64 HIGHLAND AVENUE - BUILDING INSPECTION � 5 Commonwealth of Massachusetts
Sheet Metal Permit ,
Date : \n -S— h Permit#
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Estimated Job Cost: A� JUG Permit Fee: $�—
Plans Submitted: YES NO_ Plans Reviewed: YES_ NO x
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Business License# Applicant License
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Property Owner/Job Location Information:
Business Information:
Name: Q:.Lkns A �esAr Name:
\ �i Street:
Street:��t� - A _ —
City/Town: !Z'ex\:rC+.A M City/Town: NN A
Telephone: SOJ� !polo Telephone:
111 Photo 1:D required/Copy of Photo I D attached:- YES_Z�NO�
4 1
Building
Residential: 1-2 family_ Multi-family_ Condo/Townhouses_
Commercial: Office_jZ Retail_ Industrial_ Educational— Institutional_
Building Cubic Footage: under 35,000 cu. ft._ over 35,000 cu.ft.
Sheet metal work to be completed: New Work:— Renovation:
HVAC Metal Roofing_ Kitchen-Exhaust System_ Chimney/Vents
Provide brief description of work to be done:
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`jo�c-Nees
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INSURANCE COVERAGE:
I have a current fiability insurance policy or Its equivalent which meets the requirements of M.G.L.Ch.112 Yes LR!ao❑
If you have checked Yes,indicate the type of coverage by checking the appropriate box below:
A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this boxO,I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and
accurate to the beat of my knowledge and that all sheet metal work and Installations performed under the permit Issued for this applkedon will be
In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General laws.
Duct inspection required prior to Insulation installation:YES_NO_
Progress Inspections
Date Comments
Finallnsoection
Date Comments
Type of License:
By L9 Master
Title
❑Master-Restricted
Cltylrown
❑Joumeyperson - 04SIg'3rutre of Licensee
Permit# 2r�❑Joumeyperson-Restricted 12, t
License Number:
Fee$
Check at www.mass.novIdol
Inspector Signature of Permit Approval
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CONTROL # 5 7161. 6 9,9
IMPORTANT
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it license is lost, damaged or destroyed; is inaccurate; or
3 to be corrected, visit our web site at mass.gov/dpl for
ctions to ensure the proper mailing of your Renewal
ration and any other correspondence.
..........Y .. ........
. ......... ...............
cense is subject to Massachusetts General Laws and
lions. Your license is a privilege, and cannot be lent or
ied to any person or entity under penalty of law. Keep this
on your person or posted as required by law and/or
tions.
• 1
'\ The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
�M1'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print LeEiblv
Name (Business/Organization/Individual): ,;/ ;
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Address:
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City/State/Zip: t 601%one#, noZ J6 IQ
Are you an employer?Check the app to box: Type of project(required):
l.Mam a employer with _employees(full and/or part-time).* 7. []New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in S. ❑Remodeling
any capacity.[No workers'comp.insurance required]
'. 3.❑I ann.homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or am sole I I.❑Electrical repairs or additions
proprietors with no employers. 12.[]Plumbing repairs or additions
5.❑I am a general contractor and I have hued the sub-contractors listed on the attached sheet. ]3. ROOF repairs
These sub-contmetors have employees and have workers'comp.insurancel ❑ p
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box q1 most 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.
iContractos that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those=rifles 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 job site
information. -
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
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Job Site Address: � City/State/Zip: pq 7D '
Attach a copy of the workers'coloftemiNtion policy declaration page(showing the policy num er and expiAiltion date).
Failure to secure coverage as required trader MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby r r'ft,6 u er the`pa r( nd penalti of perjury that the information provided above is true and correct.
Si nature.L ' �^ Date:
Phone#:
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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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 house 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 on 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."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter 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 subcontractor(s)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 an 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 Officials
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 fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemtittlicense 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.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Commgnweplt)t of Massachusetts =�
6 �
City of Salem
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Inspectional Services 1
RECEIPT 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641
Application For Building Permit (For Buildings other than a One- or Two-Family Dwelling)
(This Section for Official Use Only)
PIN: TB-16-1250 Date Applied: 10/27/2016
I
.Building Official(Print name):
SECTION 1: SITE LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
84 HIGHLAND AVENUE , Salem, MA
SECTION 2: PROPOSED WORK
Are Building plans and/or construction documents being supplied as part of this permit application?: No
Is an Independent Structural Engineering Peer Review Required? Yes[-] No❑
Brief Description of Proposed work: SALEM PEDIATRICS:
RETROFITTING THREE (3) GAS UNITS TO EXISTING OFFICES (REPLACEMENTS) & MODIFY &ADD TO
EXISTING DUCT WORK
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 34))
Existing Use Group: Proposed Use Group:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floors/Stories(Include basement levels)&Area Per Floor(sq.ft.) 0 1 0.00 0 1 0.00
Total Area (sq. ft.) and Total Height(ft.) 0.00 1 0.001 0.001 0.00
SECTION 5: USE GROUP
SECTION 6: CONSTRUCTION TYPE
Resid/Commercial
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 inside Flood Zone ❑ Municipal will not required ❑ Licensed Disposal Site
or or
Identify Zone: Is enclosed ❑ or specify:
Railroad right-of-way: Hazards to Air Navigation: MA Historic commission Report Process:
Not applicable ❑ Is Structure within airport approach area? Is their review completed?
or Constent to Build Enclosed ❑ Yes ❑ No ❑ Yes ❑ No ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:
Occupant Load per Floor Does the building contain a sprinkler system?:#Error
Special Stipulations:
THIS IS NOT A PERMIT
Commonwealth of Massachusetts
/
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a m City of Salem
9 Inspectional Services
RECEIPT 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641
SECTION 9: PROPERTY OWNER AUTHORIZATION
SALEM HIGHLAND REALTY TRUST BENDETSON 63 ATLANTIC AVE BOSTON MA 02110
RICHARD BENDETSON A TRS
If applicable,the property owner hereby authorizes
MICHAEL R DUBEAU 115 Mendon Street BELLINGHAM MA 02019
To act on the property owner's behalf,in all matters relative to the 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 skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name Phone Email Registration Number
Address Discipline Expiration
Date
10.2 General Contractor
Victory Heating &Air Condition Co.
Company Name
3737 Sheet Metal A Master
MICHAEL R DUBEAU Unrestricted
License no. and License Type if Applicable
Name of Person Responsible for Construction
Address: 115 Mendon Street BELLINGHAM MA 02019
Phone (508) 966-9858 Email Address
SECTION 11:WORKER'S COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152§25C(6))
A W orker's 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?True
SECTION 12: CONSTRUCTION COST AND PERMIT FEE
Total Estimated Costs(Labor and Materials): $4500.00 Building Permit Fee: $55.00
Enclose check payable to the City of Salem, Ck#
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.
(508) 966-9858
Please print and sign name Title Telephone
Address: 115 Mendon Street BELLINGHAM MA 02019 Date: 10/27/2016
_ THIS IS NOT A PERMIT
SCornmonwaa)th of Massachusetts 4 4
City of Salem f '
Inspectional Services
` '° �' 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641
RECEI PT:;
z + SECTION 9:PROPERTY OWNER AUTHORIZATION ' • - p
SALEM HIGHLAND REALTY TRUST BENDETSON 63 ATLANTIC AVE BOSTON MA 02110
RICHARD BENDETSON A TRS
If applicable,the property owner hereby authorizes
MICHAEL R DUSEAU 115 Mention Street BELLINGHAM MA 02019
To act on the property owner's behalf,in all matters relative to the work authorized by this building permit application.
;.' ' SECTION 10: CONSTRUCTION CONTROL(Please fill out Appendix 2
1'. (If building is less than 35,000 cu.ft of enclosed space andfor not under Construction Control then skip section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name Phone Email Registration Number
Address Discipline Expiration
Date
10.2 General Contractor
Victory Heating &Air Condition Co.
Company Name
3737 Sheet Metal A Master
MICHAEL R DUBEAU Unrestricted
License no. and License Type if Applicable
Name of Person Responsible for Construction
Address: 115 Mendon Street BELLINGHAM MA 02019
Phone (508) 966-9858 Email Address
SECTION 1'1 WORKER'S COMPENSATION INSURANCE AFFIDAVIT(M.G.Lc.152§25C(6))
A Worker's 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?True
1
SECTION 12: CONSTRUCTION COST AND PERMIT FEE
Total Estimated Costs(Labor and Materials): $4500.00 Building Permit Fee: $55.00
Enclose check payable to the City of Salem, Ck#
`'SECTION 13 :SIGNATURE OF BUILDING PERMIT APPUCANT '
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.
(508) 966-9858
Please print and sign name Title Telephone
Address: 115 Mendon Street BELLINGHAM MA 02019 Date: 10/27/2016
THIS IS NOT A PERMIT
Nco>'mq� Commonwealth of Massachusetts
f
6
3 q R City of Salem
Inspectional Services
RECEIPT 120 Washington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641
Municipal inspector to fill out this section upon application approval: 10/27/2616
Name Date
( _ THIS IS NOT A PERMIT