17 LEAVITT ST - BUILDING INSPECTION (2) 2qo - I Z13� °®
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The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(730 CNIR)
Building Permit Application for any Building other than a One-or,rwo-Family Dwelling
(This Section For Official Use Onl )
Building Permit Number: Dater\pplicd: I�r�l-13 BuildutgOfficia:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for wh' t h ss ' of avail c)
p LEAVIZT )o
No.and Street Cit /Town Zip Code Nam, tiding(if applicable)
Ir7' t'I L,1_yaUtvl— SECTION 2.•PROPOSED WORK
Ediho F-Stth-fr w Construction check here❑or check all that apply in the two rows below
'Existing Building)? Repair(aY r\Iteration ❑ r\ddition❑ Dcmulition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: _
Are building plans and/or construction documents being supplied ns plrt of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No Ilk
Brief Description of roposed W rk:
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i.Jxr}XN CC.0 t-rN-n G
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SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
=Area(sq.
Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 3.4) ❑
up(s): Proposed Use Grou p(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
ories(include basement levels)dr Area Per Flour(sq.ft.)
q. )and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly r\-10 -:\?❑ Nightclub CI r\-3 ❑ A4❑ r15❑ B:.Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ If: Ili h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-t ❑ 1-2❑ l-3❑ f-4❑ NI: Mercantile❑ R: Residential R-10 R-2❑ R•3❑ R-1❑
-- - - - S: Storage S-I ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION"TYPE(Check as a licable)
IA ❑ Ili ❑ I—IT❑ IIB ❑ IIIA ❑ IIIB ❑ IV VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 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❑
Private❑ or indentify Zone: or on site system❑ required ❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: %1-A I hsjonc i � nunfsi ,I . �.
Not Applicable❑ Is Structure within airport approach area? Is their review co mpleted?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTEN"r OF CERTIFICATE OF OCCUPANCY
Edition of Cade: Use Group(s): 'Type of Construction: Occupant Load per floor:
Docs the building contain,m Sprinkler System?: Special Stipulations_
� � � � 401-- 720S
SEC•T[ON9: PItOPERlYOVVNERAU"TIIORIZA"TION _
Nance and r\ddress'of Property Owner
rr�2o s�A\J ka-T 0sm Sk ZnP
��7 �n
Name(Print) No.and Street City/Town
Pro erty Owne C nfonnation,
Title Telephone No.(business) 'Telephone No. (cell) e-mail address
If applicab the property owner hereby authorizes �rV\
oRN tATl)PAs PO- t3o! PB6�l3o�y
N.Sntic `-- `- '- =` Street Address City/Town State Zip
to act onfthe property owners behalf,in all matters relative to work authorized by this building ermit aeplication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If btlildiag is less than 35,000 cu,ft.of enclosed s ace and/or not under Construction Control then check here O and skip Section 10 l
10.1 Registered Professional Res onsible for Construction Control
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. E . l address
ss Registration Number
NnG (Bgist oi9�a U /0
-/6-/3tur
Street Address -City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name ' y g a�
�n�i N (t��iv�-nwas `1 Z y y
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip I
_ T9 -yo/- 7aoS' �Hfv PflNTAPASQ Ho71 cvl,Cdo,
Telephone No. business Telephone No. cell a-mail address
SECTION 11: %V'c:1ltRIlR9 Cl)MPIN:S,\I'ION INSURANCE AfwuAV1 l M.G.L.c.132.§ 25C6
A Workers'Compensation Insurance Affidavit from the NIA 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
Estimated Costs:(Labor --11 GDo oa
Item and Nfaterials) Total Construction Cost(from Rent 6)=$ of n
1. Building S '3 oC) Building Permit Fee-Total Construction Cost s_(Insert here
2. Electrical $ F SOo — appropriate municipal factor)=S
3. Plumbing $ SOO
Note: Minimum fee=5 (contact municipality)
1. Mechanical (HVAC) $
5. Mechanical (Other) Enclose check payable to
6.Total Cost S a o� �o (Contact munieipalil )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering lily name below, f hereby attest under the pains and penalties of perjury that all of the information contained in this
Application is true and accurate to t .be. of lit• 'nu vlcllkand understanding.
NN AtvtARe5 ifA / (�
Please print and sign name n�.,r�r� Title Teleph���neq�No. Date
Street Address City/'Town State Zip
Municipal Inspector to fill out this section upon application approval:
Nance Date
"� CERTIFICATE OF LIABILITY INSURANCE 9DAM/ (MNvDD13YY)
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 Linda Gallant
NAME:
EA Stevens Company, Inc. PHONE - (781)322-2329 F^XC No:(781)397-7672
389 Main St. Ab%LESS.lindag@eastevensins.com
P. 0. BOX 188 INSURERS AFFORDING COVERAGE NAIC9
Malden MA 02148 INSURERAAcadla Insurance Company
INSURED INSURER B:
JOHN PANTAPAS INSURER C:
PO 13OX 4065 INSURER D:
NSURER E:
PEABODY MA 01961 INSURERF:
COVERAGES CERTIFICATE NUMBERCL139304655' ' - 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 ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE JIM Jm POLICYNUMBER MWDDIYYYY) (MWDDfYYYYI LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE T RENTED
PREMISES Ea occurrence $ 50,000
A CLAIMS-MADE OCCUR 114194-10 /18/2013 /18/2014 MED EXP(Any one person) $ 5,000
PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PERK PRODUCTS-COMP/OP AGO $ 2,000,000
X POLICY PRO LOG $
JFCT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea acrltlent
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per aeCitlern) $
HIRED AUTOS NON-0WNED PROPERTYDAMAGE $
AUTOS Per accident
E
UMBRELLA LAB OCCUR EACH OCCURRENCE $
EXCESS LMB CLAIMS-MADE AGGREGATE $
DED I I RETENTIONS I $
WORKERS COMPENSATION VvC STATD- OTH-
ANDEMPLOYERS'DABILITY YIN
ER
ANY PROPRIETORPARTNERIEXECUTIVE❑ NIA E.L.EACH ACCIDENT $
OFFICERRMEMBER EXCLUDED?
(Mandatory In NMI E.L.DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is requiretl)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Miroslaw Kantorosinski ACCORDANCE WITH THE POLICY PROVISIONS.
17 Leavitt St.
Salem, MA 01970 AUTHORIZED REPRESENTATIVE
Thomas Cares, Jr/LG
ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved.
INS025 oni nnsi n1 Thn arNTRrh nsmn Ind Inns nro ronia:forod moAc ITS Ar.npn
C[TY OF S:1LE.NI, , L1SS.ICHUSETTS
BUILDINIG DEPARME.�iT
120 WASHLNGTON STREET, 3'a FLOOR
. T EL (978)745-9595
FAx(978) 740-9846
KIJfSERI.EY DRISCOLL
�tiLr1YOR TriOMAS ST.PIERRs
DIRECTOR OF PU13LIC PROPERTY/BUILDING COSMISSIONER
Workers' Compensation insurance Atiidavit: Builders/Contractors/Electrkians/Plumbers
Applicant infirrmation Please Print Lefalbly
N;iinc(nusiitvss Organixatiarvindividual):
Address: Q'G - �?-oj( L16CoT'
d
City/StatclZip: QF— W1,Ps- Phone#: 0t2T--"/d/—
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑Now construction
employees(full and/or part-time).* have hired the sub-contractors"
2.�airs a sole proprietor or partner- listed on the attached.sheut t 7. E gZemodeling
ship and have no employees These subcontractors have V. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition
(No workers'camp.insurance 5.'❑ We are a corporation and its
required.) officers have exercised their 1O.I&ISlectrical repairs or additions
3.❑ 1 am a homcuwnur doing all work right of exemption per MGL I I.KPlumhing repairs or additions
myself.[No workers'comp c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.LNo workers' I3.❑Other
cump:insurance requircal.l.
•Any applicant that cheats box Al I must alwt fill out the salion below showing their workers'compeewlon Polley inaumation.
'I(,m uwnms who submit this anldavit indieming they am doing all wort and then bite outside contractors must submit a new amdavil indicadng such
=rlumracton that Ow this box most attached an additional sheet showing tho name ofthe sube ntrsclers and their workers'comp,pulley inistemsdon.
I arm an employer that/s providing workers'compenratlon insurance for my employees Below Is the policy and Job site
informations.
Insurance Company`lame:
Policy A or Scif--itts.Lic. 4: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaratlon page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 untUar one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up(o 5250.00 a day against Ina violator. Ile advised that a copy of this statement may be forwarded to the Ofliea of
InvestigallUnsuftlieDiAferin4uraii vcragovcrilicatiun.
I do hereby rerdf i ud the paters n pert It per/trey that the inforntullon provided above is true and correct.
OJ/fciul use ordy. As not wrile ire this area,to be completed by city or town a/jhlal
i
city oe*ro%vn: __ Pcrmit/i.lcensed ____
Iasuiag Autltority(circle one)
I. Guard of Ileailh 2. lluildinq Ueparhnent 3.Cilyi rown Clerk a. Electrical Lupectar 5. Plunlhing inspector
6.Other
I
Contact Person:
i
i
. CITY OF SAI.EM, N.LksSACHUSETTS
' BUILDLNG DEPARTMENT
\ 130 WASHINGTON STREET, 3A°FtoOR
T .I.. (978) 745-9595
FRx(978) 740-9846
KIJtBERLEY DRISCOLL
INLAYOR T Ho.%w ST.PiERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONNI5SIONER
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 1 I LS
Debris, and the provisions of MGL c 40, 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 disposal 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)
st
(address of facility)
i
signature of it applicant
date