicating.arch.
:Csntrxulrs that check this box must anachod an additional shaca showing the name of the subcontractors and their workers'comp.policy information.
1
any all eunployer that is providing)vorkers'compensation insurance for my employees. Below is the pulley and)ob site
iufornautiom
Insurance Company Name: ------
Policy is or Self-ins.Lic.f: .___ Expiration Date:
Job Site Andress: City/StateiZip:
Attach a copy of lite workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 fine
of up to 5250.00 a day against lite violator. Be advised thut a copy of this statement may be forwarded to the Offer of
111%" illations of the DIA for insurance coverage verification.
I do hereby certify d e s penalties of perfnry that the information provided above is true and correct.
Sie:rnuret Date:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License
Issuing Authurity(circle one):
1. Board of llcalth 2. Building Department 3.City/rown Clerk 4. Electrical luspector 5, Plumbing Inspector
6.Other _—..._
Contact Person: -_- - -_ ---_ Phone 8: -
.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 hoose 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 un 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."
Additiwmlly. MGL chapter 153,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
,_inter 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-contractors) 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 all 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 Offlclals
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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that most submit multiple penmiu'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
(i.e. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 5-26-05
www.mass.gov/dna
CITY OF SALEM
i PUBLIC PROPRERTY
T'.1vIENT
DEPAR
I A c1ti 1.1 r . NA I I M. N h
- 'I-s.'4 C'';7s.'44.,
Construction Debi-is Disposal Affidavit
(I'CCILlired lor all dell jolition and renovation work)
In accordance %,6it I I the sixth edition ofthe State Building Code, 780 CMR section 111.5
-Debris, and the provisions ot"MGL c 40, S 54;
Building Permit 0--. is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal I'acility as del'ined by MGL c
I 11. S 150A.
The debt-is will be transported by:
&74VAI.
manic Eli hattlel,
I he debris will be disposed of in
(naine u(Cacility)
(addrey,10"lacifitv)
date
§L
oDw� ,� wl$3'" w�336 w3al16 W303r, i
38a ! k1303� Z 9
/ t $Fp 3b , 63015 �QE r6 DID 362oD1 _1
lA
_ I — — ---_._ ---- --
s: 25 I
bwp-
CTR -ra G;._
qol
ar 12„
@ -OIbF I)
-- Ll
11 i
WA I L
QQu I
i
W1']q u. io I
Gov -
1 ,.
�� rr CL.I-k 9JT�
�4 st ' W 3316 1 kW.rJG c.°of Tp,--// AT 90„ -z� •�
JFROM FINISHFD {=LOOK
W)MATCHING SMCK 10
CEILING -
z
0
�7
IA
ALL DIMENSIONS AND DESIGN PLANS ARE PROVIDED FOR THE FAIRDESIGNED FOR
$12E DESIGNATIONS USE BY THE CLIENT OR HIS AGENT IN FA,LLCN� KEZ:o
GIVEN ARE-SUBJECT TO l
COMPLETING THE PROJECT AS LIS TED m IINN
,V E'RIFICAT.CON 'ON. JOB THIS CONTRACT. DESIGN PIANS REMAIN THE SPOOK.-iAJtn�% /ISTD
SITE AND ADJUSTMENT TO ow^
PROPERTY OF THIS FIRM AND CAN NOT BE .F11JtSH SIER.F k c.�J
FIT JOB CONDITONS. National Kitchen & Bath Association USED OR REUSED WITHOUT PERMISSION. - CHEF-"
FLOoK PLAN SPEcIRCAlioN5
I Q5S 0,191-34 TALL FILI- CPQ
--------� 2 W33 n -24" DEEP 2 DoovS )ABDVE EXI'ar REF r d
KEWACKE ELITE TDP FPEEZEK 334)<6LLx27
3 Pw 4891-a4 slDE, PANEL
1-F W )7/z. 36 1 DOOR H-L > FIIJISHED RIGHT SIDE
5 W3636 oDh1f- DLIND FINISHED 7"TD RIGHT
I DOOR, H-R ,PlnISHED LEFT SIDE
(a W 1836 0.51 V DOOQ. H-L, SPICE RACK 6LOSE FILL,
1936 I-- DOO',VL H-R FWISINED RIGHT 51DE
g W301S Z DOORS AHoNE MICROHOOD GS
9 2 DOORS, 2 FINISHED 51i,E5
\O PjID 12 DTP I pzAWER I DooR N-L,I �ERTIcAL bIvrDE�
. w' II 1715H W�FSt-{EIS EXI<jT
Ii D5C 291/2- 5INK BASE FOR 51ACYLE 51NK
- nLT-DovjA DRAwE -KrAID 2 DOOP.S
IS SID 21 6DPg 1 1.?RAvj5P- I PULL-OUT DOOR. W/
CDDL 1-kASH 'HINS
19 >?jjiLp3io CORNER CAR.ov5EL-
15 6aD 15 3 DRAYOE-K BASE
16 30"FIMGE
6 D1 1 0 -ou
q ID 30 20 DRAWER 2 DooRS R LL T-�r:A
. FINISt1Ep RIGS Sr Ds w�RFC£55fiD SuggASE
18 33D 33 3 DRAWER EASE FIN\S\tED /�'✓L SIp�S
RECfiSS£"D 5u6HASE ALL SIDES
19 (EKG �6 5UP?=OR.T COR6EL
Y i -tom—
PLG 0596-14 -roEKICK
MN[,6FLG96-34 TRIM
LDL + i
FOR. SOFlprr i
PLG- 1067-34 VALANCE i
PLG 076-7-34 CEILING UNDETC
VALANCE
FILLM
q 'l
QSS O434 3'i UM>W REF.CA6.
1 i !
I)ALL DIMENSIONS ARE FINIS146D bIMCN51otIS,
2) AMIAh\CES MOS'C HE Ch1 -10?i SITE AT TME "1S9
OF 114%l-AlLATDN TO ALLOW FOR
24
1 i
1 !
FINts-H6D X2002
BY I DATF I BY ESCALE DWG
Cos rOl,EP",APPR-SAL , 21 I „ NO.
HDWR:
6 U6 -Doops tt�,.,,
.!a I - DRAW EXI 1/a ----—
23°�
i
o
12'7 2`{ --�-- 2`S%zu--�—2 1 � 36
ZA
-ALL DIMENSIONS AND DESIGN PLANS ARE PROVIDED FOR THE FAIR
'DESIGNED FOR
"SIZE DESIGNATIONS USE BY THE CLIENT OR HIS AGENT IN FALL-01-
GIVEN ARE SUBJECT TO m COMPLETING THE PROJECT AS LIS TEDMRImm
VERIFICATION O,N JOB THIS CONTRACT.DESIGN PLANS-REMAIN THE �/ISTA GeO =�'ry
SITE AND ADJUSTIIfI11ENT TO _ - PROPERTY OF THIS FIRM AND CAN NOT.BE SIERYJ. oN C."E'R
FIT JOB CONDITIONS. National Kitchen 6 Bath Association USED OR REUSED WITHOUT PERMISSION.
I"
t.
CIO
i
O O
O�O
0
I
BY DATE BY SCALE DWG
2-
' FINAL- QI'-I lid
t•
_t
i
j
n
3 23 ,
/
z � 3
K)G4-1T SIDE bac nIC� p.R.TA3) ( aFr SIDE
ALL DIMEMSIONS AND DESIGN PLANS ARE PROVIDED FOR THE FAIR DESIGNED FOR
\
SIZE DES;tGNATtONS USE BY THE CLIENT OR HIS AGENT IN FALLax)l�,•y {Z:"!1
GIVEN AF&SUBJECT TO '-r m COMPLETING THE PROJECT AS LISTED WITHIN
VERIFICATION ,O,N JOB THIS CONTRACT.DESIGN PLANS REMAIN THE s
SfTE C
AND..ADJWS7MENT TO. Iffi_ PROPERTY OF THIS FIRM AND CAN NOT BE
'FIT JOB'CONDITIONS. 'National Kitchen & Bath Association USED OR REUSED WITHOUT PERMISSION. -
ON
ema 3:W36 A9 Uyu A9 Q c
sb—
- I