63 JEFFERSON AVE - BUILDING INSPECTION (12) J T/- _ 3 - cK 10 504
pep d I - -2,ES
-- _ monwealth of Massachusetts
W
Department of Public Safety
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 Only)
Building Permit Number: Date Applied: Building Offici
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for whic a str t add ess is uibt ilable)
3 a aa-7o G �z "1'9 ,
No.and Street City/Town Zip Cede Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check a6 that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 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 ❑ N ❑
Brief Description of Proposed WorkA (�}2�ro� t2evx o.�e.t-r.w.S Due h)
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 CNIR 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 ❑ A-3 ❑ A4❑ A-5❑ B: Business E: Educational Cl
F: Facto F-1 ❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 14❑ 1-2❑ f-3❑ I-4❑ 1 M: Mercantile❑ R: Residential R-111 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ HA ❑ IIB IIIA ❑ Hill ❑ 1 IV ❑ 1 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❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Ceder Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?:_ Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
s
Nome and Address of Property_Owner
I 1 �tC ojet UIV 6 �ti-r�� �u( evl ✓Wt9 01, 97'0
Nat (Print) No.and Street City/Town Zip
Property Owner Contact Information: Jp h�vr.,a �•e^-�
'CvuglCe. c176_ o 0660 _
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 a0 matters relative to work authorized by this buddingppermit application,
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2).
(If building is less than 33,000 cu.ft.of enclosed space and/or not under Constmction Control then check here 0 and skip 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
hk stlrft ti t ►7Pw � L
Compvry Name f `
Name of Person Responsible for Construction License No. and Type if Applicable
)eqL-,,X., AM
Street Address City/Town State Zip
l -?�l i�ov Ta-. .1 � 6tln k t3 tad(-) c2
Telephone No. business Telephone No. cell address
SECTION 11:eVORKFIS'COn-IP6NSA I ION INSURANCH ARPIDAVI I 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 0 No ❑
SECTION I2:.CONSTRUCTION COSTS AND PERMIT FEE.
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Mininmm fee=$ (contact municipality)
5. Nechanical Other $ Enclose check payable to
6.Total Cost $ 590 0 (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 pe alties of perjury that all of the information contained in this
application is true and accurate to the best of my knowlAigeandjAdIrstanding.
Pleas pru and sign name nc Title Telephone No. Date
��e��� d--T .c '___
Street Address City/Town .date Zip
Municipal Inspector to fill out this section upon application approval: wr+rry h
Name Date
CITY OF S U_EEN1, ANSSACHUSET TS
BUILDING DEP.ARTMEINT
',cal 120 'WASHC�IGTON STREET, Saw FLOOR
b -ILL (978) 745-9595
F.A-x(978) 740-9M
KiNrBERLEY DRISCOLI
MAYOR - THOR4IS ST.PI&BR6
DIRECTOR OF PUBLIC PROPERTY/BUIIDLNG CONLUISSIONER
Workers' Cornpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legi/bly
Value (l3usinesm Organiraliowindividucal): &CA Sit' fe L Ji-tC I -B�PiL
Addretis: ('(7.
City/State/Zip: Sc LPAw AA (<] OIffo Phone 9: 935 1 L4 Od
Are y an employer? Check the appropriate box: 'Type of project(required):
I.V1 am a employer with 4. ❑ I am a general contractor and 1 fi. ❑New construction
employees(full and/or part-time),* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached.sheet.; 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 ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL l 1.❑ Plumbing repairs or additions
myself. [No workers'comp, C. 152,91(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.] .
-Any applicant dual checks box 91 most also fill out the necli on Wowshowing their worked'compensmiun policy inlunnalion.
'I homeowner,who suhnnil this anldivit indicating they arc doing all work and then hire outride cantrectors trial submit a new afr.davit indicating such.
:Qnntncwn shut check this box must anachal an addiniunal shwa showing ilia nwne of the sub-conlraelorx and nheir workers'comp,policy infermation.
1 ant an empluyer that is providing workers'curttpeasa tan hrsuruncefor my employees. Below Is the pulley road job Nile
information.
Insurance Company Name: A\wk ✓M✓Ney S
Policy 4 or Self-ins, Lic. ti: t)n ' :A c _ Expiration Date:
Job Site Address: 6 a JAn.f0✓1 A` City/State/Zip: �e� 'r•-K K14
Attach a copy of the workers'compensation policy declaration pale(showing the policy number and expiration date).
Failure(o secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition ofcriminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and aline
of up to SM.00 a day against the violator. Be advised that a copy of this statement may bs:forwarded to the Office of
Investigations of the DIA for insurance coverage veri-cation.- - -
lido hereby certify till tit pull$?a penuitles u erju rat the iufuramtlon provided above is true acid correct.
Phonc Ai:
Official use wily. Do not write in this area,to be completed by city ur lawn ojjiciuL
City 0e Town: Permit/I.lcense#
Issuing Authority(circle one):
I. Board of health 2. Building Bepartincill 3.Ci(yfrowll Clerk 4. Electrical lnspector 5. Plumbing Inspector
6.0(her . ._--
Contact Person: .... . . Phone#:
]
CITY OF SALEI,f, tiL-USACHUSETTS
' BLILDLNG DEPAR'I1ZNT
130 WASI-INGTON STREET, YO FLOOR
'� = T'M (978) 745--9595
FVC(978) 740.9846
lU\BERL Y DRISCOLL
AILYOR T�10. t,ST.PtEma
DIRECTOR Of PUBLIC PROPERTY/BL'ILDLNG CO\DfIS5IO�ER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit f« is issued with the condition that the debris resulting from
this work shall be
1
1 1, S I SOA.
disposed of in a properly licensed waste disposal facility as defined by tYIGL c
The debris will be transported by:
y
Name of hauler)
The debris will be disposed of in
(narne of facility)
(address of facility)
'nature of permit applicant
LA
date
- 63 JEFFERSON AVENUE 571-13
GIs#: 1529 COMMONWEALTH OF MASSACHUSETTS
Map: 24
Block: CITY OF SALEM
Lot: 0210
Category: RENOVATIONS
Permit# 571-13 BUILDING PERMIT
Project# JS-2013-001935
Est. Cost: $694,842.00
Fee Charged: $7,639.00
Balance Due: $.00 PERMISSION IS HEREBY GRANTED TO:
Const Class:.. Contractor: License: Expires:
Use'Group: Martins Construction Company Architect-20243
Lot S1ze(sq.'It.): 42393.0276 s
t f
Owner: HUGH REALTY TRUST,KERR HUGH TR
Units Gained: s,
Applicant: Martins Construction Company
Units Lost: AT: 63 JEFFERSON AVENUE
Dig Safe#:
ISSUED ON. 29-Jan-2013 AMENDED ON. EXPIRES ON. 29-Jul-2013
TO PERFORM THE FOLLOWING WORK:
RENOVATIONS AND REPAIRS DUE TO FIRE DAMAGE AS PER PLANS SUBMITTED
„. POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House# Smoke:
Water: Alarm:
Assessor Treasury:
Sewer: Sprinklers: Final:
T
1THIS:PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
j'
{' ` F Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2013-0021 I I 29-Jan-13 2708 $7,639,00
GeoTMS@ 2014 Des Lauriers Municipal Solutions,Inc.
63 JEFFERSON AVENUE 571-13
1529 COMMONWEALTH OF MASSACHUSETTS
Map: 24
Block: CITY OF SALEM
Lot: 0210
Category: RENOVATIONS
Pemnt# 571-13 BUILDING PERMIT
Project# JS-2014-001112
Est: Cost: $0.00
Fee Charged: $25.00
Balance Due: $ 00 PERMISSION IS HEREBY GRANTED TO:
Coast.Class: Contractor: License: Expires:
Use Group: lt' *'" -=s, .may `. Baystate Building& Remodeling General Contractor-062684
Lot Size(sq fr.): 42393.0276
Zoning.'c0;, I`a' �.� ;:; ,1 Owner: HUGH REALTY TRUST,KERR HUGH TR
Units Gained r G c :AppltCarit: Baystate Building&Remodeling
�,
Units Lost: 1 AT: 63 JEFFERSON AVENUE
Dig Safe#:
ISSUED ON. 06-Ian-2014 AMENDED ON: 06-Jan-2014 EXPIRES ON. 06-Jul-2014
!TO PERFORM THE FOLLOWING WORK:
("t,
571-13 AMENDED-ADDITIONAL INTERIOR RENOVATIONS DUE TO FIRE. (REFER TO PLANS SUBMITTED ON
571'113 AND PERMIT FEES)
tr
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric - Gas Plumbing Building
Underground: Underground: Underground: Excavation:
` Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House d Smoke:
.��., Treasury:
Water: Alarm: Assessor
'•. t ..` Final:
ewer: Sprinklers:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
;MULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2014-001)11 06-Jan-14 10504 $25.00
GcoTMS®2014 Des Lauriers Municipal Solutions,Inc.