9 KOSCIUSKO ST - BUILDING INSPECTION 'I(13- iL4 1 (0 L-1 GJ a0LF (;�7
The Commonwealth of Massachusetts
y ^ Department of Public Safety
• II \I.issachusetts State Building Code(780 CNIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only) Y
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Building Permit Number: Date Applied: Building Official: v
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SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is n vailt.'
Cka�+ucko5+ 3 * v D
No.and Street City/Town Zip Code Name of Building(if ap&able)pm
SECTION 2:PROPOSED WORK cn.
Edition of NIA State Codu used_ If New Construction check here❑or check all that apply in the Iwo ows tv
Existing Building❑ Repair❑ 1 Alterations I Addition❑ 1 Demolition ❑ (Please fill out and submit emlit'P
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: 4J Gp
Are building plans and/or construction docwnents being supplied as part of this permit application? Yes ❑ Nog.r��
Is an Independent Structural Engineeri h,Peer ev'ie�w�rrequ_ir�ed?/ 1 / I_1 Ycs ❑ No P4
Brief Description of Proposed Work: `Yfl� fIXSr (Y)S ItlG,ll(3'1 r7C I �IC�I SAA�
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 CMR 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.) 10A&^-5 D qq IfLCIs —5-5-b
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5: USE GROUP(Check as a plfcable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ F B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ ti. Hi h Hazard H-1 ❑ H-2 ClH-3 ❑ H-4❑ H-5❑
L• Institutional 1-1 ❑ 1-2 CI [-3❑ I-4❑ M: Mercantile Cl R: Residential R-10 R-2❑ R-3❑ R=4❑
S: Storage S-1 ❑ S-2 Cl U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION G:CONSTRUCTION TYPE(Check as applicable)
fA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ II100 IV ❑ 1 VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 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 municipalm A trench will not be Licensed Disposal Site❑
required 9 or trench or specify:
Private❑ or indentify zone:AE or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: 11-\ 1 111101 is C': mnu, 1 n Ijr
Not Applicable ct o rew,bi Is Struitbin airport approach area? Is their review ConhplUted?
or Consent to Build Unclosed ❑ 1 Yes❑ or NoW Yes❑ No ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Coda: Use.Croup(s): Type of Construction: Occupant Load per floor:
Does thO building Contain an Sprinkler System?: ._ Special Stipulations:
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M(N,*tI-a-!D ( t a
SECTION 9: PROPERTY O6VNEll AUTHORIZA"FION
Name and Address of Property Owner
Q1C� 1GY?� binle rn 9 6,,Ecj .S kD 3Q km W p U
Name(Print) No.and Street City/Town zip
Property Owner Contact Information:
85`-7-. lz- _ rkdict, hp fmai),(
Title Telephone No.(business). Telephone No. (cell) _ e-mail address
If applicable, the property owner hereby authorizes
rr_ �
u.. ±i
Nmne� Street Address City/Town State Zip r
to act on-the property owner's behalf, in all matters relative to work authorized by this buildbig permitaEElication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If 6u ilding is less than 35,000 cu.R.of enclosed s ace and or not under Construction Control then check here.N and skip Section 10.1
10.1 Rekistered Professional Responsible for Construction Control
Name(R'aPistra ' Telephone No. e-mail address Registration Number
w
Street.Address . . City/Town State- Zip- . Discipline Expiration Date
1f0.I2,General Contractor
W i lley Ie- Se Vi cc S S l o t;-
C mp Nee ID( IS- Cons C(IUn SU VI peKSUVI LjFCpr1 .
�''�amy m
Vi �e I b 12-9 3 - NDmc- Impravemenl corl frcfc (1
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town Sttaattee - Zip
Telephone No. business Telephone No. cell T e-mail address -
SECTION 11: 110N INSUU NCH:\J FIU,\VIT M.G.L.a.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:CONSTRUCTION COSTS AND PERMIT FEE
Item Estunated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
1. Building S Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)='S
3. Plubing S
d. �1 mechanical (HVAC) $ ,Note:illininmun fee=$ (contact municipality)
5. Mechanical Other) Enclose check payable to
6.Total Cost `5 367 aJ (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 ell of the information contained in this
11( lication is truee�and accurate to the best of my knowledge and understanding.
K-i o-rd 6pyllel5r m
P II
sprint
and si n name Title
I/K st=, IS+ i3 Sale YI f A,�Tclep o17e�J Date
Street Address Cit Cown I"y 1
y/ State Lip
Municipal Inspector to fill out this section upon application approval:
Name av,
Printed: 'r0/10/2014 12:31:22 PM Sales Order#6273
Store: NRE
Ordered: 10/10/2014
Cashier: Michael Associate: Michael
HEARTH WORKS FIREPLACE CENTER, INC.
250 MAIN STREET
NORTH READING, MA 01864
Phone: 978-664-0100
Fax: 978-664-8007
Email:HEARTH WORKS1 @COMCAST.NET
Richard Danielson
9 Kosciuskco St
Salem, MA 01970
978-223-0926
857-2224229
Order . Lookup Description Price E)dPrice
1 EFMINIA MINI FS PELLET STOVE W/ HEAI $2,599.00 $2,599.00
1 . SDV3PVPT SINGLE TEE W/CLEAN OUT TEE $93.15 $93.15
1 SDV3PVPAD APPLIANCE ADAPTER $16.00 $16.00
3 SDV3PVP36 36" STRAIGHT LENGTH PIPE $61.45 $184.35
1 SDV3PVPF6 ADJ ROOF FLASHING $18.00 $18.00
1 SDV3PVPSC STORM COLLAR $5.80 $5.80
1 SDV3PVPVC VERTICA CAP $44.40 $44.40
2 SDV3PVPE45 45 DEGREE ELBOW $60.60 $121.20
1 SDV3PVP24 24" STRAIGHT LENGTH PIPE $45.85 $45.85
1 SDV3PVP12A 12'ADJUSTABLE LENGTH PIPE $46.65 $46.65
1 PELLETS BAG-OK DOBAG OF PELLETS-DOUG FIR $0.00 $0.00
1 SDV3PVPFS3 CEILING SUPPORT FS 3" CLEAR $78.85 $78.85
Total Oty Ordered: 15 0 15
Subtotal: $3,253.25
Deposit History MA SALES TAX 6.25%Tax +$203.33
Document Dal Receipt# Amount Payment TOTAL: $3,456.68
10/10/2014 21227 $372.80 Credit Card Deposit Balance: $372.80
Balance Due: $3,083.78
INSTRUCTIONS: Install When $599 + Permit
2nd weed of november customer will be gone
Up thru roof install
Signature
ALL SALES FINAL PLEASE SEE REVERSE
CONDITIONS OF SALE
1. All sales are final with exception of stocked screens and tool sets may be exchanged
within seven days. Extra chimney,stove pipe and gas venting purchases may be
returned for a refund within 30 days provided it comes back in its original condition
with a receipt. Management reserves the right to charge a 20% restocking fee if a
decision is made to allow any product to be returned or sales order canceled.
2. All products must be paid for in full before installations can be done. Your installing
contractors will not be able to provide delivery/installation if not paid in full.
3. All products must be picked up within 30 days of notification to the customer of its
arrival in either our warehouse or stores. Hearth Works Fireplace Center, Inc. will not
be responsible for product left over a 30-day period.
4. Applicable building or other permits(if any) must be obtained by a licensed contractor
for wood, pellet or gas products.Gas permits are obtained by the customer's plumber.
5. All warranties are by and through the manufacturer. Travel fees are not covered under
warranties.
HEARTH PRODUCTS-
INSTALLATION CONDITIONS
HEARTH PRODUCT INSTALLATION IS THE RESPONSIBILITY OF THE CUSTOMER. If the
customer so chooses, Hearth Works Fireplace Center, Inc.will, on the customer's behalf,
contact a hearth product installation contractor,who is prepared to perform installation
services in accordance with these prices and conditions. CONTRACTORS PROVIDING
INSTALLATION SERVICES ARE THE AGENTS OF THE CUSTOMER and all charges for
installation are payable directly to the contractor by the customer. Contractors will provide
you with a written warranty of their work outlining their responsibility for the quality of their
installations. SECURE YOUR COPY FROM THE INSTALLER. All installers require payment on
completion of work. Installation prices quoted at our stores are minimums that our
contractors charge.
INSTALLATION INCLUDES:
1. Delivery.
2. Assembly of a product.
3. Assembly of product attachments(Fans,Surrounds, etc.)
4. Mechanical venting.
5. Clean up (removal of all product packing).
CUSTOMER RESPONSIBLE FOR:
1. Removal of existing stoves.
2. Removal of an existing chimney to be replaced.
3. Removal of existing glass doors, debris or grates in fireplaces.
4. Carpentry if needed.
5. Electrical services(including thermostat wiring in walls).
CONTRACTORS ARE INSURED AND REGISTERED AS HOME IMPROVEMENT
CONTRACTORS. Customer satisfaction is a primary concern Hearth Works Fireplace
Center, Inc. If for any reason you are not satisfied with some aspect of your
CONTRACTOR'S SERVICE, CONTACT US FOR ASSISTANCE AT 1-800-265-0585.
DERBY HERITAGE TRUST CONDO ASSOCIATION "
26 Daniels & 9 Kosciusko Street, Salem, MA 01970
November 6, 2014
City of Salem Inspectional Services
120 Washington Street, 3rd Floor
Salem, MA 01970
RE: Approval for Building Permit for 9 Kosciusko Street, Unit 3
Dear City Inspector:
The purpose of this letter is to state that the members of Derby Heritage Trust Condo Association held
our annual meeting on Tuesday, September 9, 2014 where owners of 9 Kosciusko Street, Unit#3 Rick
Danielson &Jennifer Cusick informed the condo association of their intent to install a pellet stove into
their unit by end of year 2014.
The members present that evening voted and a quorum unanimously agreed to permit the installation
of a pellet stove in Unit#3 of 9 Kosciusko Street.
Please approve the permit required for this installation. Should you need further information, please
feel free to contact me at 781.665.8919.
Respe ly,
Eliza th Cronin
Trustee of Derby Heritage Trust Condo Association
26 Daniels Street, Unit#4
Salem, MA 01970