320 LAFAYETTE ST - BUILDING INSPECTION (5) ; . The Commonwealth of Massachusetts
&/
Department of Public Safety
\la...vchus.•Its date BuildingCode(780 C:SIR)Seventh Ediuu n
City of Salem
% BuildingPermit Application for an Buildingother than a I- or 2-Famil Dwellin
�a (rhis Section For Official Use Onlv)
aBwldi 'ermtt Number. Date Applied: Building Inspector:
eSECTION l: LOCATION (Please indicate Block 0 and Lot 0 for locations for which a street address is not available)
320 5F. So Wm I µ.A ola7t(
No. and Street City /Toren Zip Code Name of Building lit applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all thatapply in the two rows below
Existing Building ❑ Repair❑ Alteration � Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:•
Are building plans and/ur construction documents being supplied as part of this permit application? Yes GY, No ❑
Is an Independent Structural Engineering Peer Review r uired? Yes ❑ No 0
Brief Descnptio f`Pro tsrd Work: Nlf7
r klar�
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,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
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area (.sq. ft.)and Total Height(ft.)
SECTION S:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑. E: Educational ❑
F: Facto F-I ❑ F2❑ H: Ht Hazard H-I ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1.3❑ 14❑ M: Mercantlle❑ R: Residential R-10 R-2❑ R-3❑ Ri❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and lease describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ HA 11110 IIIA ❑ 1118 ❑ I IV ❑ 1 VA ❑ V.
SECTION 7:SITE INFORMATION Irefer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage D s osal: qa Trench Permit: Debris Removal:
I'ubht• ❑ Check it outside Fluud Zone 0Y Indicate mumdpal ❑ A trench will nut be Ltcc•metl Dia>as.d Sltr❑
:t:quired❑or trench ,tr .pectiv:
I'ncn A or,ndcnt,h' Zone: ttr un,rtr.c.trm ❑ permit i*enclti ed 0
• Railroad rigbt•of-way: Hazards to Air Navigation: CIA I16.1,•r„ (-, mm......n It,t n it Pn•
\oI Ap ,I,ioblyla/ 1,'�Irurlurc tc,lhnt atrpnrt el+l•ruach ure.t I.their re%ie%% omipleted.'
a'l nt�••nl h, liu,Id vttcLtvd ❑ Yv,❑ ur .No e )'e*❑ \„ ❑
SECTION 8:CONTENT OF CERTIFICA-rE OF OCCUPANCY
I.,filwn ,4 Code. L,c rt pcul C n ,truclwn: Occulmnl Load pvr I-tune:
I luv. the buidlor; .111.un.111 Sprinkler;%.turn': ;hyc,al1;I,puh1wn.:
SECTION 9: PROPERTY OWNER AUTHORIZATION
N�r�m�e��and Address of Property l)wnrr r t
4 )M, de, V 4 15' �^^f1 K�L�vr+ oS
Name(Print) No..md Street City/town Zip
I'rop.rly Chvner Contact Information:
Title Telephone No. (business) Telephone No. (cell) a-mad addrvas
If ap •tic. plr, Ih pnrpe t)• uw r hereby authorizes
I X I agar tuccf�Crl1� 2 $4lfP,ti�A Rip Id LCA&gpd UA 610?4-
v
Name Street Address City/Town State Zip
to act on the pro•erty owner's behalf, in all matters relative to work authonted by this building permit a p lication.
SECTION 10:CONSTRUCTION CONTROL fPlease fill out Appendix 2)
(it Intilding is less than 35,0011 cu.tt..d endusad p+ace and/ur not under Construction Control than check here O and..+ki Svti'twn I0.1)
10.1 Re istercd Professional Responsible for Construction Control
Iyln riCr�1 iQ.x A91. 3C74 �2103 Wd" 9VA 4t-) �1�_
N tin (Registrant) T' a one No e-mail a rrss f� R gis atiun Number
lei-
Street Address City Town State Zip Discipline E pire
10.2 General Contractor
rtrnp4futt� e� '( ��fJ'ffYYlMllNlCf �YI� SGW1�
Curtlpy_ mL(ACl/171/�1 CS 1��7�
M A!Y{N �
^me u(��.yn Rrs�r�b ur Construction d '' �/.y�Li�rnse No. and Type if App ....Q24q
treet f„•ddr ��,�j -- 1 City//iT1o4w1.ln/!l. State Zip
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11:WO KERS' ENS INSURANCE AFFIDAVII(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 theJ'ssuance of the building permit.
Is a signed Affidavit submitted with this application? Yes` 3 No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated 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. Plumbing S
4. Mechanical (HVAC) S Note: Minimum fee=S (contact municipality)
5. Mechanical (Other) S Enclose check payable to
6. Total Cost I S +RCV (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 cnniatned in this
application it true.md accurate to the best of my knowledge and understanding.
C�uk V 60# 'M -tea 494M
f itlrfelephh�on \o. Uair
street .Nddres Cthi T,p%n State zip .
Municipal Inspector to fill out this section upon application approval:
Name I)ate
rJ
Massachusetts- De1 m rartent of Put ( Sato)
li c Sato ,
Board (it' Buildim-, Rcgulaliuns and Standards
Construction Supervisor License
License: CS 103065
Restricted to: 00
MARK LUDWIGcr"t
20 MEADOW DRIVE
MIDDLETON, MA 01949
��- �•��� Expiration: 9/112012
(oauni vinnur Tilt: 103065
Io + I moaar.I.,..u:A A: nlo.a.l:m/ ""'.Ice ^a"W llcL..gpllO lDsu/apce ID U.;.1 Date 7/132009 C934 AM Page :?of2
ACORD_ CERTIFICATE OF LIABILITY INSURANCE OP ID Bs 'A�7/23/09
1 CTSZN-1 07/23/09
THIS CERTIFICATE IS ISSUED AS A NATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
IFlc Lauchlin Insurance AFTency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
82A Lynn Fells Park'.:nv ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Nclrosc I•A 02176
Phone: 781.665_2775 Fax'7RI-665-00295 i INSURERS AFFORDING COVERAGE NAICA . +
111419F') NH.REra Ohio Casualty Group
Ixl Peerless Insurance Co. f 24198
CTS, Inc
Mr.
99 CreSGCfI. .0:1 Tie
Chelsea 1-1A [i$150
nY.nP FC
COVEFAGES
•110 Lv,Y nd50rED;W:ED h:•T:E I Fix NP=1'-.
MSS DIr,E
1 ul 141 f( - 4 = L-l"111,11 rtn AF.nLl11.-,eu NG r2nM1r.Ex,L .I 4'-SV:<i. i_:. , .
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POLKY U4En POLICYEFFECTIVE POLCvr)(FIRATION
FmI., 1PI'JF1rLRAt1 I
DATE('.%V:D0ANj DATE IIt'ITS] A
elm. LLu urr E I. nrnEr f1,000,000
rru. F'.. F1-1lrn
.ti'.r-a > i-i-+.� - �I BIGi71052737657 07/01/09 07/01/10 la I. I IEa t 300,000
� '•:L� q': .. . ';r. Ak Er :ta >�I 110,000
1
54r.,,,,.., 1,00D,COO
I (ise�RAL •o;.NEr-Ale s 2, 00,000
wF.' ll. ..I .-I. I PFxlT-m- r swrT it ZP000,000
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1Essc.„y,�' t1,000,000
E ( I t
III011;D 1 BA8697750 07/01/09 07/01/10 r- 1 _ I
E IL'rl Ef.I nl _rt �.
11)'JI'6H 1 P.1'A"I 1
F.res5amm5ELt A I.c.'I:T+ E/iHECCIWCCN`_- 5$6,000,000
A [xiV YLIF y�rtA.'la�{C US00952737657 07/01/09 07/01/10 -xx"'E[:ATE 5 $6,000,000
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A Property- BM'1052737657 07/01/09 07/01/10 BPP $20,000
Leased/rented Equi IBM41052737657 07/01/09 07/01/10 Equipment $25 000
IJLtf.Sl�`N.i:!!+a nnF.RGiIIII:':Llr,+l l.^,�;vEwlCtlS/E>CLLSIONSADOEN IFF1. ORSEM.EIR/SPECKL 1RON510115
CERTIFICATE HOLDER CANCELLATION
GLOBA-6 SPOULOAY.YOFiHE P00'/E DESCRIBEp PoLICIES RE C<r:CELLE02EFORF THE Evgq<TIO-I
DAM IHEREOT.THE ISSUING RISWFR WILL EIATEAVOR TO NPII. 30 rAYS'.11 IT
NOTICE 10 THF.CERTIFICATE HOLDER NAIAD TO THE LEF1.BUT FAILURE TO 00$0 SHALL
IMPOSE 1:0 ODLIGATON 09 LIAHA TIN OF ANY µRIG WON UPC INSURER.ITS AGENTS OR
REPRESEWATNES.
AUTH<I PR71AT
cf OPp 7S(JfI01J08) 0 ACORD CORPORATION 1988
_ The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
' Office of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Construction Telecommunication Services Inc.(CTS)
Address:99 Crescent Ave
City/State/Zip:Chelsea Ma, 02150 Phone #:617-884-9811
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or Part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P tY� $ 9. ❑Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.[:3 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no Wireless Construction
employees. [No workers' 13.❑ Other
comp. insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
Granite State Insurance Company
Insurance Company Name:
Policy#or Self-ins. Lic.#:7429800 Expiration Date:07/10/2010
Job Site Address: 3_ {' a ; _ra P, YI City/State/Zip: 01a 70
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 $250.00 a day against the violator. Be advised that 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 true and correct
Siynatuure: Date:
Phone#:
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: