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51 LAFAYETTE ST - BUILDING INSPECTION (6)
The Commonwealth of Massachusetts / 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 Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) St LATWu eTTE ST SALE01 MA 0t9-)0 eEQgN LOFT& 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 T( I Alteration ❑ Addition ❑ 1 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 ❑ Brief Descriptiono Proposed Work: rCHQVI� {.'AT� TILE AN!\ Tut! ►NSTTrX EIrJ SHoWFR. PAt,l -nL.E WALU< A FLool� 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.) Total Area(sq.ft.) and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5 ❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 El ❑ H-5❑ 1: Institutional 1-1 ❑ 1-2❑ 1-3 ❑ I-4❑ M: Mercantile❑ R: Residential R-10 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) IA IB ❑ IIA ❑ 11B ❑ IIIA ❑ IIIB ❑ 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 4 Check if outside Flood Zone Indicate municipal ❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system required ❑or trench or specify: permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner F1bPM Lal Fl` lETTE S�. SALEPt I�Fl 9� '1 0 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 �0—tj (iJREWC) (s- cis ' aAL-9 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 less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O 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 Nov co'\S ti�?_Uczl.0 f.8 n o L.LtJ ` 1WG � Company Name Tt+ W cl 9S Name of Person Responsible for Construction 9P L£LA License No. and Type if Applicable ir., Ub,W, HA o L) Street Address City/Town State Zip 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 issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 009 Building Permit Fee=Total Construction Cost x_(insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ ci 0 0 c� (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,1 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 of my knowledge and understanding. Please print and sign name Title Tele o. Date Street Address City/Town ate Zi ''') l/ ` Municipal Inspector to fill out this section upon application approval: / D1 / Name Date 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. PI fill in the information below and submit this ap pendix ppendix 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) No. and Street City /Town Zip Name of Building (if applicable) For the above described property the following action was taken: P p Y g Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off. Yes ❑ No ❑ 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) 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 applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities, Wettand,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investi ation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) `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 Street Address City/Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Discipline Expiration Date Street Address City/Town State Zip s 1Lta:rrhu.rll. - Dc ranmcm of Public :":dco _...___:_,.__,_„ ,_- --•----_—.—.—.—____..___...._... Bu;u'd ns 13uildin_Supervisor . :ce 11:wd;i rtls Office0 onsumer Al�alrs 0 sines e'.I.ta , Construction Superv(sor License 1. _� • HOME IMPROVEMENT CONTRACTOR License: CS 89905 Registration: 146850 Type: Restrc[ed to: W Expiration: 5/20/2013 Private Corporatio 1 N TOMASZ A WABNO CONSTRUCTION$REMODLEING, INC. 15 HIGGINS RD TOMASZ WASNO MARBLEHEAD, MA 01945 ,.#L. 15 HIGGINS RD. go MARBLEHEAD, MA 01945 Uudersecretary Expuatron: 6/4/2012 ( ...... i..urr 1 B: 26405 Restricted to: 00 License or registration valid for individul use only 00- Unrestricted before the expiration date. If found return to: IG- 1 2 Family Humes Office of Consumer Affairs and Business Regulation t 10 Park Plaza-Suite 5170 Boston,MA 02116 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. p Referto: WWW.Mass.Gov/DPS Not valid wit out signature ® DATE IMM/DdYYYY) acoRv CERTIFICATE OF LIABILITY INSURANCE 7i13i11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,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 endorsement(s). PRODUCER CONTACT NAME: Circle Business Ins. Agcy, Inc PHOXC.NE Emi (976) 777-5619 F"X No): 1978) 777-4898 247 Newbury Street ADDRESS: PaulaBalas@CircleInsurance.net Danvers, MA 01923 PRODUCER 1061 INSURE SAFPORDING COVERAGE NAIC It INSURED INSURERA:Northland Ins Company Nova Construction S Remodeling INSURERS:Travelers Insurance i 15 Higgins Road INSURERC:Liberty Mutual Marblehead, MA 01945 INsuRERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE AWL SUBR POLICY EFF POUCY EXP LTft R MID POLICY NUMBER MM/OONYYY MM/DUYYYY LINTS GENERAL LIABILITY EACH OCCURRENCE $ 1 000 OLIO _ t A X COMMERCIAL GENERAL LIABILITY WS073626 5/18/11 5/18/12 DAMAGE TORENTED $ 100,000 CIAIMSMADE FXIOCCUR MED EXP(Any one Persm) $ 5,000 PERSONAL B ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 1 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2 ,000,000 POLICY PRO LOC $ AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT S 5/18/11 5/18/12 (Eaaccidert) B ANY AUTO BA1427R926 BODILY INJURY(Per person) $ 100,000 -II X SCHEDULED AUTOS ALL O WPE D AUTOS BODILY INJURY(Per accident) $ 300,DDD PROPERTY DAMAGE HIREDAUTOS (Peraccidenp $ 100,000 X NON-OWREDAUTOS $ $ UMBRELLA LIM OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN �y I 5 18 11 5 18 12 C ANYPROFFICERMIEMBERU(CLLDED?ECUTIVE L N/A WCI-31S-366560- E.L.EACHACODENT $ 100,D00 (Mandatory in NH) E.L.DIS EASE-EA EMP LOY EE $ 12 2 ,DDD If yes,descrThe under DESCRIPTIO N OF OPE RATIONS below E.L.DISEASE-POLICY LIMIT $ 50D ODD DESCRIPTION OFOPERATIONS/LOCATIONS/VEHICLES (Atwell ACORD 101,Additional Remerus Schedule,if more space isesgdred) I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tos.E.ey ��m�Pcu,..Wnv. .cnn= City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington St. , 3rd Floor Salem, MA 01970 AUTHORRED REPRESENTATIVE o:: Paula Halasoa o; 11051ed W.a. © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD