600 LORING AVE - BUILDING INSPECTION (4) The Commonwealth of MassacQWWL E'�tVCt F
Department of Public Safety
Massachusetts State Building Code(780 difit)JUN 2 9 P 2: S b
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#and Lot#for locations for which a street address is not available)
600 Loring Avenue Salem 01970 Pediatric Health Care Associates
(1 No.and Street City/Town Zip Code Name of Building(if applicable)
\— SECTION 2:PROPOSED WORK
Edition of MA State Code used 2015 If New Construction check here❑or check all that apply in the two rows below
Existing Building Cq Repair❑ 1 Alteration 10 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
I� Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No C(
Is an Independent Structural Engineering Peer Review required? Yes ❑ No %
Brief Description of Proposed Work: Interior office renovations to include selective demolition,drywall patching,and new
architectural finishes flooring,paint and minor ACT patching. Minor MEP also included as needed.
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): B-Business Proposed Use Group(s): B-Business
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 1 3500 sf 1 3500 sf
Total Area(sq.ft.)and Total Height(ft.) 3500 sf 9ft 3500 sf 9ft
SECTION 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❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage 5-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV 1 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 trench will not be Licensed Disposal Site
Public IN Check if outside Flood Zone$1 Indicate municipal� required IN or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process.
Not Applicable IN Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No® I Yes❑ No ® N/A
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: 2015 Use Group(s): B Type of Construction: IB Occupant Load per Floor:
Does the building contain an Sprinkler System?: Yes Special Stipulations: N/A
Co P&9-rn.wn * Co. R*.%. Ts f" Tt,I)
30o A 5i-cee.+
3656t), MR OZ2" 0 < mnti1✓e7r�' -7 li
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Neal Stephany 10 Centennial Drive Peabody 01960
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Office Manager 978 535 1110 603 - 566 - 7758 njstephany@phcapediatrics.com
Title Telephone No.(business) Telephone No. (cell) e-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.ft.of enclosed space and/or not under Construction Control then check here El and skip Section 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
Corderman&Company,Inc.
Company Name
Anthony Cocuzzo CS-059574
Name of Person Responsible for Construction License No. and Type if Applicable
19 Gentleman Way Waltham MA 02452
Street Address City/Town State Zip
617 502- 4421 617- 201 - 6731 acocuzzo@cordermancompany.com
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION 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? Yes PSI No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)_$ 69,285
1.Building $ 56,720 Building Permit Fee=Total Construction Cost x (Inert here
2.Electrical $ 7,390 appropriate municipal factor)_$
3.Plumbing $ 450 90Z
z Wl
4.Mechanical (HVAC) $ 1,975 Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Z750
Enclose check payable to City of DwAmdr � Q`11
6.Total Cost $ 69,285 (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.
Jim Tully � Assistant Project Manager 978 390 3448 (4 Z.$' '6
Please print and si ame Title Telephone No. Date
300 A Street Boston MA 02210
Street Address City/Town S,ttaate Zip
Municipal Inspector to fill out this section upon application approval: /
Name Date
. t
i CITY OF S�U-EM, ,NAXSSACHUSETTS
• BUUMI )G DEPART%MNT
120 WASHINGTON STREET,3aa FLOOR
\ TEL_ (978) 745-9595
FAX(978) 740-9846
KINBmEY DRISCOLL
MAYOR DIRECTOR
ST.PtF1tR8
DIRECTOR OF PLBLIC PROPERTY/Bl:1LDLNG co%M(ISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lealbly
Name(Busirn s/Organizatiotvindividmi): Corderman &Company, Inc.
Address: 300 A Street
City/State/Zip: Boston/MA/02210 Phone #: 617-542-9200
Are you an employer?Check the appropriate box: Type of project(required):
l.❑ 1 am a employer with 4. ® I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ® Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition
[No workers'comp.insurance S. ❑ We are a corporation and its
required,] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself[No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp. insurance required.]
Any applicant that chocks box NI must she all rut the section below showing their workers'enmpenstafon policy infutrnarim
t I Inmeuwters who submit this affidavit indicating they ate doing all work and then hire outside conuactms must submit a new affidavit indicating such.
'Contractors that check this box most attached an additional sheet showing the tome of the sub�commMrs and their workers'comp.policy information.
I am an employer that Is providing workers'compensatlon Insurance for my employees. Below Is thepoll y and job site
information.
Insurance Company Name: Travelers
Policy#orSclf-ins.Lic.#: DTOUB-1171N31-1-10 Expiration Date: 1-09-2017 '
Job Site Address: 60Q�.G� AyGArL City/State/Zip: 5AIiA4 I MA 014�0
Attach a copy of the workers'compensation policy declaration page(showing the polity nol bor and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine 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
of up to S250.00 it day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ida hereby certify u rde for pains and penalties of perjury that the information provided above is true and correct.
t tr Dntc: z
Phone#: 97S - 34D 44 '12'
Official use only. Do not write in this area,to be completed by city or town oJjiciaL
City or Town: Permit/License#
Issuing Authority(circle one):
I. Board of health 2.Building Department 3.Cily/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other,
Contact Person• _ Phone#:
June 28, 2016
City of Salem
Building Department
120 Washington Street, 3rd Floor
Salem, MA
RE: License Builder Authorization
To whom it may concern:
Please be advised that Jim Tully has been granted permission to act as an authorized agent to
sign Building Permit Applications and apply for Certificate of Occupancy on behalf of Anthony
Cocuzzo, Principal of Corderman & Company, Inc, License#059574
Please contact me at 617.201.6731 should you have any concerns.
Sincerely
Anthony Cocuzzo
Principal
ffC�! Massachusetts-Department of Public Sa:a.fy =
u Board of Building Regulations and Standards.
Construction Supen isur
License: CS-059574 tt
Anthony C Cocuzzi
19 Gentlemaw M
Waltham MA 02452 ;
11 1"ss Expiration
,Commissioner 06f WO16
Unrestricted-Buildings of any use group which
contain less than 35,600 cubic feet(991 m3)of
enclosed space-
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DVS Licensing information visit: Ww .Mau.Gov/DPS