1 HOLYOKE SQ - BUILDING INSPECTION (2) Microsoft Word- form bbrs municipal—building_perry t"3-16 2011... http://www.salemcom/Pages/SaleniMA PublicProperties/applications...
The Commonwealth of Massachusetts
Department of Public Safety
1 q Massachusetts State Building Code(780 CMR)
"'RRR%%%ttt Building Permit Application for any Building other than a One-or Two-F it I'
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which r street ad dre i -,,able)
o .s NN Arl looms -P"
No.and Street City/Town Zip Code Name of Building(if applicable)
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
Existing Building Repair c3AI[eratior Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other O Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ,X No ❑
Is anIndependent Structrual Engineerin eer Review11r�equired? ��77 '1 / Yes ❑ No/q
Brief Des tion of Proposed 4t'ork: a�n SK�'VvCl fit. c� or 4 1L I
—F��� , � Kyrle
SECTION 3:COMPLETE THIS 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 C\dR 34) ❑
Existing Use Group(s).- 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.'O A-3 ❑ A-4❑ A-5❑ 1 & Business E: Educational ❑
F. Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-3❑
I: Institutional I-1 ❑ I-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use: -
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
La ❑ IB ❑ IIA 12 1111 IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA 13 VB 13
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
'Nater Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Zone❑ Indicate municipal 13A tren< iv not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system required or trench or specify:
permit i enclosed❑
Railroad right-of- y: Hazards to Air Navigation: MA Historic Conunissicm Review-Process:
Not Applicablen oIs Structure.within airport pproach area? Is their rev.ery co leted'
or Consent to Build sed 13Yes❑ or No Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Cade: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
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Microsoft Word-form_bbrs_municipal_building_permit 03_16_2011... http://www.salem.com/Pages/SalemMA_PublicProperdes/applications...
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
IJI,�Id(,���s ► -�a ly�� � � (om o jS�1 �
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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 owner's 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 lass than 35,000 ca ft.of enclosed space and/or not under Construction Control then check here O and sldp 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
Com by Name
,.
�4
lCS c 3 3�P
Name of Person Responsib a for Constructioh License No. and Type if Applicable
ID (( AYIG Q R5 � U���e �— &M— Cl) M o
Street Address City/Town State Zip
`--")V(-?DS --
Telephone No.(business) Tel hone No.(cell) e-mail address
SECTION 11:WORKERS'C0MPENSAT'ION 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 a lication? Yes Q No E3
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building `- �o'Z S 2 Civ'U Building Permit Fee=Total Construction Cost x—(Insert here
2.Electrical $ appropriate municipal factor)=5
3.Plumbing $
4.Mechanical (HVAC) § Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) - $ Enclose check payable to
6.Total Cost S ry✓ (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 owledge and understanding.
of my ' 6?A/ CPAV J �'%
.Please printand sion n er Title Telebo �N\o. Date
v'h l c Yr' >\1
Street Address City/Torun State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
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t Massachusetts -Department of.Public Safety.
Board of Building Regulations and Standards
Cumti-uction Supcn-icer
License CS-043536
4
DANIELE TREMBLAY„ '
2 MARGIN TERRACE
Peabody MA 01930
1)-
,tn
Expiration
Commissioner 12/02/2014
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards -
Construction Supcnisur
License: CS-MS36
DANIEL E TREMIR AY
2 MARGIN TERRACE -
Peabody MA 01990 3>
Expiration
Commissioner -12/02/2014.
Unrestricted-Buildings of any use group which.
contain less than 35,000 cubic feet(991M3)of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DPSuomsinginformationvisit: ww .Mass.Gov/DPS
Microsoft Word- form_bbrs_municipal_building_permit_03_16_2011... http://www.salerncom/Pages/SalemNLA PublicProperties/applications...
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block # and Lot#for locations for which a street address is not
available)
pp II �
No. and Street. City /Toc+m Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑
Electricitv Shut Off? Yes ❑ NTo Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No_? Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
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The Commonwealth of Massachusetts Print Form
Department oflndustrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
VV www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:Roger A.Tremblay Contractors,INc.
Address: 10 Colonial Road Suite 4.
City/State/Zip:Salem MA 01970 Phone #: (978) 745-3056
Are you an employer? Check the appropriate box: Business Type(required):
1.2 1 am a employer with 20+ employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8• E]Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.El Health Care
4.❑ We are a non-profit organization,staffed by volunteers, General Contractor
with no employees. [No workers' comp. insurance req.] 12.❑✓ Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
-*If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Hartford Insurance Company
Insurer's Address: 828 Lynnfells Parkway
City/State/Zip: Melrose MA 02176
Policy#or Self-ins.Lic. # 6S60UB-4735P982 Expiration Date: 7/1/2013
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 $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. 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, ,under
✓the pains and'Alpena/ides ofperjury that the information provided above is true and correct
Signature:
Phone#i (978) 745-3056
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. Licensing Board 5.Selectmen's Office
6. Other
Contact Person: Phone#:
www.maae.onv/dig
RightFax NI-2 7/13/2OIZ 8 :03:44 AM IJAUL 4/v0D rax Server
ISSUE DATE
t'+
I z t_t::'c I tg;�
7113/2012
_TFD;CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOESNOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED By THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONMnTE ACONTRACT BETWEEN THE ISSMC WSUR]WS).AI,7IHORIUl)
REpRES]pPrATTw'R ORPRODUCER,AND THE CERTIFICATE HOLDER
-
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must-be endorsed.If 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 endorsernent(SI.
PRODUCER CONTACT
JASTERN INS GROUP LLC NAME:
233 FAX
WPHLST CENTRAL ST tJUC71,,EQ: (AC,No),
N9J'JCK,MA 01760 E-MAIL
ADDRESS:
PRODUCER
LNSICRED
CUSTOMER K)M INSURER(S)AFFORDING COVERAGE NAIC#
ROGUR ATRUJAWAY CONTRACTORS INSIMERA ILAARTFORD UNDERWRITERS INSURANCE
INC COMPANY
10 COLONIAL RD INSURER B
SALLK MA 01970 INSURKRC
INSURER D
INSURER E
INSURKR V
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE RCSUREDWANJEDABOIIE FOR THE POLICY PERIOD ENDICATED
NOTWITHSTANDING ANY REQUIREMENT,TERM ORCONIXTIONOF ANY CON7?ACT OR OTHERDOCLIVIENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE
I.S'SLI141)()R MAY PEA 1AIN. 1111: N4LJ((AM%A11014DIA)BY I 111;.P(N.101is D1,40011:1)111,1410'413 8L11JFX7 110 AIA, 1111: MI(Mg.hXCIA-910NI AND(N)NDI PI ONS OF
SUCHPOLICIES.LINfITS SHOW-NMAYILAVE BEEN REDUCED BY PAID CLALMS.
INSR TYPE OFINSUPUNCE ADDL SURE POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR mse WV_D — a-B4,DD,,YYYY 'DD,`YYYY)
GKNIMAIAAAMIXIT PACHO�,ARWCE $
.DAMAGE ruR Nlw S
I CO1aIMC1AL GENERAL UAMLITY PREMISES(lull
0
CLAMS MADE E occm
PERS(INAL&"V. S
I LVLRY
I
GENIL AIGAI(18[E Lvwl ALIPUES PER:
I POLICY E PROJECT 0 Loc
AUTOMOBILE LIABILITY cu]Wlk`WSINME S
HODMYINJURY S
I AKYAWO
AT.T.O%WPDA[=S f82tYd1NZU)RY
IT'LIMIYUAMAGE
I RMFM AMOS
NONE NTDAI.70S
I INBRET.T.ALTAR I OMAR S
I P.XCR.%9 LTAA I OAMtNIADF
DM. r.TnITX
R mwwONs
WORKERS'COMPENSATION WC
A AND 170FLA)YRRS LIABILITY YA RxIvroky
FIN uwvs
�VJIVE UFFI�MEM� N/A 6S450UD-4735P982 07/0112 07,101113 ELFACHAC.C.MM7 $500'000
E1'I:LUDWI
E.L. LA(:H
F.J..DTSF.ASE-POLICY
I
GPFR.ITIONS W.
M.qRF.PFA.MANWRIOR"RTMICAW.Li.q.TDMMM"UCAnKOT,DRRAMr.1 C.WORRRRRMMPC.OIWAr.E
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
A';U "RIN "ghagami.
Microsoft Word- form bbrs_municipal_building_permit_03_16_2011... http://www.salemcom/Pages/SaleniNIA_PublieProperties/applications...
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where a licable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
-5 Fire Alarm(mav require repeaters)
6 HVAC
7 Electrical
8 plumbing(include local connections)
9 Gas(Natural,propane,Medical or other)
10 Surve ed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Buildin Survev/Investiation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Miff ation Documentation
20 Other(S ect�)
21 Other(Specify)
22 Other(S eci ,)
''Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
an
Street Address City/Toxon State Zip Discipline Expiration Dam
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address - Ci /Town State Zi Discipline Expiration Date
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