17 LEAVITT ST - BUILDING INSPECTION DO St 5L $ 132C�b
RECEIVED
a The Commonwealth of Massac use s
Department of
din Safe
Massachusetts State Building
Code(7Nk,NJG 22 A & 04
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block k and Lot#for locations for which a street address is not available)
0 LE1912-17- s,�- Stilew, M19 a/920
No.and Street 7P '� City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK -
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Or I Alteration ❑ 1 Addition❑ 1 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 Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
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) O
Existing Use Group(s): Proposed 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.)
SECTION 5:USE GROUP(Check as applicable)' -
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4 Cl A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Huard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ 1-2❑ I-3❑ 14❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ Rol❑
S: Storage S-1 ❑ S-2❑ Uo Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ I 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 Situ
required El or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \dA"H wtnn�t'gnu,ncv�n 1 i i y Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build 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 Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
-
N e and Address of Proper Owner I
micosltip kn"Io•Lask /? oo2el t
Name(Print) No.and Street City/Town Zip
Property OwTer Contact[nfonnefion:
CLAM/ 9V 9GS- 8-/5W
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
�)d///v N7 10/AI e o. E o- yo(S ppAwv 00
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.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
7)nHN WANTMA$ 9,'-'Y01- 7,10f_>Hn/OA62,1P19" Q IoT d CS ?- oo.�,
Narne(Registrant) Telephone No. e-mail address Registration Number
�l) QoX yOfo5, P&S 0Y rnA o/°J(a/ Dr-1 /0 /6
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
4'16&Y OflN7 A�
Company Name
loHN PAWAPW
Name of Person Responsible for Construction License No. and Type if Applicable
po. aa)( M69 0/5,6
Street Address City/Town State I ' Zip
M y®/2--A ad— -FaLnz ArY7A 07S 4E l o-,A I � Lo
Telephone No. business Telephone No. cell e-mail address
SECTION 11:7')RKFhS'COt.11 FNSA'1'ION tNSURANC. 1FFIDAVI'f 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? Yes ' No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Budding $ -<-00 Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ / S-OO appropriate municipal factor)=S
3. Plumbing $ Qp
4.Mechanical (HVAC) $ Note:bfinimum fee=$ (contact municipality)
5.Mechanical Other $
0o Enclose check payable to
6.Total Cost $ �/ ,�OQ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT.
By entering my name below,I hereby attest under t ie pains and penalties of perjury that all of the information contained in this
application is true and accurate to th est f my wl dge and understanding.
Ohry krg7- OA/ z2or
Please print and sign name Title Telephone No. Date
.a , O f a.022 / W4 n/g<a/
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: - -
Name - Date
i
CITY OF SALEM, MASSACHUSETTS
. BUILDING DEPARTMENT
120 WASHNGTON STREET,31D FLOOR
TEL. (978)745-9595
F
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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:
Cnyy� S C> 1SYoCc ;l
(name of hauler)
The debris will be disposed of in:
j
PFfl (2='OY)�-/ -`ry) NS �
(name of facility)
i
(address of facility)
ignature of applicant
Date
B p � DATE(MMIDDlYYYy)
/'E "� IpFI A'T E Oa_, t R iPia FF
$ey.�-••'� La�� . 3 5 s R'^'t, �,�.
_ oa; Drzo7a
IT HIS CERTIFICATE IS ISSUE A 'IA C: INFORS'A 1 Oh AID CONI .,1c. R liTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOTAFFIRMATI I'EL1 Or NECA71vtu ANIC14D, EXTEND OR ALTER THE CO✓CRAGE AFFORDED BY THE POLICIES
EE;OW.THIS CERTIFICATE OF IN SURANCE GOES NOT CONSTITU E A CONTRACT BETWEEN THE ISSUING INSURER{S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. _
WPORTANT if the certificate holder is an ADDITIONAL.INSUURED,il-ie Policy{ias)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
certif:Cato holder m'ei;of rue,11 ondors menus)
PRODUCER CONTACT Brenda Cozzo'ino
E A Kelley Arc�'i4�(401)709 8338 FAx . (800)3742924
450 Veterans Memorial Parkway ADDRESS brendac@eakelleycom
Building 5 PRODUCER 216303
East Providence RI 02914 INS ER(a F,[, RDINO RAGE N I
INSURED INSURERA: Atlantic Casualty lns Co 42046
John Panepas INSURER B:
407 Lowell Street NSURERC:
INSURER D:
Peabody MA 01960 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTFI)BELOW HAVE BEEN ISSUED TU THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REOU:REMENT.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 TOALLTHE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS S140VUN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR TYPE OF INSURANCE ADOL SUBR POLICY NUMeeR POLICVEFF POLICY EXP LIMITS
GENERAL LIABILITY °?=F 9:JJU='F_'JCF. f000,060
�( _rnenEcCiAL CEO".aL LIA31L7.. _-`-'G:E> -�`: Dd-nce1 q 50,000
❑ AY,j -h,-__ Ixnp__P -D1 line aaa Seri b 5,000
VIE- I r.,
A L11 8001204 _ 0306/2014 03/262015 1000,000
:}E'lEc- :EGIE $ 2000,000
C EN'LAc13.�,=GATBLILIn=F'P IES%EP 1000.000
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AUTOMOBILE LIABILITY SUM,=IIJE :;S NI LE LIVIT
.WJ IAUTJ _
_ 6a-'L 11-JP_=ltea:rrrsoy
ALL O'ntlep A.J GS
SCH3V LCC c�?O; c - _v LiliR•':per 6:5a?nil
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Hli F.G,UT03 Fer a.-aa lrnP E
pli:.l_CvtEGe -05
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UMBRELLA LIAB 3�,N C-"-tiff F'E $
EXCESS LIAB CL'-.:I<E.,IADE _ Er_ATE 4
OEUJC T IELE e
RET-NTCIN
WORKERS COMPENSATION AND )ST4' i0i
EMPLOYERS'LIABILITY V I N - -
'F Ni N/A Ar DEN T
(Mandalory Th IT, - ._ EL D,i 11n- �+E cp el.PLCYEE
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L I N11 -Fh �FIJ,_I�o�:-:.- L CI .,+EE-Fr.LG°'LIMIT I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Rem arks Schedule,it more space is requi red)
Carpenter
CERTIFICATE HOLDER CANCELLATION
i
tAirosiav K2 ntornsinski SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE'THEREOF,NOTICE WILL BE DELIVERED IN
I17 Leavitt Street#2 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOR:ZEO REPRESENTATIVE
Salem MA 019% K€?lherifie . IiCelllei /I AT� I1C
I?1988.2009 ACORD CORPORATION.All rights reserved.
ACORD 25(M'910 9), The ACORD name.rd iag^_are r^Bls4er:d wards e.if fiCORD
I
A
rV
r CITY OF SAL.EM, �L1SS:ICHL'SETTS
y L uILDING DEPARTMENT
120 WASHNGTON STREET, Sou FLOOR
T EL (978) 745-9595
F.,tx(978) 740-9846
IU\tBERt F.Y DRISCOLL
"SLAYOR THoNus ST.PIERRE
DIRECTOR OF PLOLIC PROPERTY/13UUDrNG CONNISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information L / /Ir �� y) Q r+ Please Print t e ih1Y
Name (Rosiness,Oro•vliraiiaro'InJividuall: L/LY A41t/ 7y®/J J
;Address: 610 yU6j— q G
City/Srate/Zip: 0) ✓✓I d X61 Phone 8:
Arc you un employer.'Check the appropriate box: - 'Type of project(required):
1.Q I am a employer with 4. Q I am a general contractor and
6. ❑New conswction
employees(full and/or pan-time).* have hired the sub-contractors
t 2.KI am a sole proprietor ar partner•' listed on the attached sheet. t 7• Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity. workers'comp. insurance. y, Q Building addition
[No workers' comp. insurance S. ❑ We are a corporation mid its
required.) officers have exercised their 10.Q Electrical repairs or additions
3.Q I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. (No workers'comp. C. 152, §I(4),and we have no 12.❑ Roof repairs
insurance required.) I employees. [No workers' 13.❑ Other
camp. insurance required.)
'Any applicalil glut chucks but PI most aku fill uua the acctiun below showing their workers'cumpenutiun pulicy inliumunun.
'I lomeowncn who wl+rasa this snldwil indicating they arc doing all work and then hire outside cuntnctan mint submit a new amdavil indicating such.
$\nemaun thus chvek this boa maut anachni an addhiunal shut chewing IN name of the subaamneturs and their w'urkcn'camp.policy information.
I unr an employer that ix pruvfding workers'compensarlun bixurance for my employees. Qeluly is die pullcy and fob Nile
infirnnurinn.
Insurance Company
Policy U or Self-inn. Lie, 0: Expiration Date:
full Site Address: Cityis(ate/Zip:
Attach a copy u(the Ivoriten'camper log Policy dcclaratian pugs(showing the policy number and expiration date).
F'ailuru to secure coverage as required under Section 25A of XIGL c. 152 can lead to the imposition ofcriminal pcnalties of a
tine up to S 1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
or up to S250.00 a day against the violator. Be advised that a copy Of Ihis.statement may be funvardcd to the Offiec of
Insr.ligaaion.e of the nlrl for insurance coverage verification.
I du hereby cerri ur or the Miss oil pen ubiex of perjury that the infuntrudmr provided ubuvve is
I rrue wid c'orrecr.
011hiul use wr1y. Oar not rvrile in this area, to be completed by city ar row"nfficiuL )
City car 1'u+vn: ll,,
rmitA.kcnsc.4__._
Issuing,lWhurily (circle one): -_ _- -- -- i
I. Board of Ilcalth 2. Ileillling Ilcparlutcnt J.Cilyi town Clerk 1. I?Icctrical
h. lus )cror 5. I'llubingOdler u Inspactor
Contact Pertno: Phone :1: