48 LIONS LN - BUILDING INSPECTION SPECr ECfIVED Syd° CK (p 3
lOib ` VVfiWommonwealth of Massachusetts
FEB 18 A Department of Public Safety
b: Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
_ (fbis Section F Of 'cial Use Only) . -
^ Building Permit Number: Date Applied: 8,11 V71((O I Budding_Official: -
�J I SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
44R ( iykn 1-we, SC�lH Mn . o(G—
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK I I 1 11 -
Edition of MA State Code used - ff New Construction check here❑or check all that apply in the two rows below
p� Existing Building Repair Alteration ❑ 1 Addition❑ Demolition V (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 re9�ired? '�tp� Yes ❑ No f9
Brief Description of Proposed Work�✓1,1111.( 2r�2 k)p_ ri . �.mt)14- L��+93 neA rn4 '. u
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):
SECTION4: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 Cl A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
R Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1 WF R-2❑ R-3❑ R 4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below: li
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 117' Ill ❑ IIA O IIB ❑ HIA ❑ !Till ❑ IV ❑ I VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Sup Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal:
Public. Check if outside Flood Zone Indicate municipal W A trench ww''I not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required®or trench or specify:
permit is enclosed❑
Railroad right-of-w Hazards to Air Navigation: MA I listoric„Cunmii_sion Rcyigw Pnnc= :
Not Applicable Is Structure within airport roach area. Is their review completed?
or Consent to Build enclosed❑ I Yes❑ or No 7 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Dues the building contain an Sprinkler System?: Special Stipulations:
N•o .— wor tN s�rrvtes
'I�✓2-\�f> 'ro (jar\. .. GL"' ,a f-. _'�.'( � NCa.fit n1 \-!a„TIEfL14
°
SECTION 9: PROPERTY OWNER AUTHORIZATION '
Name and Address of Property Owner
Name(Print No.and Street City/Town Zip
Property Owner Con tact Information: kt� ;tj C1
rtle Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes n �J
00 aYtt )ed _42�(J<-a ! S oQt/ nCt/fr�y 9s5
Name Street Address City/Town State Zip
to act on the property owners behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)1
f I Ming is less than 35,000cu.R:of enclosed space and?or not under Construction Control then check here d Alp Section 10.1
10.1 Registered Professional Responsible for Construction Control - -
rra
fs" ,5 �a2 G� /�c address
Name Re istran Tee hone o. _ e-mI iddress gis r ti n 1`u—her
treet Ad ress City/Towr( State Zip Discipline Expiration Date
10.2 General Contractor
Company Name 3c;,l
Vbr),M s6usck `tom C�a��yuc
Name of Person Responsible for Construction License No. and Type if Applicable
s
Street Address City/Towd State Zip
�7�1 1 tt �c�o a�cl rrr� ci Corn
Telephone No. business Telephone No. cell a-mafl address
SECTION 11:WOHKEhS'COMPENSA'1'RY,V INSURANCJS AFF[DAVt'f' M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accid is must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the suance of the building permit.
Is a signed Affidavit submitted with this application? Yes No O
SECTION 12.CONSTRUCTION COSTS AND-PERMIT FEE -
Estimated Costs:(Libor
Item and Materials) Total Construction Cost(from Item 6)=$T�D O
1. Building $ Building Permit Fee—Total Construction Cost x_(Insert here
2.Electrical $ ,� appropriate municipal factor)_$
3. Plumbing $
d. Mechanical (I-IVAC) $ / Note:Minimum fee=$ (contact 5Wicipali�
S.Mechanical Other $ Enclose check payable to
6.Total Cost $ , Q (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
application is true and accurate to the best of my knowledge and understanding.
cal 78.7c�2_ L r
e print nam
jand s' r et `� �itle Telephone No. Date
G_? 5 � f lJ n us; C549 65
Street Address City/Town State p1� '7Zip J
Municipal Inspector to fill out this section upon application approval• �""'�' 1/
Name - Date
The Commonwealth of Massachusetts
Department oflndustrial Accidents
l Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
rkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A IicantInformation Please Print Le 'bl
Name (Business/Organization/Individual): Ispi.
Address:_ Uri d (s
City/State/Zip: CVC .p . o�G�� Phone#: —1 l(1 — -7(6--02�
[4-R
you an employer?Check the appropriate box: FNe
project(required):
I a employer withemployees(full and/orpart-time).' onstruction
I am a sole proprietor or partnership and have no employees working for me in elingany capacity.[No workers'comp.insurance required.]I am a homeowner doin all work m self. tion g y [No workers'comp.insurance required.]t I am a homeowner and will be hiring contractors to conduct all work on m g addition
Y Property. I willensure that all contractors either have workers'compensation insurance or are sole ectrcal repairs or additions
proprietors with no employees. -
12-❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insusamml 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing an 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 most 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.
iInsurance Company Name:
Policy#or Self-ins.Lie.
II#: VVCVlJ�1._LR Expiration Date: 1 —'LC)((n
Job Site Address: ""l� / 1 �n5 Ql.{� City/State/Zip:UOM I HQA rD( t la
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.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 pena es ofperjury that the information provided above is true and correct.7 //
S�atur.I .�� �—,� Date I Z-7 2-ct ! b
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as".-every person in the service of another under any contract of hire,
express or implied,oral or written." -
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the a pro hate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all ocations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
07 Y OF SALEM MASSAa-RESEM
BmDmDEPAjmvmr
120 WWgmYG=NSmtRRT,3'DRoDR
UL(978)745-9593.
FAZ(978)740-9846
SIIIvIBZERLEYDRISQ7LL
MAYOR 7�s STYMLU
Construction Debris DispoSW Afdavit
(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#1 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:
ff-lat,tuei
b
(name of hauler)
The debris will be disposed of in:
(name of facility)
'j?3
(address of facility)
Signature 6flapplicant
2 / /7 / 24 /C,
Date
l
A'tassachusetts
,Board Of auildi DeFaKment of Public Safety C„;<,truc ng Regulations
anq
Llcense•onPenisor Standards
Man C`S 07r33.,
9 uelM Sousa _� �^
Otis Road U <,
Bever►y 1y11 019 5 � f F-
�y
commissioner Ex
Piration
1112512p16
i
&/�
Office of Consumer Affairs and Bus-iness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
— - Registration: 155795
Type: Individual
Expiration: 5/912017 Tr# 265821
MANUEL SOUSA
MANUEL SOUSA ?�
9 OTIS ROAD UNIT 15 � �ti tiv
BEVERLY, MA 01915
ZUpdate Address and return card.Mark reason for change.
--r .❑ Address Renewal Employment Lost Card
SCA1 0 2010-05I11 / � ,/� / ��-- -_ -----
CJ/!DE l0rnn/I9L 11111AII o1C�/UL(llU'CLC"4dtd
License or registration valid for individul use only
Office of Consumer Affairs&Business Regulation before the expiration date. If found return to:
'WkOME IMPROVEMENT CONTRACTOR Type. Office of Consumer Aftairs and Business Regulation
eglstratlon A55795 10 Park Plaza-Suite 5170
Expiration 5t9t2017-! Individual Boston,MA02116
rr
MANUEL SOUSA P ..
MANUEL SOUSAt=�
9 OTIS ROAD UNIT 15
Not valid witho t signature
BEVERLY,MA 01915 Undersecretary
11
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O
SIMV y
Marcia Kirkpatrick
From: Cyndy Anselmo <cyndy@ecpllc.net>
Sent: Wednesday, February 24, 2016 1:45 PM
To: Marcia Kirkpatrick
Subject: Unit#2401, 48 Lions Lane, Salem, MA
Hi Marcia
Please be advised the Board of Trustees of the Highland Condominium at Salem Trust have approved the request of the
new owners of the condominium unit to install new bathrooms and do additional work in the condominium unit.
If you need anything further, please do not hesitate to call.
Cyndy Anselmo
East Coast Properties, LLC
Real Estate and Property Management
400 Highland Avenue Suite 11
Salem,MA 01970
P: 978-741-2003
F: 978-745-9684
cyndy(a�ecpllc.net
1