204 JEFFERSON AVE - BUILDING INSPECTION SECTION 9: PROPERTY OWNER AUTHORIZATION IP.b
Name and Address of Property Owner
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:Name(print) No.and Street City/Town Zip
operty 0%%ner Contact Information: Sciry,L
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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a
Name Street Address Citv/Town State Zip t
to act on the pro perty owner's behalf, in all matters relatk a to work authorized by this building permit a >,lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,(N)0 cu.It.of endos d s ace and/or not under Construction Control then check here Oand,kip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Dm S o�S 'yam IlG �8 S78 dan/cledinsc>✓er Loo38
Name(Registrant) Telephone No. �� e-mail address Registration Number
/OO G(//7M%i1Q 3 CGn,L/' J�-Lr/'eN` "C
Street Address 6 t. Y2514 City/Toi4n State Zip Discipline Expiration Date
10.2 General Contractor
Company Nam /J D� 40 L7 S /0Z9Z
Name of Person Responsible for Construction License No. and Type if Applicable
Cc 4heQ97-r?` Ram �i'✓ //a(s rao0�/ --1a
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Street Address 377 City/Too
wn State Zip
77K 270- y7V49 rJ8 $b
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the suance of the building permit.
Is a signed Affidavit submitted with this application? Yes f?No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ / (o +i Oa Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ /I, Oar appropriate municipal factor)=$
3. Plumbing $ /9,m,✓O
4.Mechanical (HVAC) $ /$ 000 Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ v0 Enclose check payable to
6.Total Cost $k Z67O eov (contact munici alit )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 an accurate to the best of my
knowledgeand underslandin
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e' onm/'9 . ,u7pjn QQc/ 9/� f 02. 2 sY( 7 /O
Please print, 1 sign n�a e Title clop one No. )ate
i � +�%gym✓�//� f Ss��2 /fly ® s7
Niect :\ddress City/Town 5tat i
.Municipal Inspector to fill out this section upon application approval:
Na e I).ite
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The Commonwealth of Massachusetts
Department of Public Safety
v-,,.✓ %lassachusetls Stale Building Code(780 CMR)Seventh Edition
City of Salem
Building Permit Application for any Building other than a 1-or 2-Family Dwelling
A (This Section For Official Use Only)
O� Building Permit Number: Date Applied: �O Building Inspector:
SECTION 1: LOCATION (Please indicate Block N and Lot 0 for locations for which a street address is not available)
�a,7 ir-C G✓`smn k✓G Sgle,,r'f O(q-7a v
No. and Street Clty /Tumvn 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 RepairSKI Alteration ❑ Addition❑ Demolition O (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 Mr No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Descripption of PrujJused Work: S-/-✓� e .r n
vela yam •/o4`iy ��4 ` � 2zp�. � ��e s n� B I
/1'aily;n�o�+s
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDMON,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Ex' ting Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) q. 114
Total Area(sq.ft.)and Total Height(ft.) lzicpa Ss c
If, SECTIONS:USE GROUP(Check as ap meable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ I-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 a liable)
IA ❑ IB ❑ IIA ❑ 1180 IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Lune Indicate municipal A trench will not be Licensed Dispm rsal SitIn
Private❑ or mdentik Zone: or on site scstem ❑ required❑or trench ur.pecifv:
permit is enclosed Cl
Railroad right-of-way- Hazards to Air Navigation: \l:\ I II nmi—wn Hrn,•a Pro,,
Not \pl+hed+le B" I.Struclure mailhin airport apprn,tch,t rea' Is Iheir rrcie,c cum-plel/vd.'
r Convent In Rudd cndo.ed ❑ 1'es❑ or.No l2i� Yes❑
SECTION 8:CONTENT OF CERTIFICA"rE OF OCCUPANCY
I[,ldion ul Code L.e Crou +(sl: N +e u l ) I Conslruitwn: Ckaipanl I„ad per Fluor:
Dt,v, the building conlam.in Sprinkler Scstem.': Spenaltitipulation,:
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1 100 Cummings Center,Suite 424G
DMS design, llc Beverly,MA 01915
Tel 978 578 5748
Architectural Design Services Fax 866 648 8251
dmiel@dmsdesign,wm
Building Code Analysis for 204 Jefferson Avenue, Salem, MA
Massachusetts Building Code Analysis based on the Seventh Edition effective 10/17/08.
CHAPTER 34—EXISTING STRUCTURES
3400.1 General: The provisions of 780 CMR 34.00 are intended to maintain or increase public safety,
health, and general welfare in existing buildings by permitting repair, alteration addition, and/or
change of use without requiring full compliance with the code for new construction except where
otherwise specified in 780 CMR 3400.
3400.2 Compliance: Repairs, alterations, additions, and changes of use shall conform to the requirements
of 780 CMR 34.00. Where compliance with the provisions of this code for new construction is required
by 780 CMR 34.00, and where such compliance is impractical because of construction difficulties or
regulatory conflicts, compliance alternatives as described in 780 CMR 3406.0 may be accepted by the
building official.
3400.3 Applicability: The provisions of 780 CMR 34 apply to repair, alteration addition or change in use
to existing buildings which qualify to use 780 CMR 34.00 (see 780 CMR 3400.3.1) based on the
proposed continuation of, or change in use group,as follows:
1. Continuation of the same use group, or a change in use group which results in a change in
hazard index of one or less as determined by 780 CMR 3403.0 shall comply with 780 CMR
3404.0.
3400.3.1 Buildings which qualify: The provisions of 780 CMR 34.00 shall apply to existing buildings
which have been legally occupied and/or used for a period of at least 5 years.
3400.4 Special Provisions for Means of Egress:
3400.4.1 Existing Non Conforming Means of Egress: The following conditions, when observed by the
building official, shall be cited, in writing as a violation. Said citation shall order the abatement of the non
conformance and shall include such a time element as the building official deems necessary for the
protection of the occupants thereof, or as otherwise provided for by statute.
1. Less than the number of means of egress serving every space and/or story, required by 780
CMR 10.00.
2. Any required means of egress component which is not of sufficient width to comply with 780
CMR 10.00, or is not so arranged as to provide safe and adequate means of egress, including exit
signage and emergency lighting.
According to 1004.1.1 Actual Number: This building contains (3) three bedroom units. The
actual number of occupants per unit is 6, assuming two persons per bedroom, or 18
occupants for the building.
According to Table 1004.1.2, R=200 gsf/person. Each unit is less than 1,000 gsf. By
calculation, the occupant load of each unit is 5 persons. 3 units at 5 persons each = 15
persons.
Per Table 1005.1 Egress Width per Occupant Served,Use Group R,with sprinkler system
2" for stairs and .15" for doors with sprinklers 18 persons x .2"= 3.611, 18 persons x .15" _
52.7"
1009.1 Stairway Width: The width of stairways shall not be less than 44 inches. Exceptions:
1. Stairways serving an occupant load of 50 or less shall have a width of not less than 36"
1009.4 Stairway Landings: There shall be a floor or landing at the top and bottom of each
stairway. The width of landings shall not be less than the width of stairways they serve. Every
landing shall have a minimum dimension measured in the direction of travel equal to the width of
the stairway.
The width of the existing landings is equal or greater than the width of the existing stairs
they serve.The depth of the existing landings is less than the width of the existing stairs they
serve at the top landing of Stair #1 on the second and third floors. 3404.3 New Building
Systems. Any new building system or portion thereof shall conform to 780 CMR for new
construction to the fullest extent practical. However, individual components of an existing
building system may be repaired or replaced without requiring that system to comply fully
with the code for new construction unless specifically required by 780 CMR 3408.0.
3402.1 Building Permit Application Requirements for Existing Buildings: A building permit shall be
required for any work regulated by 780 CMR 34.00.
3402.1.1 Investigation and evaluation: For any proposed work regulated by 780 CMR 34.00, which is
subject to 780 116.0, as a condition of the issuance of a building permit the building owner shall cause the
existing building(or portion thereof)to be investigated and evaluated in accordance with the provisions of
780 CMR 34.00.
The investigation and evaluation shall be in sufficient detail to ascertain the effects of the proposed work
on the structural, egress, fire protection, energy conservation systems and light and ventilation systems of
the space under consideration and,where necessary,the entire building or structure.
3402.1.2 Submittal: The results of the investigation and evaluation, along with any proposed compliance
alternatives, shall be submitted to the building official in written report form.
3403.1 Hazard Index: In the implementation of the provisions of 780 CMR 34, the hazard index
associated with a particular use group shall be as identified in table 3403 and 780 CMR 120.5..
Existing Use Group=R-2,Multi-Family(3 dwellings) Existing Hazard Index=2
Proposed Use Group=R-2,Multi-Family(3 dwellings) Proposed Hazard Index=2
Change in Hazard Index=0
780 CMR 3404.0 Requirements for Continuation of the Same Use Group
3404.1 General: The requirements of 780 CMR 3404.0 and applicable provisions of 780 CMR 3408.0
shall apply to all repairs and alterations to existing buildings having a continuation of the same use group.
3404.3 New buildingsystems : Any new building system or portion thereof shall conform to 780 CMR for
new construction to the fullest extent practical. However, individual components of an existing building
system may be repaired or replaced without requiring that system to comply fully with the code for new
construction unless specifically required by 780 CMR 3408.0.
3404.4 Alterations and Repairs: Alterations or repairs to existing buildings which maintain or improve the
performance of the building may be made with the same of like materials, unless required otherwise by
780 CMR 3408.0. Alterations or repairs which have the effect of replacing a building system as a whole
shall comply with 780 CMR 3404.3.
3404.5 Number of Means of Egress: Every floor or story of any existing building shall provide at least the
number of means of egress as required by 780 CMR 3400.4 and which are acceptable to the building
official.
3404.6 Capacity of exits: All required means of egress shall comply with 780 CMR 10.00. Existing
means of egress may be used to contribute to the total egress capacity requirement based on the unit
egress widths of 780 CMR 10.00.
3404.7 Exit signs and li ts: Exit signs and lighting shall be provided in accordance with 780 CMR
10.00.
3404.8 Means of euess lightiM Means of egress lighting shall be provided in accordance with 780 CMR
10.00.
3404.9 Height and Area limitations: The height and area requirements of 780 CMR 5.00 shall apply to
existing buildings when such existing buildings are modified by addition and/or change in use.
3404.10 Existing Fire and party walls: No further compliance is required with 780 CMR 7.00. The height
above the roof of existing fire,partitions and exterior walls need not comply with 780 CMR 3404.0.
3404.11 Fire Protection Systems: Fire Protection Systems: Design, installation and maintenance of fire
protection systems shall be provided in accordance with 780 CMR 3404.3 and 780 CMR 3404.12 as
applicable.
3404.12 Fire protection systems are required for the followingcases:
ases:
1.Additions where required by 780 CMR 9.00 for the specific use group.
2. For existing buildings modified by addition and/or change in use where required by 780 CMR
504.0 or 506.0 to satisfy height and area requirements.
3. Existing buildings, or portions thereof which are substantially altered or substantially
renovated,and where otherwise required by 780 CMR 9.00 for the specific use group.
4. Existing buildings or portions thereof when changed in use to an A-2nc.
3404.13 Enclosure of stairways: Open stairways are prohibited except in one- and two-family dwellings
or unless otherwise permitted by 780 CMR 10.00. There shall be no minimum fireresistance rating
required for an existing enclosure of a stairway. Partitions or other new construction which is added in
order to fully and solidly enclose a stairway shall provide a minimum fireresistance rating of one hour.
All doors in the enclosure shall be self-closing and tight fitting with approved hardware. All doors in
those portions of the stairway which are fireresistance rated shall comply to the applicable provisions of
780 CMR 9.00.
3404.16 Residential Use Groups: Notwithstanding the provisions of 780 CMR 3404, Residential Use
Groups shall comply with the provisions of 780 CMR 3400.3,item 8.
3404.17 Fire hazard to adjacent buildings: Any proposed change in use or occupancy of an existing
building which has the effect of increasing the fire hazard to adjacent buildings shall comply with the
requirements of Table 705.2 for exterior wall fire resistive rating requirements, or with approved
compliance alternatives.
3404.18 Accessibility for Persons with Disabilities: Accessibility requirements shall be in accordance
with 521 CMR.
3404.19 Energy Conservation: Energy conservation requirements shall be in accordance with 780 CMR
3407.0.
780 CMR 3407.0 Energy Conservation
3407.1 General: Energy efficiency provisions for existing buildings shall comply with the International
Energy Code (IEEC) 2006 with the 2006/2007 Supplement and with the Massachusetts amendments to
the IEEC as provided in 780 CMR 13.00.
521 CMR 3.1 Scope:
3.3 Existing Buildings_ All additions to, reconstruction, remodeling, and alterations or repairs of existing
public buildings or facilities, which require a building permit or which are so defined by a state or local
inspector, shall be governed by all applicable subsections in 521 CMR 3.00:Jurisdiction.
For specific applicability of 521 CMR to existing multiple dwellings undergoing renovations, see 521
CMR 9.2.1.
9.2.1 Renovation and Reuse: Any building previously occupied for any purpose, which is converted,
renovated, reconstructed, altered or remodeled for residential use after this date is exempt from 521 CMR
9.3, Group 1 Dwelling Units.
9.2.2 Renovation and reuse of dwellings units is subject to 521 CMR 9.4, Group 2 Dwelling Units
through 521 CMR 9.5 Dwelling Unit Interiors provided the work being performed, in a three year period
exceeds 30% of the full and fair cash value of the building. Work performed to public use and common
use areas however, is subject to all of 521 CMR 3.3.
This building does not contain any public use or common use areas.
9.4 Group 2 Dwelling Units: In multiple dwellings that are for rent, hire, or lease (but not for sale) and
contain 20 or more units, at least 5% of the dwelling units must be Group 2A units. This building
contains less than 20 units and is exempt from Group 2 Dwelling Units.
CONSTRUCTION CONTROL AFFIDAVIT
PROJECT LOCATION: 204 Jefferson Avenue, Salem,MA
PROJECT NAME: Renovations to 204 Jefferson Ave.
NATURE OF PROJECT: Interior renovation
ARCHITECT: DMS design, Ile
ADDRESS: 100 Cummings Center, Suite 424G,Beverly,MA 01915
TELEPHONE: 978-578-5748
In accordance with Section 110.0 and 116.0 of the Massachusetts State Building Code,I,Daniel M.
Skolski,Registration No. 20038,being a registered professional Architect,hereby certify that I have
prepared or directly supervised the preparation of all design plans, computations and specifications
concerning, ARCHITECTURAL Plans,for the above named project and that,to the best of my
knowledge, such plans, computations and specifications meet the applicable provisions of the
Massachusetts State Building Code,all accepted engineering practices and applicable laws and
ordinances for the proposed use and occupancy.I further certify that I shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to determine
that the work is proceeding in accordance with the documents approved for the building permit and shall
be responsible for the following as specified in Section 116.2.
Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for the building permit,and approval for conformance to the design
concept.
Review and approval of the quality control procedures for all code required controlled materials.
Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in
Appendix G.
Pursuant to Section 116.2.2,I shall submit periodically,_daily,_X_weekly,or _other periods
(specify)Weekly progress reports together with pertinent comments to the City of Salem Building
Department.
Upon completi of the work,Architect, shall submit final affidavits as to the satisfactory completion and
readiness ofth project for occupancy.
i
Signature
Then personally appeared the above named LalA.illl M ' w4d made oath that the above
statement by him is true.
KLARENTA BRACO
Before M Notary Putli,
OOMMONW<M 01 MASSACMU M
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Licrncr or reKisfratioa valid for individul use only �
0 T,,of Consumer ARain A Rusiness Regulatim. before the ezplrallon date. If found return to: rj
" HOME IMPROVEMENT CONTRACTOR office of Consumer Affairs and Buslness Regulation N
RaOtstratton: 164675 10 Park Piaza-Suile 5170
Expiroon: -0O12712011 Td! 290056 Roston.MA 02116
i `3" type: Private Corposatlon
' REDCO CONSTRUCTION WC,
PATRICK REODY `
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NEV4eURYPORT,MA01950 UaAtrsecrerary l J Not vetM without renature
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Apr 07 10 02:43p Erica Makrys 978.255.2489 p.3
MASSACHUSETTS ASSIGNED RISK POOL
REQUEST FOR CERTIFICATE OF INSURANCE
Use this form to request a Certificate of Insurance from an Assigned Risk Pool Carrier.
Please provide all of the requested information, including the facsimile number(s) of the person or persons to whom the
Certificate of Insurance should be issued. if this form is fully and accurately completed, the Certificate of Insurance will be
issued and distributed by facsimile to each fax number provided below, within two(2)business days of the carrier's receipt.
This Form may be mailed or taxed to the Assigned Risk Pool Carrier To obtain each carrier's contact information refer to the
Certifcales of insurance section located in fhe Producer Community section of the Bureau's website,(www.wcrr me arc)
1. Name, address, telephone number and facsimile number of the INSURED:
Name: _ Red co Construction Inc.
Mailing Address: 8 Pheasant Run Dr. Newburyooerl MA 01950
Physical Address: Some
Phone: 978-27M740 Fax 978-285-248;3.�
2. Name, address; Well number and facsimile number of the CERTIFICATE HOLDER:
Name'. 205 Jefferson Ave.LLC
Mailing Address 204 Jefferson Ave. Salem, MA 0197C _
Physical Address: _ Sarno
Phone: Fax:
3. Name,address,contact person,telephone number and facsimile numbar of the PRODUCER:
Name: _Artttur S. Page insurance
Mailing Address: P.O. Box 391 Newtwrypgr4 MA 0195C
Contact Person: ,Mate Quill
Phone: 978 466-5301 Fax: 978 462-0890
4. Policy Number,Policy,Effective Data and Policy Expiradon Date
If a Certificate of Insurance is needed for more then one policy ten, provide the Policy Number,
Effective Date and Expiration Oate for each policy term.
If the policy has not yet been issued,you must attach a copy of the Notice of Assignment.
Policy Number. 0020111597
Effective Date: 03/05/2010 Expiration Date: 0=5n 1
5. List anyspecial requests for optional coverages/endorsements(see Page 2 for listing of coverages available
in the pool aft the conditions of avallabNlty) oradditionat information (including changes In exposure not yet
ropej"d to the carrier)that will assist the carrier in the issuance of the Certificate of insurance.
NOTE: An additional insured(s) shelf not be fisted on any Certificate of Insurance unless such additional
insured(s)Is a named Insured an the polky.
Apr 07 10 02:48p Erica Malvys 978-255-2489 p.1
CERTIFICATE OF LIABILITY INSURANCE P,p O-jfy71 OAnImDOnv I
REDC Oa 07 10
mue S RTIF A ISSUED AS A MATTER OF INFORRIATNON
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Arthur S Page IaHu.--anCa Agency HOLDER.THIS CERTIFICATE DOES NOT AMEMO,EXTEND OR
57 State St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Newburpport MA 01950
Phorse: 97B-465-5301 Faz:978-462-0890 INSURERS AFFORDING COVERAGE NAICB
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THE PO-LIES OF IN6URPNCE USTEO ItMoW KAM BEEN ISSUED TO THE 013UREC NAMED A60VE FOR THE POLICY PE40D INLX Wn VOivATHST.W0l4G
ANY REQUIREMENT.TERM OR LCBmRtlN pF ANY GONTMCT Oft pTNEF OOOUMENT W(lN RELPECT Tp Vil'aQF.11T9 CERTIfItFTE MAY Bi 4`S.'ED OR
MAY nATAN,THE INSURMILE AFFORDED SY THE POLIC'EE DESCRJBED HEREIN IS SUBJECT TIC ALL THE TERMS,E;CiU6R)NS AND COMpTION4 OF SIGH
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SHOULD ANT QTIE ABOVE 09SW REO MUG 98 RE: *N ..O REFOa6 THE SRPIRATWL'
DATi TNER80F,THE NkA:INOIN3Wt®t WILL EMOMYOR TO NAIL TOO DAYSWRTMN
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IYPO06 NO ORL'OATION OR UAnW TY W 0.NY Rtl10 UPON THE IRSOI�R.RS AOENYS OR
204 ,7e££ereon Ave. IS,C AWREmnTATME
204 .'e£terson ATre. ANTMaRVER iNTw
08-lem MA 01970 None
ACORD 2842009101) 0 ISSO-ZU09 ACORD CORPORATION. All rIgINA risaI
-Iha ACORD Hann and loan are m0lRered marks of ACORD
c CITY OF SM-E.` I NIaISSACHUSEM
& O.DLNG DEP..%xn(LiT
I 2o W.AsHLNGTON STREr►r. r FLOOR
TEL (978)7+5-9595
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lrJ-CBERLEY DRISCOLL
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DIRECTOR OF FL tuC PROPERTY/et:IwLNG COSMOSSIO\ER
Wurkers' Compensation Insurance Affidavit: Buildert/ContractorWElectriclsnsiPlumbers
Analicant Information Please Print
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atta N: / - 3 7
Arcytr an emplaya'Check the appropriate boa: Type of project(requlra*
1.(z I am a employer with e. Cl 1 me a general contractor sot!1
employees(full and/or pan-ems).
• have hired the stsdaorerannto b Now construction
2.❑ 1 am a sale proprietor or partner• listed an the attached shiest: 7. (ErRe modeling
ship and have no employee Then sub-commetors have e. O Demolition
working for me in any capacity. workers'comp,insurance. . 9. O Building addition
i No worken'comp insurance S. ❑ We an a corporod"and in 10.❑Electrical
Repairs or additioro
rtquimd.j ofters have attrttised their
3.❑ I am a homeowner doing all work right of exemption par MOL 11.0 Plumbing repairs or addLions
myself.No workers'comp. e. 15Z 11(41 and we hew no 12.[3 Roof mpaim
insurance required.] r employee.(No workers'
comp insurance requited.) I3.❑Other
'Any AppliCat the chska bad e1 mar eke mM ter the Brim belle rbediy tb&warkata•oontpet"w pokey utave"dis a
'16wteaednsa who ladle it this aredevit iNloliq they me Joins At we*as thin him a milk inane I I alert submd a need arrtdovk indintiy r ds
l,ntra9ota der cheek like bm~awaked as additional giber dtwiue Jed term or will w o cmi swee ad their woAeda'w7.Policy isanma•a,
/am as employer that Is providing workers'compeassdea/nsareacial my eaylatyers edsw 4 thepdfi7r awl�el start
informollon.
Insurince Company Name: /wr ✓/'
Policy f at Self•ins. Lie.M: WC
uv2011 897 Expiration Dan: 35� //
Job Site Address: " py ,1tYf/,aSbn A, City/SlaWZip: rSC"
,%track a copy of the workers'compessadoe policy doelaratlon pop(showing the policy Mumbler sad eapirsid"daft)6
Failure to sesurs coverage a required under Seeders 25A of MGL c. 152 can lead to the imposition of criminsl penalties card
fine up 10 S 1,500.00 and/or cant-yesr imprisonment,a wall as civil penalties is the lotion of a STOP WORK ORDER and a floe
Of up to S230.00 a day against the violator. lie advioxl that a copy of this slatcment may be forwarded to the 0171ce of
InvcaUymiuna arihe n1A for insurancs covcraga vchfwaiioa
1 do hereby cenijy Mad aped n rod _ as of ty that At be ormaden provided above is Irmo and correct
O/Jle'ief ate a/Jy. Do not write in this and,to be,atnp/erd by city or tetvel o//level
C iry or Irwin: Prrmit/t.lanre d
hsuint Atilhurity (circle line):
I. heard ut 11ra11h t. Rudding Depirimcni J.City/town Clerk t. Electrical Inspector S. Plumbing Inrpeetor
6. other
L-,atacl Person: _ ... Phone ill:
�S CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
J'd I> M I t 1 •Nlv.'•I I
\I\1.'N raLCT•5.11 I'%I- \1-%%'%4
Trt:v:U N.;.',;vs •I 979.7+0-9446
Construction Debris Disposal Afriidavit
(required fur all denwlition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 1 11.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit q _ _ is issued with the condition that the dcbris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris will be transported by:
Ilia c of hauler)
The debris will be disposed of in :
(name of as ny)
(address of facility)
%ignatu of Itennit applic
/ JP
date
Icl.ri•ill.:.w
`s 4
M. s/fp AF
LEGEND: 13' ! ,� — 1 ) A2C 4t_ �Lt " �� MO/ZlV -I/ST/W La Pro2GO38` � 0[ - - --] WALLS TO BE REMOVED V �/f' X O
r-----------------1
NEW WALLS ,S/` & AI — CCirtco.v C
o&�' ETQ
O EXISTING WALLS TO REMAIN /y10�/OX/.qF
I I x
iN
UP
I I ,
I ' 1
I v
I
I Id
1 I
I
I I �
I I J
N W 2 FLO R JO STS ISTE ED
T EXI TING FLOG JOK TS FOR �+
I All FIRIE DA AGEG FLO R J ISTS •� C7
I _ELEC. IN THIS ARE A5 REQUIRED.
I PA EL5
O O O
y a
I A �
I
U P nn
MIX
T •• D
I
I I I
O no i o
1 C
L , I O £
BOILER I C
I O
� BOILER H.W.
O o
ti9t 1�,GD - / .o I Q
Sabject to approv .by auy c
au caer i G+•���1
thorit hv. aLmg ur 2a1c ao
CITYo£ m N �� v
Z, SAmmff,ioij i a: 0
EW 2,8 FL OR JOISTS SIST ED
O EXSTINC FLOOR JO STS I IOR F' _ v l.>1: crw
LL FI E DAMAGED FLOOR J ISTS `j�
I THI ARE AS REO RED. rj�a i �
( PU-NS Ane APPROVED SOLELY FOR IOEAif i,^.>i O:OF I
to !7IJ® n TYFE AND LOCAiFON OF FIR' ^"pT��, ; [ J rrg, I Q) a o
n/!'-L FIRE PROTECTION ^E1,QE� J:.Ci TO A I O �I 1 0 E
FIIlALTESTAND INSFF(MION,FOk::0.�5.= CII,,i=*• �,,y d
w W a n A O
w I� --------------
o_
L
AB'
BASEMENT PLAN
SCALE: I/9"=1'-O" ,
LEGEND: S�Fp la°n
C = _ = WALLS TO BE REMOVED
v �
NEW WALLS
O EXISTING WALLS TO REMAIN U o
OO UP III
O O I D.W. C�fl
.
BEDROOM BATH Y ' +
REMOVE EXTERIOR V
o PORCH WALLS. INSTALL
E NEW 42' HIGH RAILING. I
NEW CABINETS, COUNTER, APPLIANCES
AND PLUMBING FIXTURES., IIIIQjj
'
Gm illy � � �II
PORCH c v
IIII m
KITCHEN
CL.
O NV
P III °4
V *REPLACE FIRES SMOKE DAMAGED
V FINISH MATERIAL NECESSARY. CL STAIR #2 n iUy U v A
U AIR #I l PORCH
IIII
IIII
IIII o
O ___--------- n
C
---------------------
CL. CL. . I ili I •p O v
O o
;„4
° A
IIII '77 �[, -• /1\ °
a O W 5
LIVING ROOM BEDROOM. • • BEDROOM a N $
2 ' I '
W o
t/a O q o
a
III W l+y �y e a Ap
rl QI mo o a
gFIRST FLOOR PLAN Al
Iv SCALE: I/9°=1'-O'
ED �flq
LEGEND: M. �hr�c w
C _ WALLS TO BE REMOVED O
NEW WALLS
O EXISTING WALLS TO REMAIN S
------- -------
O O L__� �ro__ ___J R. uP
0 0 D.W. i t^--1
REMOVE EXTERIOR
PORCH WALLS. INSTALL II
NEW 12' HIGH RAILING. n
BEDROOM BATH U
NEW CABINETS. COUNTER, APPLIANCES
AND PLUMBING FIXTURES. II
/ /�� III • �
C L. to U
------------
KITCHEN
I II ^ «
N
U N
U eA ooIR
N�
C
*REPLACE FIRE AND SMOKE`DAMAGED
� ' FINISH MATERIALS AS N CESS Rr. CL STAIR #2 t� U ; G ,•
STAIQIIRl PORCH ° li Q °ro"aw
I II II I
y III I
III o
------------------ C
(l CL. CL
�./ ---- i 'li p O %
w ^,
tt/ i u i > m
I III a[i �1
� � d
III C TTT�� It
LIVING ROOM BEDROOM BEDROOM 0 N �� o
I ;; I
lli b O
I
I III o
"o
a
0
II �Vy
I , I a N a N A A
SECOND FLOOR PLAN A2
�" SCALE: 1/9"=1'-O"
i
r
LEGEND: M. T
[ _ =WALLS TO BE REMOVED O
NEW WALLS Y,
O EXISTING WALLS TO REMAIN •� a
0 0 1 � __--
R. III I
0 0 D.W. -- Cfl
III II I
BEDROOM BATH J�
REMOVE EXTERIOR U
c PORCH WALLS. INSTALL
NEW 42' HIGH RAILING.
LNEW CABINETS, COUNTER, APPLIANCES III AND PLUMBING FIXTURES.
III I
r.
-----CL.----- v^l' bJ)
Q a
KITCHEN ° A
N us N
III I � N CN
U Q,��
DN i II II � 4� •�� ro.c
AIREPLACE FIRE AND SMOKE DAMAGED
FINISH MATERIALS AS NECESSAR7-.\ STAIR #2 (� o °off
STAIR ttl £ �J CL. i; o t 0 9
PORCH waw
SIf ® fl ill
O
p ri
" ------- ___CL. II o i-1
------- III
III v1 `y..l U
LIVING ROOM BEDROOM BEDROOM a O �� o
I
T
I III I
I III I
I I I I O
III I
CL. In
" �I
Q (� •^ C aptp
I a M
I
A3
•. THIRD FLOOR PLAN
iv SCALE: I/'4 1'-O"