14 HUBON ST - BPA-11-223 2ND FL ADDITION i� The Commonwealth of Massachusetts
Department of Public Safety
�.-,..Z -fassachu>etls State Buildirg Code(780 CMR)Seventh Edition
City of Salem
/ Building Permit Application for any Building other than a I- or 2-Famil Dwellin
(This Section For Official Use Only)
Q llllll Building Permit Number: Date Applied: 2'I-/D Building Inspector:
SECTION 1: LOCATION (Please indicate Block N and Lot M for locations for which a street address is not available)
ry /-kbr" s-t Sa law. 0/9-716
No.and Street City /Town Zip Code Name of Building(if,applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair Altrratiun ❑ 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 required? \ Yes ❑ No ❑ /
Br�ijef,D1escripti�n of Proposed Work: SGca.n!( 1-'/por l�rl r'f �t Z J �r,rti- C+C,S.I C(e�ihy
I�GTN.HTaTti.
SECTIONS: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 3402.0) O
Existing Use Group(s): - / I Proposed Use Group(s): Y
Existing Hazard Index 780 CMR 34: 1 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.) .2 ya-S
- Total Area(sq. ft.)and Total Height(ft.)
` SECTION 5:USE GROUP(Check as applicable)
PFacto
bly A-I ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business (� E: Educational ❑
F-1 F2❑ H: Hi Hazard' H-I ❑` H-2❑ H-3 ❑ H-4❑ H-5❑
onal 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ R-3❑ R-4 ❑S-1 ❑ S-2 ❑ U: Utility ❑ Special Use❑and please describe below:
:
SECTION 6:CONSTRUCTION TYPE(Check as ap licable100 IIA ❑ 11813 IIIA ❑ 1116 ❑ 1 IV ❑ I 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 it outside Flood Zunel ` Indicate municipal A trench will not be Licensed Dinpusol Sit-A
Prwate ❑ or ❑adentife Zone: / or on site S%,tem ❑ required or trench or .peal%:
permit s enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: I61,,ri\c", nnni��inn It,\u•„ I'n err..:
\nt :lpplicable� I.Strorlu[e%\](lain eirport approach area' k their review completed'
n l nn.vnt to B%nld Cndov'd ❑ YCs ❑ or.\'n Ye.❑ \o ❑
N SECTION 8: CONTET OF CERT FICATE OF OCCUPANCY
f[d,uon .d Cndr. l.r Gnn,pl.l: fa peot Construction: (-)ca,panl Load per 1:1,
1)o1-1 the boddoah conlam,an Sprinkler S,% turn: SpectalStipulations-
SECTION 9: PROPERTY OWNER AUTHORIZATION
amg in Address of Properly Owner f
(Ira� LLB 3LfLf
Name(Print) No. and StALVt CA'/ own Lip
I Z k�6h�'naerh�Oayner Comtact Information:
BLt L b� L VZ �cl�fZ
Title Telephone No. (business) Telephone No. (cell) e-mail address
If.applicable, the property owner hereby authorizes
Name Street Address City/Town Stale Zip
to act on the property owner's behalf, mall matters relative to work authorized by this buildin •i2ermitapplication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) '
(If buildin•is less than 35,U1x)cu. ft.of enclosed space and/or not under Construction Control then check here 0 and ski Section Il`.0
10.1 Registered Professional Responsible for Construction Control
i
Name(Registrant) e-mail address Registration Number
Street Address City/Town State Discipline Expiration Date
10.2 General Contractor -
t� ?�wC 1r1�$l2 trt3. �yU�h�
Company Name: 97 Z�d833
me of Person Re�}xtin bl chun License No. and Type if Applicable
A, oEZ Rl1f4«. c CS z5 9 4 Z
Street Address City/Town c State Zip
_ S78 -$�Z-al!k7 —(° 5 W., l�`fFc a v�t4 C9 t,92Z
Telephone 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 t e issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item Total Construction Cost(from Item 6) _$—�L—,�,—"_—
and Materials)
1. Building 1 $ O Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ 8 a appropriate municipal factor)_$
3. Plumbing $ C�C�
4. Mechanical (HVAC) $ b Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ En )se
check payable to ��� -
6. Total Cost $ 0 b (contact munici alit )and write chJck Aumber here
SECTION 1 :SIGNATURE OF BUILDING PERMIT APPLICANT
B •en FILJ
name belo , i hereby attest tinder the pains and penalties of perjury that all of the information contained in this
a1 plicatio iae and, urate to the best of my knowledge and understanding. _
o g1b8S? 374-Z .9 0
I'Iera s—�e priilA'a�•amcr_� !pale Telephone.\o. i Date
�t reef :\ddr•ss- t Cih/Town State lip
.Municipal Inspector to fill out this section upon application approval: V
N e Date
CITY OF SALEM
PUBLIC PROPRERTY
` DEPARTMENT
D
.1 sus:a:rY:18NCa m.l.
12C W MIHING IUN S rXEET • SALEN,MASSACt tt lP.'1'11 G197..
'11.L:978-745-9595 0 p.%X: 978.740.9846
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
� 1 ilit.dnt informrfion �7�,{�[� � T
A Plcrse Print Lecihly
V 81nt: lnusioess/OrBaniratinNlndrvlduull: �e�vJ'�""'� - —�_ �
:lddress: Co 'N1E "7
City/Start;Zip F' IF�V-�) V1111 O192Z Phone /::���
Are y1 sun a employer with m 6. ❑ou an employer! Check the appropriate box: 'type of project(required):
1.❑
4. ❑ 1 n a general contractor and 1 New construction
eln tlu ces full and/ur art-tiine).r have hired the sub-contractors
1 Y ( P� 7. ❑ Remodeling '
2 1 sun a sole proprietor or partner- listed on the attached sheet. :
.hip 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 10.❑ Electrical repairs or additions
required.] officers have exercised their.
right of exemption c
3.❑ I um a homeowner doing all work S P P'r MGL 11.❑ Plumbing repairs or additions
myself. (No workers' comp. c. 152, ¢1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. LNo workers' 13.0 Other
romp. insurance required.]
-nay:yiphcaut dwt checks box at muss also till out rho secliou below showing Iheir workas cumpensation policy inliurruliva
'l lomemwners who submit this umCavit indicating They ate doing all work atul then him uuiside caurnctom must nutmiil a new amiLnvil indiWmg with.
-C,mtrmom shut check this box must alwhcd an additional shcel showing lire nano of tho sub.contrwtors and their workers'camp.policy inrormariun.
l um an employer that is providi"workers'c•outpens'ution insurance for my employees. Below is the policy urld job.rite
inforamtialL
Insurance Company
Policv is or Self-ins. Lie, ft: _.... ._ . . _.___ Expiration Date:
Job Sac Address: City/Stale/Zip:
Attach it copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to sccuro coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonincnt, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up in S250.00 it day against the violator. He advi.scd that a copy of this statement may be forwarded to the Office of
lavcxtiganons Ul'the DIA for insurance coverage ecrilication.
l do he chy ccrtif le /the
♦pains penalties ofperjury that the infbrmalion provri--dt1/ed 1above is true and correct.
51�'❑91I tl'e ! Date' rl f 1 O
ofjic•ial use only. Do not ivrire its this area,to be completed by city or ratvn aJjicizat
Ciiv or Town: -- _-- - Permit/License All._- ._-..
Issuing:\utlwrily(circle one):
I. hoard of health 2. Building Departlncut 3. Cilyi 1'onu Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Coatacll'erson: _. . ._-. Phone #:
Information and Instructions
,,.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statue, 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
o d the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or(he
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.rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
t
1iG1. chapter 152, v+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, sv'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 sub-contractors) namc(s), address(es)and phone nuniber(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 confinhmtion of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retuned 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennk/license number which will be used as a reference number. In addition,an applicant ,
that must submit multiple pennidlicerise 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(hat 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. it dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
I liv Office of Investigations would like to thank you in advance fur your cooperation and should you huvo any questions,
please do not hesitate to give us a call
The Dep;unnent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofitce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Itcvised i-26-US
Fax # 617-727-7749
www.mass.gov/dia
SEP-01-2010 14:38 From:HUMPHREY INSURANCE 9784622811 To:9787409846 P.1/2
ACORD CERTIFICATE OF LIABILITY INSURANCE OAIEIMWDD/YYYY)
PRODUCER (978) 462-0833 09 01/2010
THIS CERTIFICATE IS 188UED AS A MATTER OF INFORMATION
BYfield Insurance Agency, Inc. ONLY AND
THISCONFERS
CERTIFICATE R QES N UPON THE
CERTIFICATE
OR
57 Main St.P,O. Box 400 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BYfield MA 01922-
INSURERS INSuwRD AFFORDING COVERAGE NAIC III
TRUE, RICHARD INSUREKA WESTERN WORLD
N^UkEN tl
6 ERASER'S LAND
INEVRCR C
DYBIELD IN'UHEK n
MA 01922-0000 I .
COVERAGES NRURER E
VAH
ES OF INSURANCE LISTED BELOW HAVE BCCN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I IOICAT60 NOTWITHSTANDINCANY
CNT.TERM OR CONDITION OF ANY CONTRACT OR OTHhK DOCUMENT VWTH KESPECT TO WHICH THIS CER'I-IFIGATE MAY BE ISSUED OR MAY PERTAIN.
ANCE AFFORDED BY THE POLICIES DESCRIBCO HERtIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICiFS
E LIMITS SHOWN MAY HAVE BEEN REOUCED BY PAID CLAIMS
.
TYPE OFINSURarvUE PODGY NUMDER PDALTE(MICY NDSMY DATE M" A'YOjN LIMITS
ENCRAL1,1A51UTY NP81055389 08/25/2010 08/25/2013,
EAGH QrCURRENCE S 1,000,DOQ
COMMERCIAL GENERALLIAOILITY DAM khNTtD
�� PRE IS G Eamw....nan 1 50,000
GLAIM3 MMW X OCCUR / / / / MED LXP ArA m.e�—$ 5,000
PEREONALSADV IN.IURY S 11000,000
GFNF_RALAGGREUflTF: S 2,000,000
N'L AGGRCOATE LIIMI I APPLIES PER'POLICY aFMNUDU TS-CUMPIOPAC;C S 2,000,000aTOMOMH-F LIABILITYANY AUTO COMBINED SINGLE LIMII
(Enn Idov) S
All AWNED AUTO_HOwEDULED AUTOSDODILY INIIIRY
HIRED AUTOS tl[R1ILYINJURY
NON OWNED AUTOS• PROPFA IY DAMAGE
(Pe,eLvd.,t)RAGE LIABILTry
ANY AIRO AUTO ONI Y-EAACI.IDFNT S
OTHLK THAN EA ACC E
AUTO ONLY.
ExcFeSNMERCLLA LIABILITY / / / / AUG $
FAfJH OCCURRF.NCC 4
OCCVRMAIMS MAOE
AGGREGATE §
DFOUCTIOLC $
S .
XE'1'ENTION S
WORKERS COMPENSAnON AND pp��II11 S
EMPLOYERS'LIABILITY / / / / TO V WITS -FK
ANY PROPKIETOR/PARTNERICXCCU I IVt OFFICER/MF.MRF.R EXCLUDED? C L GACH flCf.II S;NT $
/ / / /
I?Ye=AesaTbe Vnder E L.DI$CA$t-EA EMPI.pYEE 6
SPECIAL PROVISIONS Wt.
OTHER / / / t L.OF EASE-POLp:v LIMIT 4
DESCRIPTION OF OPCRg710N$1LOCA'1IUNSNEHICI,EWEXCLUSIONS ADDED AY ENDORSEMENTISPECIAL.PROVISIONS
JOB Site: 14 Bubon St. , Baigm, NA 019'/0
CERTIFICATE HOLDER CANCELLATION
( ) - (978) 740-9846 SHOULD ANY OF THE ABOVE OESCRIDED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDDAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CCRTIRCATE ITULDER NAMED M THE LFPT,BUT
City O� galeDl FAILV DO SO SBgLL IMPOSE NO OBLIGA OR LIABILITY
120 Washington 8C OF ANY KIND UPON THE
INS I SAG OR REPRESsWA
AU ORq RE ESENTATTVE
Salem tIA 01970-
ACORD 25(2001/08)
INS025(01m0E ID CORD CORPORATION 1988
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