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184 LAFAYETTE ST - BUILDING INSPECTION (3) 110 CV, 3nOz .gg��g, The Commonwealth of M chusetts 4Yu Department ofljpf�lcc$a 1�t1VED AlassachusettsStateBuildingC e(780CMR)SAl FVICES Building Permit Application for any Building other than a One-or Two-Family Dwelling .(This Section For Official Use 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) /0-1 4AEA4om a e.k,c,0" io Zo I 1'r No.and Street City/Town - Zip Code Name of BAWing(if applicable) SECTION 2•PROPOSED WORK l Edition of MA Slate Code used_ If New Construction check here❑or cheek all that apply in the two to below Existing Building❑ 1 RepairRr Alteration ❑ 1 Addition O 1 Demolition O (Please fill out and submit Appendix I) Change of Use ❑ Change of Ocatpancy ❑ 1 Other ❑ Specify: . Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 6- Is an independent Structural Engineering Peer Review reyulred? r Yes ❑ No 9— Brief Description of Proposed Work: $e.wteuL Nt,�yj-L,..n� b.4 7 0 e c wr 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): I Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA _ - Existing Proposed No.of Flouis/Stories(include basement levels)&Area Pcr Floor.(sq.ff.) Total Area(sy.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 ❑ F: Facto F-I❑ F2❑ H: High Hazard H-1 O. H-2❑ H-3 O U4 O H-5 O L• Institutional 1-I❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R. Residential R-I0- R-2❑ R-3❑ 'R-4❑ S: Storage S-I❑- - S•2❑ U.. Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) - IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ [fill ❑' . IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details an each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal; Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench willnot be Licensed Disposal Site❑ Private❑ or indentity Znne: or on site system❑ required O or trench or specify: permit is enclosed❑ _ Railroad right-of-way: Hazards to Air Navigation: MA I hilwir C,mind,slon M,i. r 1'mics�: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Budd 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[ Dees the building contain an Sprinkler System?: - Special Sliputations: 7-0 WNtTSACPU GitZ _ rn f�L 1O�Z � SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner . Alr�r}{n Sat-c �p�c 6`l go qr,� Sr 1,q-dVdf wa 019a�_ 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 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 thin 35,000 cu.ft.of enclosed spam and/or mat under Construction Control then check here D 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 SA b a-1-1 a i �ve\o olvl Company Name -JA%ho 5A6aA-dal, GS -o6ge\�( Name of Person Responsible for CoAstruetion License No. and Type if Applicable ��, .3`-( WVtl}6 yes-..� Ll'r«� [>JeY(-i `"LSD le .f+C - Street Address City/Town State Zip _ IDS - O7 93Rf 54bb,( S-76 (e C� rv\',k • COrt, Telephone No. business Telephone No. cell mail address SECTION 11:1VORKEPT COhIPENSAI'ION INSURANCE AFFIDAVIT 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 O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor _ (fit pOO and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee-Total Construction Cost x 1 (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ d.Mechanical (HVAC) $ Note;Minimum fee=$ (contact municipality) S. Mechanical Other $ Enclose check a able to pr 6.Total Cost $ 10,000 (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. per(} $vim q ,DRJ10 SAW lv �tik.14.�L (Zt� '�-�?9 1 Plese,vrint anCi sign n me Title Telephone No. Date C� �1. Vy�- 0\9 r e Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval Name Date �ovr veorrMcu/1/ti o�!� Once of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR Type. I �l? registration rP 182132 Corporation Expiation 611/2017 SABATINI DEVELOPMENT DAVID SABATINI 34 WHITEHALL CIRCLE --` BEVERLY,MA 01915 �I y Undersecretary rl. Massachusetts -Departmentjd�d Board of Building RegulationStandards Construction Surcro+sor9619License: CS-08, „sv [Sabafinf 34 veflY MA 019lMrcre Beverly 6. Commissioner The Commonwealth ofMassaehusens DepuMnent oflndustrialAccidents 1 Congress Street,Suite 100 Boston,AM 02114-2017 www.masxgov/dia 'pWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumben. TO BE FILED WITH THE PE ZA11T14NG AUTHORITY. Aaalicant Information Please Print Ledbly Name(Business/ofgaointionq dividual): SA)2A-Fl*t t l)n tn(le , ..L Address: 1 1✓ t. \s City/State/Zip: b Phone#:_ 9 8 8 O-1 q3 ct.l Are you an employer*Check the spprop, to box: - Type Of Project(required): l. a employer with !i,"uployees(full and/or part-t me).' _ 7. 0 New construction 2.❑I son s sole proprietor mpartnersh p and have no employees working forme m, 8: Q R,emodpiing any capacity.[No workers'comp.iostusnce requiraj - 3. I son a homcow doing all work myself.(No workma' 9. ❑Demolition . comp.announce required.)t 4.p I am a homeowner end will be hiring contractors to conduct all wmk on my property. I will 10 p Building addition. enure that all contractors either have workers'compensation insurance or sm sole I LE]Electrical repairs or additions Pmpt etors with m employees. 12.Ej Plumbing repaint or additions 5.a I am a general comractor and I have bhed the sub-tamate ra lWed on the attached sheet. ' These sub-contractors have employees and have wo*='rnmp.insmance l 13.Q Roofrepami 6.O We are a corporation and its officers have exercised thearight of exemption per MGL c. 14. 'Other )'"rec iN� - � X 152,§1(4),and we have no employees.(No workers'comp:insurance rationed.] -Any applicant that checks hoc ill must also fill out the section below showing thefr workers'compensation pohry,mfoimeuco. . r Homeowners who sulimit min affidavit indicating they are doing all work and then hive outside eoonactors must submit a new affidavit mdihwting such. 1Contractm that check this boa must attached an additional sheet sbowiog the mmc of the sul,-c -taut ors and state atiether m not ihace entities have employees If the subconyacmoahaveemployam theymn5tprovido their wmkers:.mmp.polirymmber. -.. I am an employe that is providing workers'compensation insurance far my employees. Below is thepolicy and jobsile Information.Insurance Company Name: r Zes/ e Rnj Policy#or Self-ins.Lic.#: ,Gl xe�. c- Expiration Date: 23 / 16 Job Site Address: !S `A PA y E(}G 5% City/State/Zip: SP 12nv1 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c.M,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up.to$25.0.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification." I do hereby certify under the pains and penalties ofperjury that the information provided above is hwe and correct Date: /a�lq�l�� Phone#: 9 - PO-) — 93�! F eonly. Do not write in this area,to be compleedbycity ortown ojjJckIwn: Perlrit/License# thority(circle one): f Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector rson: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,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 of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the 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 grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§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,§25C(7)states"Neither the cormnonwealth 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 till out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(I.LP)with no employees other then 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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned 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 be sure that the affidavit is complete and primed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that most submit multiple permit/license 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 that 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.a dQg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727A900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ATE A� CERTIFICATE OF LIABILITY INSURANCE D0/19 OD015 10/19/2015 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 r 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 Donna Nicholson NAME: Leslie Ray Insurance Agency, Inc PHONE (978)927-2600 aC No: (978)927-8938 129 Dodge Street A2b,,AIaLrss,donnan@leslieray.com INSURERS AFFORDING COVERAGE NAICIt Beverly MA 01915 INSURERA:LlO ds of London INSURED INSURERB:Safety Indemnity3618 Sabatini Development LLC INSURER C:HartfOrd c/o David Sabatini INSURER D: 34 Whitehall Circle INSURERE: Beverl MA 01915 INSURER F: COVERAGES CERTIFICATE NUMBER:2015 Certificate 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 AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE AD POLICY NUMBER EFF MM/DDY/YYYY MM/DDY EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE OCCUR TR/R/362694/001 /15/2015 /15/2015 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accdent B ANY AUTO BODILY INJURY(Per person) $ 250,000 ALL OWNED X SCHEDULED 710572 /23/2015 /23/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS 500,000 HIRED AUTOS AUTOSNMED Parr .,deROPER7iitOAMAGE $ 250,000. Uninsured motorist Blspit lima $ 250,0001 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ C WORKERS COMPENSATION VJC STATU- OTH- AND EMPLOYERS'LIABILITY LIMITS FIR ANY PROPRIETOWPARTNER(EXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 I,FICER/MEMBER EXCLUDED' N/A 6S60UB-2E11416-6-15 /28/2015 /28/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Shore Arc ACCORDANCE WITH THE POLICY PROVISIONS. 64 Holten Street Danvers, MA 01923 AUTHORIZED REPRESENTATIVE - Richard Jones/SARAHG ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005),01 The ACORD name and logo are registered marks of ACORO �,e a �ti a' •�Cyr O L . '�� `• se,°�\ sue.".`'.:_ 4 ,. ., �J is = � • 4,:� Y.���t' http://salem.patriotproperties.com/image/I 111 1110/19/2015 OTY OF SALEA MASSAML SEM BuimnYGDEPAmmEw 120 WAgmYGTONSm=T,3IDR oox 7kL(978)745.9593 FAX(978)740-9846 RIIvlBERLEYDRISWLi. MAYOR 7YKWM STAEM DntEcrcacFpuBucpxopERTy/BuwmoommomR Construction Debris Disposal Affidavit (required for all demolition and,renovation work)' In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL 00, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address o facility) Signature of applicant /0/ l4//5 — Date