16 1-2 HOLLY ST - BUILDING INSPECTION $Zzo C-r z4ys
lTS RECEIVED
CTIONAL SERVICES
The Commonwealth of Massachusetts
"OE j, Department of Public SafeV14 OCT 21 P h 01
IS� Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Onl )
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate.Block#and Lot#for locations for which a street address is not available)
try i t (01 -;,i e Jci
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK
Edition of NIA State Cade used_ 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 ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering Peer Review require? Yes. O ..No ❑
Brief Description of Proposed Work: G lv ,� ��
`�ArkLi e—reu r'-•t 6?7i--J�� -T �, - t i/ n.,\
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if nn Existing Bufldfng Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4t.BUILDING HEIGHT AND AREA
ExistAH
posed
of 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 a licable)A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1 O A-5❑ B: Business tional. ❑R Facto F-I❑ F2❑ H: Hi h Huard H-1❑ H-2❑ H- H-5❑L• Institutional I-1❑ 1-2❑ 1-3❑ 14❑ NE Mercantile❑ R; Residential R-1R4❑S: Storage S-1❑ S-2 0 U; Utility❑ Special Use❑and pl -
Special Use:
SECTION 6;CONSTRUCTION TYPE(Check as a licable)
G1 ❑ IB ❑, ILA ❑ IIB ❑ ILIA ❑ IIIB ❑ 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❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: -i C Z
permit is enclosed❑ i ,_,a N
Railroad right-of--way; Hazards to Air Navigation: �.Ln tli,ForiC lunwision Itevirr l�rvevx:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code Usc Gmup(s): 'Pype of Construction: Occupant Load p. Flnor:
Does the building contain an Sprinkler System?: __ Special Stipulations:
t to fs� 1 116 %
�1
SECTION 9: PROPERTY OWNER AUTFIORIZATION
Name and Address of Property Owner
F2,P3,Ng-DC� Lam'- Z\g 1A`1rn-,pW6 ,-4 MA - KA,
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
4A� -7&3f /o 79/ - 3ff �-3z7 SwFte1,5C14 UA)
Title Telephone No.(business) Telephone No. (cell) - e-mail address
If applicable, the property owner hereby authorizes
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.R.of enclosed space and/or not under Construction Control then check here O and skip Section 10,1
10.1 Registered Professional Responsible for Construction Control
C( R14 'I�o��10( �4-63 . I`9 D✓v Cca r4
�9 Cr �R 26 3a 0
Name(Regnstmnt) Telephone No e-ifiailaddress Re Listration Number
kl+C-1��r 0\4-('5 r4u30l
Street Address . City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name /
— �s3-V 0<1135
Name of Person Responsible for Construction License No. and Type if Applicable
ZN J!�, 00n,n�e�, 5)1. 0AA4LLeo �- NN. O\gc4cs
r
Street Address City/Town Sate Zip
-,
EteL 439 l00 ) 7 632-7 :51JFv<( sz�& ye-/rZa�L), ACT
Telephone No. business Telephone No. cell L mail address
SECTION 11:1yOItFNh9'COtnIPFNSA l'I(?N INSUIt:\`CF::vFtb;lVTl' M.C.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.CONSTRUCFION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) $
1. Oullding S Building Permit Fee=Total Construction Cost x—(insert here
2. Electrical S QO appropriate municipal factor)_$
3. Plumbing S DOO
4. Mechanical (HVAC) $ 0y Note:Minimum fee=$ (contact municipality)
5. Mechanical Other S 6O Enclose check payable to
6.Total Cost $ e) SO (contact municipality)and write check number here
SECTION I AIGNATI IRE 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 tme:md accurate to the best of my knowledge and understanding.
Please print and sign na _ Title Tel Nu. Date,,/
Z1li �d.I !S
Street Addr• u ^--- City/Torn State Zip
Municipal Inspector to fill out this section upon application approval:
l IS
Name Date
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the 81h edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: First Floor Tenant Renovation Date: October 2, 2014
Property Address: 16 Holly Street, Salem MA
Project: Check(x)one or both as applicable: New construction X Existing Construction
Project description: See attached Description of the Scope of Work
I Craig R. Bosworth MA Registration Number: 20300 Expiration date: August 30, 2015 am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans, computations and
specifications concerning[:
X Architectural Structural Mechanical
X Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, information,and belief such plans, computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted
engineering practices for the proposed project. I understand and agree that I(or my designee) shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents. Such review shall not diminish or
relieve the Contractor of its submittal and other responsibilities.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code. The Contractor shall be responsible for performing the work in accordance
with the contract documents and shall be exclusively responsible for its construction means, methods, sequences
and procedures, and for the constructions safety. f
4. The performance of the services shall not require any special testing or inspections unless specifically stated in the «.
Code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official
RED ARC
Upon completion of the work, I shall submit to the building official a `Final Construction g yt4�C
r
Enter in the space to the right a"wet"or 1n30 =
electronic signature and seal: DT
Phone number: 781-631-4949 Email: craig@grazadovelleco.com
rH OF 'N S
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1. Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other' is chosen,
provide a description.
GRAZADO VELLECO ARCHITECTS LITTLE HARBOR MARBLEHEAD MA 01945 781-631-4949 FAX 781-631-8702
October 2, 2014
Sheldon Frisch Development Inc.
218 Humphrey Street
Marblehead, MA. 01945
Re: 16 Holly Street, Salem Ma.
Description of Scope of work to accompany Construction Control Affidavit
Brief description of existing building:
Existing Apartment Building with 4 dwelling units. Two units on the first floor. Two units on the second floor,
each second floor unit with access to the attic directly above each unit. The layout is such that it's a mirror image
with units on the left and right with an existing party wall down the middle of the building. This party wall
consists of one wythe of brick& mortar with lath and plaster finished on either side of the party wall as the unit
finished material.
Use Group: R2
Construction Type: Type VA— 1 hr. fire separation requirements between tenant spaces.
Sprinklers: Are not installed in existing building.
Description of Scope of Work: Existing gut of first floor tenant unit. Reconfiguration of this unit, including new
kitchen, bathroom,windows,patio door,and interior walls. New rated assemblies required on fire separation
walls and ceilings disturbed with new construction.
International Existing Building Code Report
The existing modifications classify as Alterations—Level 2 for the permitted scope of work.
The work area is less than 50%of the floor area.
Section 701—General
Replacement and re-configuration of Tenant space will require the change of windows and patio door locations.
MEMBERS OF THE BOSTON SOCIETY OF ARCHITECTS AND THE AMERICAN INSTITUE OF ARCHITECTS
701.3 Compliance: All new construction elements, components, systems, and spaces shall comply with the
requirements of the International Building Code.
Exception:
1. Windows maybe added without requiring compliance with the light and ventilation requirements of the
International Building Code.
Section 702—Special Use and Occupancy
N/A
Section 703—Building Elements and Materials
703.2.1. Existing Vertical Openings. All existing interior vertical openings connecting two or more floors shall
be enclosed with approved assemblies having a fire-resistance rating of not less than 1 hour with approved
opening protective.
Exception: 2. Interior vertical openings other than stairways may be blocked at the floor and ceiling of
the work area by installation of not less than 2 inches of solid wood or equivalent construction.
Section 704 Fire Protection
Sprinkler system is not required per 704.2 Automatic Sprinkler Systems. Triggers apply when work area exceeds
50% of the floor area, or building has occupancy of greater than 30. Our scope of work is less than these two
thresholds per Section 704.
Section 705 Means of Egress
Egress Requirement. The work performed to the dwelling unit will not touch or affect in any way the egress paths
that are currently in place. All units have two means of egress to a safe exit area and will not be adjusted.
705.4 Egress doorways. Triggers for Egress door requirements are subject to spaces having an occupancy load
greater than 50, or work being done that is greater than 50% of the floor area. New door to front exit lobby will
have a fire-protection rating as a new door in a new fire rated corridor wall assembly.
Section 706 Accessibility
Scope of work does not trigger Accessibility requirements per 521 CMR.
Section 707 Structural
New framing beam to be sized and provided for by Licensed Structural Engineer. New beam shall be protected
by 1 hr. fire rated assembly.
Section 709 Mechanical
709.2 Altered existing systems. In mechanically ventilated spaces, existing mechanical ventilation systems that
are altered, reconfigured, or extended shall provide not less than 5 cubic feet per minute (0.0024 in 3/s)per person
of outdoor air and not less than 15 cfm(0.0071 m 3/s)of ventilation air per person; or not less than the amount of
ventilation air determined by the Indoor Air Quality Procedure of ASHRAE 62.
MEMBERS OF THE BOSTON SOCIETY OF ARCHITECTS AND THE AMERICAN INSTITUE OF ARCHITECTS
Section 711 Energy Conservation
711.1 Minimum Requirements. Level 2 alterations to existing buildings or structures are permitted without
requiring the entire building or structure to comply with the energy requirements of the International Energy
Conservation Code of International Residential Code. The alterations shall conform to the energy requirements of
the International Energy Conservation Code or International Residential Code as they relate to new construction
only.
IECC —International Energy Conservation Code
C101.4.3 Additions,alterations, renovations or repairs. Additions, alternations, renovations or repairs to an
existing building, building system or portion thereof shall conform to the provisions of this code as they relate to
new construction without requiring the unaltered portion(s)of the existing building or building system to comply
with this code. Additions, alternations,renovations or repairs shall not create an unsafe or hazardous condition or
overload existing building systems. An addition shall be deemed to comply with this code if the addition alone
complies or if the existing building and addition comply with this code as a single building.
Exception 3. Existing ceiling, wall or floor cavities exposed during construction provided that these cavities are
filled with insulation.
Commentary explanation: Exception 3 is important for a couple of the limitations that it contains. First of all,the
provision only applies when the ceiling, wall or floor cavity is"exposed during construction." Therefore, if the
cavity is not opened up,then there is no requirement to do anything. If the cavity is exposed,the requirement will
only be to "fill' it with insulation. Therefore, the level of insulation is not required to comply with the building
thermal envelope requirements,but is instead only required to be"filled"with any type of insulation and not to
any specific R-value.
In conclusion;when exterior walls are opened up if there is existing insulation within these wall cavities, no new
insulation is required. If when the exterior walls are opened up there is no insulation in these cavities, new
insulation will be required to fill the existing cavities to the best depth available with Batt Insulation.
Very Truly Yours,
Archit96
Craig R. Bosworth,A.I.A.
GRAZADO VELLECO ARCHITECTS
MEMBERS OF THE BOSTON SOCIETY OF ARCHITECTS AND THE AMERICAN INSTITUE OF ARCHITECTS
CALCS FOR SHELDON FRISCH C B DERR
16 HOLLY ST. 30/7/2014
SALEM,MA.
1.BEAM NO. 1-SIZE BEAM FOR 12 FOOT SPAN CARRYING 8.5 FEET TRIB.OF SECOND FLOOR
FLOOR DESIGN LIVE LOAD=40 PSF
FLOOR DESIGN DEAD LOAD=10 PSF
w L M MAX SHEAR
(LB/FT) (FT) (FT-LBS) (LBS)
425 12 7650 2550
reAL
TRY DOUBLE 117/8" LVL GOOD FOR 21275 FT-LBS AND 7897 LBS SHEAR
CHECK DEFLECTION;
w L E I DEFL L/360
(LB/IN) (IN) (PSI) (INA4) (IN) (IN)
35.42 144 2000000 488.4 0.20 0.40 OK
1A. CHECK SAME CONDITION EXCEPT 22.5 FOOT SPAN
FLOOR DESIGN LIVE LOAD=40 PSF
FLOOR DESIGN DEAD LOAD=30 PSF
w L M MAX SHEAR
(LB/FT) (FT) (FT-LBS) (LBS)
425 12.5 8301 2656
TRY DOUBLE 117/8" LVL GOOD FOR 21275 FT-LBS AND 7897 LBS SHEAR
CHECK DEFLECTION;
w L E I DEFL L/360
(LB/IN) (IN) (PSI) (INA4) (IN) (IN)
35.42 150 2000000 488.4 0.24 0.42 OK
2. BEAM NO.2-SIZE BEAM FOR 12 FOOT SPAN CARRYING 8.5 FEET TRIB.OF ATTIC FLOOR
FLOOR DESIGN LIVE LOAD=30 PSF
FLOOR DESIGN DEAD LOAD=30 PSF
w L M MAX SHEAR
(LB/FT) (FT) (FT-LBS) (LBS)
340 12 6120 2040
TRY DOUBLE 117/8" LVL GOOD FOR 21275 FT-LBS AND 7897 LBS SHEAR
CHECK DEFLECTION;
w L E I DEFL L/360
(LB/IN) (IN) (PSI) (INA4) (IN) (IN)
28.33 144 2000000 488.4 0.16 0.40 OK
2A. CHECK SAME CONDITION EXCEPT 12.5 FOOT SPAN
FLOOR DESIGN LIVE LOAD=30 PSF
FLOOR DESIGN DEAD LOAD=10 PSF
w L M MAX SHEAR
(LB/FT) (FT) (FT-LBS) (LBS)
340 12.5 6641 2125
TRY DOUBLE 117/8" LVL GOOD FOR 21275 FT-LBS AND 7897 LBS SHEAR
CHECK DEFLECTION;
w L E I DEFL L/360
(LB/IN) (IN) (PSI) (INA4) (IN) (IN)
28.33 150 2000000 488.4 0.19 0.42 OK
28.CHECK 6 FOOT CANTILEVER ON BEAM 2
FLOOR DESIGN LIVE LOAD=30 PSF
FLOOR DESIGN DEAD LOAD=10 PSF
w L M MAX SHEAR
(LB/FT) (FT) (FT-LBS) (LBS)
340 6 6120 2040
TRY DOUBLE 117/8" LVL GOOD FOR 21275 FT-LBS AND 7897 LBS SHEAR
CHECK DEFLECTION;
w L E I DEFL L/360
(LB/IN) (IN) (PSI) (INA4) (IN) (IN)
28.33 72 2000000 488.4 0.10 0.20 OK
" 3. BEAM NO.3-SIZE HEADER FOR 6 FOOT WIDE SLIDING GLASS DOOR CARRYING 11 FEET TRIB
OF SECOND FLOOR
FLOOR DESIGN LIVE LOAD=40 PSF
FLOOR DESIGN DEAD LOAD=20 PSF
w L M MAX SHEAR
(LB/FT) (FT) (FT-LBS) (LBS)
550 6 2475 1650
TRY DOUBLE 5.5" LVL GOOD FOR 4971 FT-LB5 AND 3658 LBS SHEAR
CHECK DEFLECTION;
w L E I DEFL L/360
(LB/IN) (IN) (PSI) (INA4) (IN) (IN)
45.83 72 2000000 48.5 0.17 0.20 OK
4.SIZE FOOTING FOR COLUMN SUPPORTING BEAM 1 AND 2
TRY 24"x 24"X 12" DEEP FOOTING;
FOOTING
REACTION AREA SBP
(LBS) (SF) (LBS/SF)
BEAM 1 2656
BEAM 2 4165
TOTAL 6821 4 1705 OK
: ` t
ACORD. CERTIFICATE OF LIABILITY INSURANCE 04/02/2014
04 02/2014
PRODUCER (978) 922-0086 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Carmen-Kimball Insurance Agency, Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
48 Beck£ord Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 73
Beverly MA 01915- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A Technology Insurance CO
Sheldon Frisch Development Inc. INSURERB:ESS&Z Insurance Co
PO Box 811 INSURER C:
218 Rumprhey Street [INSURERD
Marblehead MA 01945- LINSURERS
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 BEEN REDUCED BY PAID CLAIMS.
PoLICY EFFECTIVE PoLICY FXPPATION
L INSURANCE
D TYPE OF POLICY NUMBER DALE DATE fAUDp/YY) LIMITS
B K GENERA.LIABILITY 3DK8834 04/15/2013 04/15/2014 EACH OCCURRENCE $ 1,000,000
K COMMERCIALGENERALLIABILT' OAMAGETORENIEO
cuIMSMADE 1 OCCUR 3DR8834 09/15/2014 04/OS/2015 PREML s Eaocartswe $ 50,000
MED EXP one $ 5,000
PERSONAL A ADV INJURY $ 1,000,000
GENERALAGGREGATE $ 2,000,000
GEMLAGGREGATEpLIIMIIT APPLIES PER: PRODUCTS-COAP/OP AGO $ 2,000,000
POLICY JECT LOC
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT
ANY AUTO (Ea actlden0 $
ALLOWNEDAVTOS / / / / BODILY INJURY
SCHEDULED AUTOS (Per Person) $
HIRED AUTOS / / / / BODILY INJURY
NON-OWNED AUTOS (Per acddent) $
PROPERTY DAMAGE
(Per amMene $
GARAGE WIBILRY
AUTO ONLY-EA ACCIDENT $
ANY AUTO / / / / OTHER THAN EA ACC S
AUTO ONLY: AGG $
ELCESSAIMBRELLA LIABILRY / / / / EACH OCCURRENCE $
OCCUR �CLAIMS MADE AGGREGATE $
DEDUCTIBLE / / / / $
RETENTION $ S
A- m oLIMPBNSAToNAND WC990001B 03/31/2014 03/31/2015 % TORJ�J"Nrs R
ANY PROPRMTOFVPARTNEIVEXECUTIVE E.L.EACH ACCIDENT $ 500,000
OFFICEWMEMBER EXCLUDED? --
XYMASScnbejamer / / E.L.DISEASE-EA EMPLOYEE$ SOD,O00
SPECIAL PROVISIONS below ELDISEASE-POLICYLIMIT $ 500,000
OTHER
DESCRIPTION OF OPFAATION$ILOCATgNSNEMCLEyp{CWSN)NS ADDED BY eIDOR$EMEMSPECULL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
-Building Inspector EXPIRATION DATE THEREOF, THE ISSUBIG INSURER WILL ENDEAVOR TO MAIL
010 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
Torn of Marblehead FAILURE TO DO50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY IOND UPON THE
188 Washington Street INSURER ITS AGENTS OR REPRESENTATIVES,
AUTHORIZED REPRESENTATIVE
Marblehead MA 01945- ,.{` j
ACORD 25(2001/08) 0 ACORD CORPORATION 1988
INS=(oloe)De Pagel of 2
1
f
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-057735
- PO BOX 811 4. -
Marblebead MA 81
- at
Expiration
07114/2016
Commissioner
l
dF/ze Uamma�uaec /z o�VKaHac�u: 4
Office of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
istretion: 164546 Type: -
V
iration: ;#44%l6.- Private Corporatioc
SHELDON FRISCH DEVELOPMENT.INC.
Sheldon Frisch
218 HUMPHREY STREET
Marblehead, MA 01945 Uodersecre
CITY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
120 WASHINGTON STREET,3AD FLOOR
TEL.(978)745-9595
KIMBERLEYDRISOOLL FAX(978)740-9846
MAYOR niOMAS STTIERRE
DIRECrOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Construction Debris Disposai 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, S 150A.
The debris will be transported by:
L-A 2,
(name of hauler)
The debris will be disposed of in:
(nam of facility)
(address of facility)
Signature of applicant
D to
• CITY OF SiU.EM, KNSSACHLSEM
BCILDLNGDEPARTNE.`T
a
120 \' ASHLNGTON STREET, 3'FLOOR
TEL. (978) 745-9595
F.LX(978) 740-98.445
Kl\IBERLF_Y DR)SCOLL
.�L'SYOR "R�tonvs Sr.Flsxxs
DIRECCOR OF PUBLIC PROPERTY/BCILDi\G COXNISSIONER
W'nrlcers' Compensation Insurance Affidavit: Builders/Cont ractors/Elect ricians%Plumbers
Attlalicant Iriftwmatinn (please Print
7-t eeibty .
Name (Huhnes.Orgmiratiantlndividual): V�C/I}Cf J�-\SC.�1 c�+f�✓ 1) -.-1"'l,f
Add,,.,,: 2\V
City/State/Zip: Phone lt: 23G(s9S2' /"d
Are you an employer!Check the appropriate- bqx: 'type of project(required):
1.El am a employer with 4.j/`'2CLam a general contractor,and 1 6:- Q New construction
employees(full and/or pan-time).4 have hired the sub-contractors
2.El lain a sole proprietor or parmer- listed on the attached shout. t 7. �Remodeling
ship and have no employees These sub-contractors have 3. Q Demolition
working for me in any capacity. workers'comp. insurance. y. El Duildittg addition
[No workers*comp. insurance 5. ❑ We are a corporation and its
- required.)
officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or udditiorts
myself.[,No workers'sump. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required. employees.employees. (No workers' [3.Q Other
comp.insurance required.)
-Any upplicvn that chucks box a 1 must also rill out the scutiun below showing their wooers'compensmiun policy intirrmatiun.
'I h+meossm"who,uhmit this atndavit indicating they ate doing all work and then hire outside contractors mil.mhmli a new aiP.davit indicating suck
$mnmt0Is Our check this box must anachut an addiliurnd short showing In:narne of the subavntraclo s and their workers'comp.policy inrotmation,
f ant un employer drat is pruvidiug workers'contpensailon Atrurmice for my employees. B-alit is the policy mid Job rite
infiarnrulinn.Insurance Company Naine: �cp,(� ` _ �yar'>•s i>;,
Policy i!or SeIC-ire, Lk.N: '`•�� C 1 1��CQ ' Expiration Date: I I It -LC,
1 1 ' c\
lob Site Address: ( � — (�/t_ R d ilS% .A • City/StateiZip: D 10A 70
Attach a copy of the workers'compensatloo policy declaration page(showing the policy number and expiration date).
h'ailure to secure coveruge as required under Section 25A of MGL c. 152 can lead to the imposition oferiminal penalties of a
tine up to S1,500.00 und/or one-year imprisonment,as well as civil penalties in the torn of a STOP WORK ORDER and a tine
of up to 5250A0 a day against the violator. Ile advisedthat a copy of this statement may be forwarded to the 011ice of
Invc�tigotiuns nl'thc MA for insuranc•covcr vcrilicatiun.
/do hereby certify rider th n red altar of per%ury that the lttfunnudmr provided above is true attar correct
Si •n t uc �J p �t g Uate: _� � ��
Phone t
Of/iciul use only. nano)tvrite ire this area,to be conspleted by city ut town afJfclaL
City nr'I'ucvn:
Issuing Authority (circle one):
L.11oard ul Ileahh 2. Ouihlimg Dcpartutrut 3.Citylfuwu Clerk I. Electrical lnspectur i. Plnmbiog Inspector
6. Other
' I
Contact I'urana: _ ..
Phone
T�I - tI
IcoGS
Michael Lutrzykowski
From: Paul Gallant
Sent: Thursday, January 15, 2015 2:26 PM
To: Thomas St. Pierre; Michael Lutrzykowski
Cc: Peter Schaeublin; David Cody
Subject: 16 Holly St
Gentlemen,
I am in receipt of and have completed and approved a plan review for the sprinkler system at 16 Holly St. Mammoth Fire
Protection will, I assume, pull a permit through your office for the installation of this system per your code. We have no
further issues at this time that would hold up the issuance of a building permit at this address.
Thank you,
Paul Gallant
Fire Inspector
29 Fort Ave
Salem, Ma 01970
Tel: (978) 745-7777
Fax: (978) 745-9402
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