14 HIGH ST - BUILDING INSPECTION RECEIVED
The Commonwealth of Massachusetts
f Department ofpublic Safety
Massachusetts State Building
lding Codee(780(780;nk1i OV 20 A % 02
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 p and Lot M for locations for which a street address is not available)
/!� Nr� wt r ? d 0/720
�p No.and Street City/Town Zip Code Name of Building(if applicable)
.gym SECTION 2 PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
•--r_ Existing Building❑ Repairer Alteration ❑ Addition ClDemolition ❑ (Please fill out and submit Appendix I)
`! Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
r
^ — Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ NoD�K
'1i j(•'J Is an Independent Structurat Engineering Peer Review required? Yes ❑ No
Brief Descri Lion of Proposed Work:
c�cl RP-GZov fl � x ! re /T
SECTION 3:COMPLETETHIS 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 CNIR 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.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard f1-1 ❑ H-2❑ H-3 ❑ H--I❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ bt: Mercantile❑ R: Residential R-I❑ R-2❑ R-3❑ R4 ❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCrION TYPE(Check as a licable)
IA Ill ❑ IIA ❑ IIB ❑ 111A0 IIIB ❑ 1 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:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑
A\trench will not be Licensed Disposal Site❑
required ❑or trench orspecify:
Private O or indenlify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: I lazards to Air Navigation: I. f..,i, C m���� q�n.K .w,, Pr
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑
SECTION 6:CONTENT OF CERTIFICATE OF OCCUPANCY
Fditiun of Code Use Group(s): _ Type of Construction: _ Occupant Load per hour:
Does the building contain,ur Sprinkler System?: _,_ Special Stipu let ions:. __._
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner r
Name(Print) No.and Street City/Town Zip
r. ., r- ,•n ..
Property 0,wner'Contact,fnformatton:3� q
GC,�. Y-e— 60-/,,vr - �5707
Title Telephone No. (business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
Ja/�ry 1019-n0 R n,Ar 4162 ktc e-ll Sy � Air , ter eA O17-66
Name Street Address City/Town State Zip
to act on the property owners 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)(indskip 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
To� � oA-NTjqnPJ
Company Name
ToN f�( ®RNTfl Pv9� S 87DD3 %aZ6/—c
Name of Person Responsible for Construction License No. and Type if Applicable
you I Owe Sj /1"A (D
Street Address City/Town State Zip
Telephone No. business Telephone Na. cell a-mail address
SECTION 11: 1VOR FE RS'CON II'ENSAI iQN INSURANCE AITIDAVt1' 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 12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
I. Building $
Building Permit Fee=Total Construction Cos[x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
d. Mechanical (FIVAC) $ Note: Minimum fee=$ (contact municipality)
\/
5. iVlechanical Other t
v�y S Enclose check able to &b C.�
6. Total Cost S Co (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 accurate to the best of my knowledge and understanding.
- -011 N PANTA OM 9 _ l- 2 f Ul%y
Pie: ' pr' t and n - Title Telephone No. Date
S •et Address City/Town State Zip
yo7 t� F —1 9L 1t
Municipal Inspector to fill out this section upon application approval: /Nn.� ocl M
Name Date
QTY OF SALEM, MASSAaRNETTS
BUILDING DEPARTMENT
120 WASHINGTONSTREET,311DFLOOR
TEL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THomAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING WNMSSIONER
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, 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 deposit facility as defined by MGL c 111, 5 150A.
The debris will be transported by:
L-5h
(name of hauler)
The debris will be disposed of in:
P7-tflQ,op�/ =c,-\
q (name
of facility)
(address of facility)
ignature of applicant
ate
Q-1-Y OF Szuzm, NWSACHl;SETI'S
Bl.•1LDING DEPARTMENT
120 WASHIINGTON STREET, 3so FLOOR
TEL (978) 745-9595
R x(978) 740-9846
KI\IBERt FY DR1SCOLL
`:vf1YOR THOMASST.PIE W
DIRECTOR OF PUBLIC PROPERTY/BUILDIN'G CO\NISSIONER
Workers' Compensation Insurance AMdavit: Builders/Contractors/Ele(:tricians/Piurnbers
Applicant Information Please Print Legibly
Na inc iBusinexs,Organ irahom'Individual)SZTO
Address: p-G . Rol- LiCXo
Cily/State/Zip: rV-,1 A Phone H:_ 9��— lol- 7'�2arr—
Are you sin employer'?Cheek the appropriate box: Lr-
-Any project(required):
L❑ I am a era to cr with 4• ❑ 1 am a general contractor and 1
P Y - ew construction
employees(full and/or pan-rime).• have hired the sub-contractors
2.0 lam a sole proprietor or partner. listed on the attached sheet. temodeling
,hip and have no employees These sub-contractors have emolition
working far me in any capacity. workers'comp. insurance. ilding addition
(No workers'comp. insurance 5. We are a corporation and its
required.] officers have exercised their ectrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL umbing repairs or additions
myself. (No workers'sump. c. 152, y I(4),and we have no of repairs
insurance required.) t employees. [No workers'
comp. insurance required.) er
•Any applic:on dour checks but II mart also fit,out the section blow showing their wotkm'mmpenaatiun policy infimnallon.
'I rnmeowtwTt oho submit this atnrkavit indicating they are doing all work and then like outside contnclan mint submit anew amdavil indicating such.
k%mimcturs that chalk Ibis box maul anachad an additiurul,howl showing the name of the subwvaincton and their workers'comp.policy information.
l inn an euployer that is pruvidlnx Ivorkers'contpwuadon Insurancefor my employees Below is the polley and jab rile
inforotatian.
Insurance Company Maine:
Policy it or Sclf-itu. Lie. it: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the worlters'compensation pulley declaration page(showing the policy number and expiration dato).
Failure to secure coverage as required under Section 25A of JIGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 und/ur one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S25O.00 a day against rho violator. De advixed that a copy of this statement may be furwarded to the 011ice of
Invesligatitum ul'ihc DIA for insurance coverage verification.
/du herrby ter •y u der flit pui'inuarl peon firs of perjury r/tar rbe irrfunnullaa provide]above is true surd c orrea•L
Si•en unrc' p 666�
Ph(Inc"I O — O
O%/iriul use only. Do not i✓rife in this area, to be coorpleted by city of lown o/Jleial
City or Tuiva: _ -- __ Pcrmitll.iceese 11__.
Issuing Aut hurily(circle one):
I. Board of Ilealih Z. Building Department .3.C'ity/Tuwn Clerk J. F.leetriul Inspector S. Pbintbing Inspector I
6. Other
Cunlacl Perin,): Phone a:
DATE(MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 11/18/2014
THICERTIFICATE 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 INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT.If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed.It SUBROGATION IS WAIVED,subject to the
terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsements .
CONTACT Brenda Cozzolino
PRODUCER
EAKelley Arc No. (401)709-8338 F z , 1800)37P2924
450 Veterans Memorial Parkway ADDRESS brendac eakelley.com
Building 5 PRODUCER 216303
East Providence RI 02914 42846
INSURED INSURER A. Alta❑$IC Casualty IDS CO
Jahn Pantapas INSURER B:
407 Lowell Street INSURERC:
INSURER D:
Peabody MA 01960 INSURERE:
NSU0.ER f:
COVERAGES
CERTIFICATE NUMBER: NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PERIOD
POLICY
INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED`ED BY PAID PCLAIMS LIMBS
INSR TYPE OF INSURANCE ADOL SUER POLICY NUMBER yyy 1000,000
EACH OCCURRENCE $
GENERAL LIABILITY R tt � a oxcnence) g 50.000
X CCMMERCI GENERAL LRBTDY 5J ODD
CLAW MADE OCCUR MER EONAL&ADV person) b
L118001204 031262014 03262015 PEPsoNAL aADv IN,uaY $ 1000 000
p 2000.000
GENERAL AGGREGATE $
PRODUCTS-COMPDP.4GG $ 1000,000
GENLAGGREGATE LIMT APPLIES PER
X POLICY } LOC COMBW E95MI6LE LIMIT
AUTOMOBILE LIABILITY LE.
omitlanq $
ANYAUTO BODILY IN..URY IPBrpeSwl) $
A 1-0N EDAUTOS BODILY W,URY IF,acadentl $
SCHEDULEDAUTOS PROPERTY DAMAGE
(PB'acCldenlj $
HIREDAUTCS
$
NON-ONNED NJTOS
$
E4CH OCCURRENCE $.
UMBRELLA LIAB UCC'JR
AGGREGATE It
EXCESS LAB CL^.IM_- WADE
DEDUCTIBLE
RETENTION $ S1:4T - 0 H-
VJDRKE COMPENSATION AND
EMPLOYERRSS'LI.BILITY YIN EL EACH ACCIDENT $
AN'IPROPRIETORIPARTNER,ERECUTIYE N NIA ELDI?EASE-EAELNLOYEE $
ppppFICFR/nME^BFN EXCLUDED^-
(man a NH1 E L DISEASE-PO-ICY LIMIT $
n e uncer
C Rip IPTI J o RATIM £ al M
DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLES(Attach ACORD 101,Ad Otional Remarks Schedule.Ir more space is requlm E)
Carpentry Contractor
7F--
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICEWILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE MA 01970 Katherine M. Kelley, ALAI, CIC
(D1988-2009 ACORD CORPORATION.All rights reserved.
ACORD 2512009109) The ACORD Panne and logo are registered marks of ACORD