112 LORING AVE - BUILDING INSPECTION (4) i t
l
The Commonwealth of Massachusetts
Department of Public Safety
11 •1 �' •ter,% \Lt..,lchu.rtl>Stair Budding Code(780 C%IR)Sra'enth - -ttun
`dlh,rVA City of Salem
Building Permit ApElication for any Building other than a 1- r 2- i w lie
(This Section For Official Use()nly)
Budding Permit Number Dore Applied: Budding Imprch>r:
SECTION
N 1: LOCATION (Please indicate Block 0 and Lot 0 for locations for which a street ress is not available)
W, W(LtyA, AvC St`
No.and Street Cih' /Town Zip Cocie 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 ❑ 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 Pee�j Review required? t _ �p Yes Cl No ❑
Brief Description of Proposed Work: h��-WG C.l�Gvl-r�l O��FCe.O \n//0j,t ,11 a s t 4-
otm ika A3 A Ajz 14 tE
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑
Existing Use jnpd
Proposed Use Group(s): r
Existing Haz CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No. of Floorsude basement levels)&Area Per Floor(sq. ft.)
Total Area Is' al Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F2❑ H: !M h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 O H-5❑
1: Institutional FI-0•-1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2 ❑ - U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as a licable)
IA IB ❑ IIA ❑ 1180 IIIA ❑ IIIB ❑ 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:
A lunch will not be Di.pusal Site❑
Pubhc❑ C hciA !t outside Pluud Lune ClIndica le municipal ❑
Ltcun.ed
rcywred ❑or trench or�1+ectly:
I'nvafe❑ ur m,Ivntdc Zone:_ nr,,n mite a,tem ❑ hermit,,cndo.rd O
Itailra'ad right-of-way: hazards to Air Navigation: nh ai+ c nun...,,•n 11, ++ f'o r•
\art \ Irc.d+lv❑ 11�trucuv thin co "'rt i peach area'. I. then' re+ e+c cum dch•d.'
I
rC-,m�rnt to Build ❑ 1c,O ur .A',,❑ ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I.J.lnm oI t uJ+' l r l iruupi�r. r+pc nt i, m,(rLlCuun: Occup•nat Lead p,r I Liur
IA,c� lh+•l`tnlJn+q:unt.un an SpnnV,lcr}a•!cm �prcmlSupulotnm. - JI
SECTION 9: PROPERTY OWNER AUTHORIZATION
.No me.ind Add ress of PL,fe 2lrlq
rte Owner p,•Z "
C a leer Z�tkeey 1 ^rLry T2 k Sr
\'ame(Print) No.and Street C ih/r+nvn Zip
Property O+v nrr Contact Inform.ttion: / Sl_ e. 11— 30
Title Telephone No (business) Telephone No. (cell) e-mail add n•ss
If,l pplicable, the properth owner hereby authorizes
oYt le s r• cJ 11�u n r� wL O t ¢6 1
3 —�
rl.oi_ r(1 n( IIA�EM
Name Street Address City/Town State Zip
to act on the properiN owner's behalf, in all matters re•latipr to work ,utthunzed by this buildin • permit application.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is IcsS than 35.l)Ncu. ft.of endasad S peer and/or 1101 under Cun%truction Controt than check here❑and 4ip Sectiun 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Nam A�e: PUI(.� Ls e IS '7 SO P
aq
Name of Person Res msible for Construction License No. and Type if Applicable
3 AICTr f%_9�•JLe.- S1- . L,✓40,krLVY 116.4
Street Address City/Town State Zip
)f`t43°? 7 tor do Gill- S`70 2 cf(O
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'CObIPENSATION 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 ❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building IL Pj-emo) $ I I. 5ao 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) $ p Enclose check payable to
6. Total Cast $ ! I S00 (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 conJ1 ,n1,h,,
applicatnm is true and accurate to est of v knowledge and un entanding.
Pottera,�� Pis, z��_ - �19ea,e print and sign name title Tclephonv CAA�a oI� s—titn•rt .l ddrc•.. C nh/Lnvn Sfatr ZMunicipal Inspectorto till out this section upon application approval:
Massachusetts .•Department of Public Saretc
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 75086
Restricted.to: 00
ADAM N POLLOCK ;
41 CHEQUE r
SSETT RD
READING, MA 01867
a— �t
Expiration: 4/3/2011
('onunivxi^mr Tr#: 14073
CERTIFICATE OF LIABILITY INSURANCE DATE(M
7/22M/OD/YY/22/2010
PRODUCER (781) 641-7200 FAX: (781) 646-2410 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
W.T. Phelan ✓t Co. , Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Attn: jean.betz@wtphelan.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
645R Massachusetts Avenue
Arlington MA 02476 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:Gemini
Pro-Care Inc. INSURER B.Travelers Indemnity Company 25658
3 North Maple Street INSURER C Chartis
INSURER D'
Woburn MA 01801 INSURERe
COVERAGES
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 OR3UCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR Dp' POLICYEFFECTIVE POLICY719"
LiR N R TYPE OFINSURANCE POLICY NUMBER DATE MINOD/YYYV DATE LIMITS
GENERAL LIABILITY OCCURRENCE S 1,000,000
I X COMMERCIAL GENERAL LIABILITY R NTED
ISES Ea occurrence S 50,000
A X CIAIMS MADE OCCUR GR0001043-04 8/2/2010 8/2/ XP(Any one Person) $ 10,000
X $2,500 PD Ded-FL NAL B ADV INJURY S 1,000,000
AL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS AGO $ 2,000,000
X POLICY PRO LOC
AUTOMOBILE LIABILITY
X ANY ALTO 5tleD1)SINGLE LIMIT 3 1,000,000
B ALL OMED AUTOS A-9552WO12 8/2/2010 8/2/2011 BODILY INJURY
SCHEDULED AUTOS (Per person) S
X HIRED AUTOS
BODILY INJURY
X NONOMED AUTOS (Per a nnnrl) S
PROPERTY DAMAGE 3
(Per accitlenl)
GARAGELIAMUTY AUTO ONLY-EA ACCIDENT 5
P ANY AUTO
OTHER THAN EA ACC S
AUTO ONLY. AGO S
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 2,000,000
X OCCUR CLAIMS MADE AGGREGATE $ 2,000,000
5
A X DEDUCTIBLE A 100 0015 - 14 8/2/2010 8/2/2011 S
X RETENTION 5 30,OOD 5
c WORKERS COMPENSATION VIC STATU- OTH-
AND EMPLOYERS'UAMLITY YIN X
ANY PROPRIETORMARTNERIEXECUTIVE El.EACH ACCIDENT S I,OOO,OOO
OFFICERAIIEMBER EXCLUDED? ❑N
(Mandatory in NH) 09933600 8/2/2010 8/2/2011 E.L.DISEASE-EA EMPLOYE S 1,000,000
Ii yea describe urber
4 SPECIAL PROVISIONS Eel. E,.DISEASE-POLICY LIMIT 3 1,0001000
4 A I OTHERpollUtion GR0001043-
09 8/2/2010 8/2/2011 Each Occurrence 11000,000
k Mold laims Idade Form Each Occurrence 11000,000
$5,000 deductible etro Date B 2 2003
2,000,000
h DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 50 SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
R Ramsey, Jr./BETZJ
ACORD 25(2009101) ®1988-2009 ACORD CORPORATION. All rights reserved.
INS025(2DD9D1) The ACORD name and logo are registered marks of ACORD
s.
CITY OF SALEM
r � PUBLIC PROPRERTY
DEPARTMENT
?,.ILA r • 1.\I I M. \L\„\l .. I . 1'I
\\: 'i-g.'4:'lilt.
Construction Debris Disposal Affidavit
(rcqµtired I'm all demolition and renovation work)
In accordance \tt ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit t is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
�f J
1 name ttt lIDllter)
The debris will be disposed of in
(name ut facility)
sou 1 { S kv&fnhr
IaJdress ul'fac I I i IVl
,Ignouue ot'prnnrt .lpphcant
Cn 0 o
date