7 LORING HILLS AVE - BUILDING INSPECTION (5) -fhe Commonwealth of (Massachusetts
.f Department of Public Safety
1 Shi,s,lihumps tildte Bn ild in);CuJo 1,,80 C,\IIt)
Iiu ilding Peru)it Application for any Building other than a One-fit '1' vo-Fa el g
(Ibis Svclion For Offilial Use Oohs)
Building l'cnnit Nun,ber: ,_-, __.. U.oe Alylted: -_ Building Offici,
_- SEC I'ION l: LO 'ANION (I'lease in dicate Block .4 and Lot N fur locations for which a street address is not available) `
( i
IQt`t� 1 � `a14� fN Q D
No. ,md Strrct City ;Tew 11 Zip Code Name of Buildin);(iF.If+plic,�I11c) -
SECI'ION 2: PROPOSED WORK
- -
F, iliun of..sI;\titale Code usrd -. I(;\'c+v Gnlstrui fiun i lies k here O or sheik all That apply in the Iwo nncv below
h\isling I L111ti n)i ❑ Repair❑ Attention ❑ Additiin❑ Demolition ❑ (Plvasr till out and wbnlit.l pprndix I)
Change of Use ❑ Chop...of(kcup,o..- ❑ Olhcr 2-Spciifs:____._
Arc building Plans and/or construction d,kunlcols being supplied,is part of this permit application? 1'es ❑/ No
an Independcut Structural Enginecri I'Ver�/ evicw reyui dl `� Y's Id No
Brief Dc viptiun of I'rupusrd lVurk:_
Is -. �+e.).yyavJV[ _.—
SECTION 3:CONIPLE"FE I'IfIS SECTION IF EYIsTING BUILDING UNDERGOING RENOVA HON, AUDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here it an Existing Building Investigation and Evaluation is enclosed (See 7,40 C\IR 14) ❑
E\isling Use Grou P(s); _.__._ _ Proposed Use
SECTION 4: BUILDING HEIGHT AND AREA
- Fsistin6 Proposed
No.of Floors/Stories(include h,sen,ent levels),Ir Area Per Floor(sq. It)
Total Area(sq.ft.)and rota) Haight(it.)
SECTION is USE GROUP(Check as a licable)
.\: Amiably:\-1 ❑ A-'_❑ Nightilub CIA-1 ❑ A413 :\-i❑ B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F_'❑ I I. I li h flat,vd 11.1 ❑ H-'_❑ I ht ❑ I F4❑ 11-3❑
I: Institutional 1-1 ❑ 1-_2❑ 1-1❑ i-I❑ NI: %jsrcantiIc❑ 11: liesideotial R-10 It-2❑ It-1❑ R-4❑
S: Storage 5-1 ❑ S-]❑ U: L'lility❑ Special Use❑and please dcscnbe below:
Specmi Use
SECTION 6:CONSI'RUCHON IYIT(Check as a, ilea ble)
I:\ ❑ IB ❑ 11,\ o IIB ❑ MA 11111 ❑ IV ❑ VA \'H ❑
Sl.CT ION 7: SI'I E I.NFOR.NIAIION(refer to 780('.slit 1ILU for details on each item)
Water Supply: Hood Lune Information: Sewage Disposal: french Permit: I)cbris Rcuun'al: ---
Public Cl c he.k it uusndc Ilood /_one❑ 11 di,ale mtomkil"d Cl A la-m li will nil be I iiemm Di.pisil Silr❑
Proms-❑ or ind,owls A,w - _- or on ,uc sN Hen, ❑ w,jum-d ❑it lrvnclt or.pry dv _
p,nnn is rni load ❑
Itailruad right-it-wa
Y: Ildrards to Air..\'.n igatiu n:
j \ n .\l,phreblr❑ Hvrm tury on6in.urpnrt u),pm.nh ' j (,(heir it it it ny,I, e•d'
i Ir Crinrnl to IAidd n,lu,rd ❑ 1 li,❑ or.Aii❑ It Cl \o ❑
SIC 1IO,N 4; l'U.V Il[.Y I't)F CI I(IIIIC.\111 (11;()(( L I'.\.\'CY
I Ji It n ,.1 (, do l;ron)4.1 I,I•r of l I t"trw 11011 t'„npanl o.iJ la•r l i„„r _____-_.. _
Ins-, . Ihr Dmldin);,rnlam,,o ' nmklr r ti, ttm'
r ,
SIiC IIUN `): 1'ItOI'TRTY UWNTR +\Ul'I I(IRIZ,VIIUN
\ unc nId \ddr ss ul uprrly lla m f sj4w, VVIA O(Q`Z
i r1
�PlSr\-Pd�_ V)1'Se(\� _ 'fib '-_.._�
Vo, id Street
City/town
V,nnr(I riot) .
I'ropvfly Owner cunl.i,-tIlliufm.lfinn: 3ai�0� - ---------
-- ------
�-O �-_ --_------.--- c-nnl i I ads I n'ss
I'ille frlvphune No. (business) rclephone No. (iell)
r II applicable, the propels)'o,voer herct)v aithori/es
..._—_ N,une ~trim Address _city/rowlt—___.._. State — _Liv_—
to ai l r,it the pro x•rt owner's behelf, it'.111 matters relative to%wrk authoriZell by this buildillit, u'n»it a , l eation.
SECTION 10:CONSTRUCT ION CONTROL(Please fill out Appendix 2)
If build in'Is IC4tl 111,11%;5,001l Cu. ft. if voc Ill 4eJ s+,Ice and or not under Lit,nslruction c, ItroI then check here 0 and Oki ,Svc it,❑lU.l
10.1 Re+ister'd Professional Responsible for Construction Control f
J —a �� R +bi cntilC't Number ----
Music(Rrgistrent) -I'clephune No. c-mail address '< �l
tillers Address City/ruwn Slate Zip Discipline Expiration Date
10.2 General Contractor
Cunt ,o+ N,tit}y�_�
k�in IJ^ dY\� --
Nance of Pe rsu t Respons ble fur Construction License NO. and Type rf__r\��p��licablc
Street Address City/Town ( State zipc
Q��a� fir\
-�-� �� --- e•utailaddress �—
rele ,hone No. business Tole,hone No, cell
SECTION 11:Ila n.S.i l::rt t��)n•I v.lilt1\ IX•dnt.\]l I M.. {��',cn M.G.L.a 152. 25C 6
A Workers'Cum pensation Insurance Affidavit(rum the MA Department of Industrial Accidents must be Completed and
subnot ell with this application. Failure to provide this afftd.ivit will result in the denial of the Issuance of the building permit.
Is a si+ned Affidavit submitted with this a lication? Yes❑ No ❑
SECTION I2:CONSI'RUC-"ON COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Matcrial.$) rota)Construction Cost((font Item 6)'
1. Building Building Permit Fee'Total Construction Cast s _(Insert here
'. Electrical 5 Ob appropriate municipal factor) ' S
0
4 I'luuthin); 5 con Lict nuuliei ,lily
5 lJ 000—oJ Note; \lininnun (rr 'S_--( { )
�. \Ici ham ii al Othee) > Poi lox• iheik pavahlc to
e
n. I„sal Cost 5 )7 &QD- (i antait muniii +alitv),md ,c rite ihvik number burr
Ii SECTION 13:SIGNA Il1[it OF BUILDING PERMIT AVI'LIC'ANT
Itv entering n,v more brlmv, I herebv ,utc+t wider the Pains.Ind penalties of perjure that Al ut the intnrn,.ttion inn LunrJ in this
,Ipplii.uiun is I rue.uid.tic,urale it, the bast rd 111% knowledge and uunderm p�ill rr
�((al,�, Q-oclr� �rp5r`O�q� 47f5 �.ia.S57X1 1�4
ult. rrle)�hniq• \u ale
I�riol
l ,`Ii1/I k t n.I1,,1•
3 ; ILA `(�.'��-� �r
�1nrt Adal rt,,
C rtt', ;1,oc Zip
\luniiip,l Insp"tor to fill out this section upon.ipplication approval'
N.une I o.Ile.
'SETT S
Sri ti .-�CHL
CITY of S.\T.F.� � LisS
BUILDING DEPARTMEINT
}Y tr• 120%VASHLNGTON STREET,ate ROOR
T1 L (978)745-9595
FAA(973) 740-9846
KNIgpRf RY DBSSCOII
T
MAYOR TiOR(AS ST.PiF1tR8
DIRECTOR OF PUBLIC PROPERTY/BumnLNG COMMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A I tlicant Information Please Print Legibly
Name tBusiix'sa.OtnryganizaatiaNindividual): ��52'f f�1 li t�l C_�,1 �r•,f Vt (B/jt Z1�C.
Address: 1ul t \� 1� ri J
City/Statelzip: Leonap�o�m� ✓�P� hone#: Q-7r6-3bc�SSi�V
Are you an employer?Check the appropriate box: Type of project(required):
1.01 am a employer with i 4. [1 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub�conti actors
2.0 1 am a sole proprietor or partner. listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These sub-contractors have V. ❑Demolition
working for me in any capacity. workers'comp. insurance. 9. El Building addition
(No workers*comp.insurance 5. ❑ We are a corporation and its
required.)
officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑�,.�R�oof repairs
insurance required.)t employees.[No workers' IJ.L.TOther
comp.insurance requircd.j LI�Bu
•Any applicant that checks box of most also fill out the=6M bdowshowins their"Imm,compensation policy infurmatlon
t I1,mcuwnen who submit this affidavit indicating they are doing all work and then hire outsideconrructors most submit a new anldavit indicating such
�Cunumton that check this box muat aaached an a"liurwl start showing Iha name of the subaontmdors and thou workers'comp.policy infommtion,
f am an eaployer thatis provlding workers'eampensadan lnsarance for my employees. Below is the policy and Jab site
inforanalfan.
Insurance Company?lame:
Policy#ur Self--ins. Lic. #: Expiration Date:
Job Site Address: 0, 1 ,s City/State/Zip: Sat L , 61476
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failura to secure coverage as required under Section25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigutions ut'tlie DiA for insurance coverage vcriricaliolL
/do hereby certify under the puns and penaltl ujperJury that the injurriradon provide lJ abu is true and correca
Sicnilnne• rr� � 1 - �` - r,4—
Phone
A• qlb" -5500 ----
Ofliclal use ady. Da not write in this urea,robe canpleted by city or town a/Jfclat
City or Permititicense#
Issulog Authurhy(circle one): _------
1. Board of Ileallh 2. Building Department J.Citylrown Clerk 4. Electrical fuspector 5. Plumbing Inspector
6.Other
Contact Person:___1 Phone 4:
CITY OF SALEM, TNLkSSACHUSETTS
BL' mr,DEPxRTNtENT
s N 130 W.1,sHLNc;TON STREET, 3' FLOOR
a TEL (978) 745-9595
F.Aa(978) 740-9846
KINtgFRi f=EY Y DRISCOLL
MAYOR Tm% us ST.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BUIMNG CONL\IISSIONFR
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 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 ransported by:
(name of hauler)
The debris will be disposed of in
V (name of facility)
3
(address of fac, ity) -
signature of permit applican
date
81 RAILROAD AVENUE ROWLEY, MA 01969
TEL 978-948-2005 Fax 978-948-7002 EMAIL JAQUITHARCHITECTS®MAC.COM
DAVID F. JAQUITH , AIA
28 August 2012
Mr.Thomas StPierre
Building Commissioner
3rd Floor
City Hall Annex
121 Washington Street
Salem, Massachusetts 01970
Re: Proposed Replacement of Roof Top Units#3 and#7
Grosvenor Park Nursing Center
7 Loring Hills Avenue
Salem, Massachusetts
Dear Tom:
I have reviewed the proposed replacement HVAC Units#3 and#7 that are being placed
in the exact same location as the units to be removed. The weight, and area of the
proposed units is within 5%of the existing units. I have viewed the roof top locations in
the field and reviewed the construction drawings of the roof construction. The roof
structure is 8" precast slabs as designed by Robert Rumpf Associates and are designed
to accommodate the unit loads.
I will be glad to answer a ns you may have.
SPED ARCH/
S' rely,
w � �
i i j I
Registered Arc ' o.2853
`1c owley,MA
Cc: -.
c+
`..•.f4t IN OF VO
Alan Berry, Berry Mechanic
Lois Wheaton,Grosvenor Park Nursing Center