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267 HIGHLAND AVE - BUILDING INSPECTION The Commonwealth of Massachusetts Department of Public Safety .\Iassichusetts Stale Building;Cade 17W C%IR)Seventh Editum City of Salem Building Permit Application for any Building or 2-Fa other than a I- wellin 1 This Section For official Use Onlv) Budding Permit Number: Date Applied: I Budding Inspector. SECTION 1: LOCATION(Please indicate Block 0 and Lot 0 for locations for which a street ad Tess is not available) 2G -7 6 0 if�44 0197Z2 T No_and Street Cih- /Town Zip Code Name of Building bl'applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other X Specify: 4�/ia7 f' w 91, - Are building plans and/or construction documents being supplied as part of this permit application? Yes ,Pf No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No19 Brief Description of Proposed Work: ® •1 ! eey- / O>7 x SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDMON,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ Existing Use Group(s): '!- Proposed Use Group(s): 1' 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.) ofa A/.4 Total Area(sq.'ft.)and Total Height(ft.) /V d SECTION 5:USE GROUP(Check as applicable) A. Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional f-1 ❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ JRR-4❑ S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe Special Use: o/+r L SECTION 6:•CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ Ito ❑ IIIA ❑ IIfB ❑ IV ❑ VA ❑SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)Water Su 1 Flood Zone information: Sewage Disposal: Trench Permik Doval:PP Y= A trench will nut be Licenss.il Site❑Indicatemuniopalo requireddor trenchI'nvate O or uuirntik Zone: or on,ne system ❑ permit is UncIord ❑Railroad right-of-way: Hazards to Air Navigation: \):\ Ih,e,rn c-..onm-a.,nn•..��:I,IstrnicturUo ohm airport approaih area' 1,their rear%,o1C„n,rnt to Build rock i,cd ❑ lc,❑ ur\% 1e.•,❑ \ i SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY Ind iunn d Code -..__L:,e tin ni pi,c r%pvoi l.instruction: Occupant 1„od pur fluor U, -,the boildtog contain/a�nSprinkler>%a(cm�': �la•oal>upulation, r d l . OLN MF- ( of SECTION 9: PROPERTY OWNER AUTHORIZATION Name�.—`i�.\ddr� n+perte Owner Name(Print) No—Intystreet City/Town Gip Pruprr 2%ne Contact lntormalion: Q�'�.ii3� G z Zysr nzen Title UU Telephone No.(business) Telephone No. (cell) a-mad address If applicable,the properly owner hereby authorizes Name Street Address Cih•/Town State Zip nr act on the fro+vrty owner's behalf, in all matters rulatiye tat nvurk authorized by this buildin termit a tliattion. SECTION 10:CONSTRUCTION CONTROL!Please fill out Appendix 2) (If building is less than 3i,LW cu.tt.of endured s face and/or not un der Construction ConlNl then check here aand ski 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 0"-(d f Co piny Nam": e: "A6w P;� 790(Qg Na�+e a Perwm R .-pnnsible for Construction License No. and Type if Ap Iicable (,(rr .l (ii 'n l �31D '1 Street Address City/Town 6a—0/7- 22e71 �RdN d lIa/ (? fate(, (Zi'MpI- Telr hone 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 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=5 1. Building S Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=S 3. Plumbing $ 4.Mechanical (HVAC) S Note:Minimum fee=S (contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6.Total Cost S Z,S'O D (contact munici alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I herebv attest under the pans and penalties of perjury that all of the information contained in this application e,true and accurat o thee best of know v ge and understanding- Pleas pant and agn n.rme title Telephone\o Date 1.3 arvf��e Sa o /J l str'eet .lddress C rtc;Town St e zip / ]tuni6pal Inspector to fill out this section upon application approval: f� • \amr I We i CITY OF S U.&N , N'-WSACHUSETTS BUILDING DFBART%C&NT • 120 WASHINGTON STREET,3'a FLOOR of TEL (978)745-9S9S FAX(978)740-9946 KIN RI -Y DRISCOLL PHOMAS ST.PIFSRE �1YOR DIRECTOR OF PUBLIC PROPERTY/BUILDING COJLmISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(BusinestiOrganization/individual): G C CUY,,kSdrU-CJ,0V-) Address:_13 Rudrer/hn t a4e"" City/State/zip: Q 1N, 03 G 1 Rhone lt: 663 -817, trre yypIs an employer?Check the appropriate box: Type of project(required)- I.LI 1 am a employer with �l— 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition [No workers comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑Other. Ae .S0 ,5 comp.insurance required.] Any applicant that chocks box 91 most also fill out the section below showing their worked'compensation policy infumtation. t I loneowreta who submit this affidavit indicating thcy arc doing all work and then hire outside rnmmactorm most submit a new affidavit indicating such = lommrcots that check this box must anached an additional shins showing the name of the aub<ornractors and their worked'comp,policy inlmituo en. I am an employer that Is providing workers'compensation insurancefor my employees. Below Is the pocky and job the injornra�ion Insurance Company Name: e.SS Ely� Policy#or Self-ins.Lic.#:. CC S(} LAN L I�G g®9 q 1yd Expiration Date.-) /Q ` Job Site Address: City/State/Zip: 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 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$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 urr r the s nahles of perjary that the information provided above is true and correct Sienature: { Dare, ��U� /� Phone#: (00 3— 9� Ofciat use only. Donor write in this area,to be completed by city or town offaciaL City or Town: PermittLicense# Issuing Authority(circle one): 1. Board of lle-alrh 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: ACORD CERTIFICATE OF LIABILITY INSURANCE DATE 27/2 0 PRODUCER (603)S85-3411 FAX (603)585-3413 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Frank Massin Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 32 NH Rte 119 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 430 Fitzwil l iam, NH 03447 INSURERS AFFORDING COVERAGE NAIC# INSURED GCO CONSTRUCTION GORDON OLIN DBA INSURER& Peerless Insurance 24199 13 BUTTERNUT LANE INSURERB: RINDGE, NH 03461 INSURERC: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 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 PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH —POLICIES-AGGREGATE LIMITS SHOWN MAY-HAVE BEENREDUCED-BX.PAID CLAIMS..—_--._... INSR D' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE IMMIDWYY1 DAM jMMQD1YYI GENERAL LIABILITY CCP8095541 11/25/2009 11/25/2010 EACH OCCURRENCE $ 1,000 00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ S0,000 CLAIMS MADE a OCCUR MED EXP(Any ate parser) E S QQ A PERSONAL S ADV INJURY $ 1.000.000 GENERAL AGGREGATE $ 2,000,Q GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2, 000 OO X POLICY JECTPRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMB ANY AUTO (Ea accident) E - ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per Person) $ HIREDAUTOS BODILY II^URV NON-OWNED AUTOS E aL PROPERTYDAMAGE E (Per amdwU GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA $ P AUTO ONLY: AGO $ E%CESSNMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE E E DEDUCTIBLE $ RETENTION $ $ wORxEREGGMFENsATIDTrmm----- —------WE8094140 -31f2-5/20W -X- --- EMPLOYERS'LLABIUTY - A ANY PROPMETORIPARTNERIEXECUTNE E.L.EACH ACCIDENT $ 100,00 OyFyeeFSsICERIMEMBEREXCLUDED? YES E.L.DISEASE-EAEMPLOYE $ 100,00 SPECIALL d.sPROVISIONS below - E.L.DISEASE-POLICY UNITE 5OO 00 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS rpentry Contractor H State Statutory rdon Olin is excluded from workers compensation CERTIFICATED SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Intervarsity Christian Fellowship of USA BUT FAILURE TO MAR SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 2S2 Old Ashburnham Rd OF AW IOND UPON THE INSURER,ITS MENTS OR REPYgENTATIVES. Rindge, NH 03461 ^IlfHO MITA rr4l arnnn qs nnmmm FAX: 899-SS29 ©ACORD CORPORATION 1988 � n,J 00 P6 ty"`Ps i Zoo SZ�� Lt 7 S