8 LATHROP ST - BUILDING INSPECTION (3) "PermitNUMber:
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts tihrie Building Code(780 CNi R)Serenth Edition
City of Salem
Permit A lication for an Buildin other than a I-or -Famil Dwellin
(ThisSection Fur Official Use Onlv)
Date A +lied:PF Building Inspector:
5 SECTIO LLOCATION 1 lease ' dic a ock f and Lot M for locations for which a street address is not available)
,N'u. and Street Cih• /Town Zip Cody 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 Repair❑ 1 Alteration O Addition❑ 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 Rev[syw rei uijed? ^�, Yes ❑ No
Brief Description of Proposed Work: �-(' �� � � -.f7
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
FNo.
ck her;ann ting Building Evaluation is enclosed (See 780 CMR 3402.0) ❑sting U ): Proposed Use Group(s): —d
ting Hx 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
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-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2 Cl R-3❑ R-4❑
S: Storage S 1 ❑ S 2 ❑ IU: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 118 ❑ HIA ❑ II[B ❑ IV ❑ 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❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑
I'rica to❑ or indenlifi Zone: or on site system ❑ required ❑or trench or.pecifc:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \Lm I li+toric c „mmi+>inn Ho,i,•,+ Pn,,,—:
\ul Applicable❑ 1>Structure mrrlhin airpnrt appn,ach area.' Is their recirmc completed?
ur('„n.cnt Io Build encln*ed ❑ Yes❑ or No❑ Yes❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Ldrtion of Code: Use Gruup(s): Tcpe of Construcion: Occupant Load per Fluor
Dnes the building;contain.mn Sprinkler tim stem?; Special Stipulations:
�V
cz
e
i
SECTION 9: PROP TY OWNER AUTHORIZATION �f
e.md A,dress of Properly Owner g f ,�11h,r� �) L�y�l✓ /l U ��
Name(Print) Nu.and Street Cit%•/Town Zip
Properl%Owner Contact Information:
0iOrleic q7tY-�K k1ya
Title }} �F Telephone No. (business)
CTelephone No. (cell) e-mail address
f parleI&ei ,,erO C h n erebyoul�`hz/�7YlROGK UT- V �Ci/ObL�I�_ l'�1A' br'�1t2�
... Name J Street Address Citv/Town State Zip
to act on the pro pert%)%%tier's behalf, in all matters relative to work authorized by this buildin 6 permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is less than 35,000 cu.ft.of enclosed s pace and/or not under Construction Control then check here 0 and skip Section 10.1)
10.1 R i5tered Professional Responsible for Construction Control
e � /Lv• 47��32 ?�9� /D 79�?
Nam Regi mq Telep, e Nu / e-mail addr5h /g(„ j Registration Numb
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company- e:
Name ofPy(( 'CCu....��R�e/� n/n W n No. and Type if Aplgbley?aQ`9
t re td City/Town V State Zip
1 G a
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
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 0 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor Total Construction Cost(from Item 6)_$
and Materials)
1. Building $ 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 '3" 0
6.Total Cost $ (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 all of the information contained in this
applicatio is true and accurate t p the bes of my knowledge and understanding. —
/f t/�Ji ��- ���L-d
Please pryul.mod>ign �rme Title i ,„I vph )neektp� Date
street :\d%Irei Cit%/Town State Lip
Municipal Inspector to fill out this section upon application approval:
Name Date
"� CITY OF S.UEM, NLASSACHL:SETTS
BVILDLNG DEPARTMENT
120 W.isHiNGTON STREET, )'a FLOOR
T L (978) 745.9595
FAX(978) 740-984
Kj-
.,fBEnEY DRI5C0I1.
MAYORZ110MAS ST.POERRJ<
DIRECTOR OP PL OLIC PROPERTY/RC ILDOOIG Cosonssio.N En
Workers' Compensation Insurance Ailidavit: Builders/Contractors/Electric)anslPlumbers
An licant information 1 i
nt Lesilb
.Name Itlwine,a.Organtruionlc+Jtvtdual�l� �
`'(_i: '.
Address: o 3 tl
City/State/Zip: G Phone
,%re you an employer?Check the appropriate boa:
Type of project(required
1.El am a unployer with •. (] I ant a General contractor and 1
employces(full and/or part-throe).• have s hired the mbcorwuw 6. ❑New construction
2.❑ I am a sole proprietor or partner. listed on the attached sheet: 7• wetnaleling
+hip and have no employee Then sub-contr ones have N. 0 Demolition
working for nit in any capacity. worker'comp.inwnnea 9. 0 BuiWing addition
(No worker'comp insurance S. ❑ We are a corporation and its
mquirail otlt m have exercised their 10.0 Electrical repairs or amnions
1.Cl I am a homeowner doing all work right of exemption per MOIL 11.Q Plumbing repairs or additions
myself.(Na workers'comp. C. 132.1101 and we have no 12.0 Roof repair
insurance required.l t employees.(Nowakers' 1�.(]Other
comp insurance required.)
•Any apphea thtr ehoeka W Of mttst alw nl1 car the mmlm ado W Aawks tkdr.ak.e'centI stains p lky inavivue ms
'I Lmro im.who subete A4 aMdevis indicating shay an Joins an Was W that him outside caentstmt man atMttb a now awdavit indb d s wee
:C,WM'tota char rhaek ckia bag mug aaarhod M aJditiarwl,Irnt thowina tits note era Otte wt►searranam W th*warane'mmp.pdKr ialatmriaa
/oar ea nap/oyer that tr pnvJding rrsrbtr'roagenmat iota l nstnomejor ss .arp/ayaes, Qa/ow Is the poft awdp#sl>tg
Inrar rkra
( v' r��Insurance Company Name:-
Policy N or Self-ins. Lie.At, OV �
Expiration Date:
Job Site Address: "" City/State/Zip:_
Amtch a copy of the works",compessotba policy declaration pap(showing the policy number and expirsdoo date)6
Failure to secure coverage 3s required under Section 25A of NOL e. 152 can lead to the imposition of criminal penalties of■
nine up to 51.500.00 anti/or one-year imprisonment'as well ss civil penalties is the form of a STOP WORK ORDER and a flt»
of up to 5250.00 a day against the violator. Ile adviwd that copy of this awamcnt may be forwarded to the OIYlce of
Inveangmiuns orihe n1A for insurance coverage verification.
/de hereby real ra/i�( nAtT"r he ajper/dry that rha injararer/oa provided u0ovr is nsta and torrid
Pone A
of lria!we un//t De nor write is this area,to be'entp/eted bra airy or town n/Jlrimit t
City or ru+vn: PrrmiN.lcenre N �
i
Ivsuing Authority(circle one):
I. Iloard of Ilvalth I. Ruilding Drpartrncnl 5.City/rows Clerk J. Electrical Inspector 5. Plumbing Inppector
6. Other
Lmflact Person:
GRANITE STATE INSURANCE COMPANY 0085115-00 WC 007-43-5338
13102 --------------------------------------------
013-66-o8o9-oo
D & H CONSTRUCTION CO INC
EET
PEABODY, MA CENTRALST
EXECUTIVE OFFICES:
70 PINE STREET, NEW YORK, N.V. 10270
SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610
JOHN V. ZANNINO INSURANCE AGENCY
WORKERS COMPENSATION AND EMPLOYERS 16 FOSTER ST
LIABILITY POLICY INFORMATION PAGE PEABODY, MA 01960-5504
INSURED IS PREVIOUS POLICY NUMBER
CORPORATION RENEWAL 001278357
OTHER WORKPLACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610
ITEM 2 POLICY PERIOD 12:01 AM.standard time at the insured's
mailingaddress FROM 08/06/09 TO o8/o6/10
ITEM A. Workers Compensation Insurance: Part One"of the policy applies to the Workers Compensation Law of the states listed
here:
MA
B. Employers Liability Insurance: Part Two Of the policy applies to the work in each state listed in item 3.A.
The limits of our liability under Part Two are:
Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500.000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE ENDORSEMENT - WC2003o6A
D. This policy includes these -
SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612
ITEM4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Estimated Total Rate Per Estimated
Classifications - Code Number Remuneration $100 OF Re- Premium
Annual ❑3 Year numeration 0 Annual 3 Year
SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7754
TAXES/ASSESSMENTS/SURCHARGES $515
EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) 8 MA
MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM $7,634
If indicated below, interim adjustments of premium shall be made:
ElSemi-Annually El Quarterly _Monthly DEPOSIT PREMIUM
08/20/09 ASSIGNED RISK 66
Issue Date Issuing Office Authorized Representative WC 00 00 01
39967 (ReVil 04/08)
1
°-- �lassnehusrns - Department of Public Sateth
Board of Buildin_ Regulations and Sianditrds
F Construction Supervisor License
License: CS 68059
Restricted to: 00
MICHAEL M SHAPIRO
33 CENTRAL ST
PEABODY, MA 01960
Expiration: 6/T7./2Q1'Q
( nuuui...i+mcr Tr#: 27766
✓�te L/c+mirreoeuoe¢�lfz mp./�addac�tude%(a
i Board of Building Regulations and Standards
r HOME IMPROVEMENT 102 CONTRACTOR
Registration: 10279898
Expiration: 7112/2010 Tril 270431
Type: Private Corporation
D&H CONSTRUCTION CO.INC.
Michael Shapiro #
33 Central St.
-i„ Peabody, MA 01960 Administrator