15-17 LEAVITT ST - BUILDING INSPECTION (2) CK 0 0 52L-i 1 `cal
r T)-15
CEIVED
CT ONFL SERVICES The Commonwealth of MassachusettsDepartment of Public Safety
^ qq'' AlassachusettsState Building Code(780CMR)
JAN 3kilknAlPePi t Application for any Building other than a One-or Two-Family Dwelling
(Tuns Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
06Edition
N 1:LOCATION(Please indicate Block I and Lot N for locations for which a street address is not available)
FAyty V S9/em (114 a/`} 7Q
t^I et City/Town Zip Code Name of Building(if applicable)
tI , SECTION 2 PROPOSED WORK
ls State Code used If New Construction check here❑or checkall that apply in the two rows belowing Repairer Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
e ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify: •.
I Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No I$
IV Is an fndependentStructural Engineering Peer Review required? Yes ❑ No Ill,
Brief Description of Propposed IV*,,,
Guy v+ry r4 R s r doh ,AQCrI vie nQ a told S A3 Owl
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): IProposed 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.)
SECIRON 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ ll: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2 Cl I U: Utility❑ 1 Special Use❑and please describe below:
Spacial Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable) -
IA ❑ IB ❑ IIA ❑ 11B0 IIIA ❑ IIIB ❑ 1 IV Cl I 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❑
required❑or trench or specify:
Private❑ or indentify Zune: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: T �I i Ij,t n �_rnunissr n I mrr I'r .,a�.c;
Not Applicable Cl Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes[] or No❑ I Yes❑ No ❑
SECTION 8:CONTEN'F OF CEItTIFICA'TE OF OCCUPANCY
Edition of Code: Use Group(s):_ Type of Construction:. Occupant Load per Floor: _
Does the building contain an Sprinkler Syslem?: _ Special Stipulations: --
-OF-' t.UU:rD LI ru
SECTION 9: I'ROPERTY OVVNEIt AUTFIORIZA'CION
Nance and Addressof Property Owner
I,hl �19U kt4NT--rd s NS /S/7 LEf�1 ' S� S>9Jer
Name(Print) No.and Street City/Town t,: . i Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) a-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 than 35,000 cu.R.of enclosed space anti or not under Constmction Control then check here 17 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
T/Y, 0
N1'
V7wAY'- CS p,—v-4z-?
Name(Ryygistmnt) Telephone No. e-mail address Registration Number
h'o7 /or�rG/ sJt- ®g13l3cox r 41A G/ do r:feny /o/6 /c —
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
zj�w Ar-re n A6
Company Name
//
n
HrvtAPAC /7iC. Vzz'1i6
Name of Person Responsible for Construction License No. and Type if Applicable
Z/a 7 16,1"r/� J 'R"13 6V y U 6-0
Street Address City/Town T State Z-iip�
�L-�
Telephone No. business Telephone No. cell e-mail address
SECTION 11:re'0RKF.16'COAu't NSAI10N 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? YeAM No ❑
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
I. Building $ g-(Ooe Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ 060 appropriate municipal factor)_$
3.Plumbing 5 00
d. Mechanical (FIVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ 4100 (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 anti penalties of perjury that all of the information contained in this
application is true and accurate to the b Est f in now ledge and understanding.
�JArY P4* 7tgW CS ?X _ o/_ 70� 3 /
Please print and sign name Title Telephone No. Date
a S QEAGc- v lam& c/ 6tf
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: �`B""`�
Name Date
CITY OF SALEM, MASSAC HUSE M
BUILDING DEPARTMENT
120 WASHINGTON STREET,3ADFlooR
ItL. (978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THomm ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/Bu1LDING ODjaffssIONER
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 c40, 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:
y/Y1Y �/ 61\15-ke-
(name of facility)
LYNni t-,A y L--- y_
(address of facility)
F/L�L
� .
ignature of applicant
Z 3,�i S�
Date
T CITY OF SM E.N•I, NWSACHUSETI-S
t 13ULLDLNG DEPARTNIE-NT
120 WASHLNGTON STREET, 3a°FLOOR
T EL (978) 745-9595
FA_X(978) 740.9846
KI\IBERLF_Y DRISCOLL
',V1,1YOR THoitw ST.PIERltB
DIRECTOR OF PUBLIC PROPERTY/BUILDI\IG CO.\L%IISSfONER
Workers' Compensation Insurance,07davit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Legibly
Name(Boaitus0(ganiratinnl•Individu:1): —Airy p/7 fy/ 1T 0'f/Y
Addre,s: Po - F d)( h'oG r
City/State/Zip: 6E4 aQV X aa O/9& Phone ht:_ V of t;W
Are you un employer?Check the appropriate box: Eiotu"3110n.
projeet(required):
1.0 1 am a employer with 4. 0 1 am a general contractor and 1ew construction
employees(full and/or part-time).* have hired the sub-contractors
2.9 lam a sole proprietor or partner- listed on the attached sheet temodeling
,hip and have no employees These sub-contractors have emolition
working liar me in any capacity. workers'comp.insurance. ilding addition
I No workers'comp. insurance A 0 We are a corporation and its
required.) officers have exercised their ctrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL mbing repairs or additions
myself.(No workers'sump. C. 152,§1(4),and we have no of repairs
insurance required.) t employees.[No workers' or
comp.inwrance require d.j
•Any applicuti lka chucks bar et meet also Meet lite section bdowshowhig their workew'campemoum pulley inrutmadon.
'I hvnouwrwna who.uhmit this a1flonvit indicming they arc doing all wark and then him outsidecuntmctaa mint soh rdl a new affidavit indicaort such
:V.mrmcmra shut check ibis bus most anachal an addiliurud shrel showing the rumc of the sub rom»cton and their workers'camp.pulley Information.
/unr ua eurpluyer rhar 4 providing rvdrkeri'romparsadun htsurunee jot my emp/uyers. Be/uw is rbe pol/cy aid jab slid
iujurnrurinn.
Insurance Company
Policy 4 or Self-itu. Lic.th Expiration Date:
Job Site Address: City/State/zip:
Altaeh a copy of the worliers'compensalloo pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Suction 23A orMGL c. 152 can lead to the imposition of criminal penalties at it
fine up to S1.500.00 undor one-year imprisonment,as well as civil penalties in the form ufo STOP WORK ORDER and o line
orup in 5230.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Ofrice of
Invrsligwiuns ul'the MA for insurance coverage vcrilicatiun. -
/de,hereby cerdjy reader the pains a,d penahles ujperjury rhar the/njuraruda,r provided above is True and correct.
Sill cure' Data:
q -7
Phonc y_
O/jicia/wr atly. Du nor write in this area,to be completed by city l r raves djJlehd
City nr'I'uvn: Permit/f.leense q
L.Ssuing,lulburity(circle one):
L hoard of Iicalth 2. Building 0eparlutenl .1.C'ityffowo Clerk J. Electrical L,spcctur i. Phimbing Inspector I
6. 01 her
i Contact Person: Phone a:
-
� 3 R
n
CERTIFICATE OF LIABILITY INSURANCE DATE MMIDDryrm
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ON AND CONFERS I
CERTIFICATE S10ES NO?AFFiR919 A?'.•��' v OR ON. ER,S NO RIGHTS S UPG THE CERTIFICATE HOLDER THIS BcLO I THIS CERTIFICATE OF INSURANCE D ES NOT CONSTITUTE A CONTRACT BETWEEN THECOVERAGE
INSURER(S).AUTHORIZED
REPRESENTATIVEOR PRODUCER,AND THE CERTIFICATE HOLDER.
161PORTANT It the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject t0 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 hoidar in Ileu eT such endorsements.
PRODUCER
EA Kelley °ONTgCT Brenda Cozzolino
450 Veterans Memorial Parkway A1D,N., (401)709-8338
ADC Re FAX (8005370-2924
Building 5 SS brendac�eakelleycem
East Providence PRODUCER 216303
RI 02914 QUE'
INSURE° Ir' URER S AFFORDING C V G'
John Panlapas INSORERA: Atlantic Casualty lns Co NA
42846
407 Lowell Street INSLRER a:
INSURER C:
Peabody INSURERD:
MA 01960 INSURERS
COVERAGES CERTIFICATEINsuRER F
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISdUED TO THE INSURED NAMED NUMBER:
E MAYNOT BE ISSUED O ANY RED IRE ENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMEN'W�H RESp'eCT TO UMICH RI
VE FOR THE
CERTIFICATE MAYBE ISSUED OR MA"PE RTA!N,THE INSL'RANCEAFFORDEp BY THE POLICIES DESCRIBED HERc'iN IS SUBJECT TOALL THE TERMS.
E%CLUSIONSAND CONDITIONS OF SUCH?OLIC'IE LIA! H.pi.'E REEV RFDucED BY PAID CLAWS, _
,rs_EI TYPE OF INSURANCE
ADEL SUB VOL YNUNBER POLICY EFF POLI YEXF
GENEK LUAEILITl I F _ _ r:d IA9CfSr9'v- i v I L&:"'a
R;
X lEPFi.LIA6.-T'r �Pi rC URvtl
V 3 W 1000.000
U A.lih--M.FlDE X _UP - L� fat i a`c v..yy<
A Q'�`--' 1 : 50,000
o sue. ari b 5.000
L 118C012041 032672014I 032620/5 R a-. . a[ .. JJFy $ 1000.00D
r'EV yr.aecA.E urulr rFPLIe3 P_P I ,r ICH-_-�,,,r-:ec.� � B 2000,000
)( PC, ICY F4�- LOf FFUD'J=T3-,�pLtal^P.4rG 1 1000.000
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