56 MARGIN ST - BUILDING INSPECTION pLllM MWT gE f4L-E94AG AffkROVED BY T+IE
JN Z=DB PRIOR TD.A.PEAANT 9WMG GRANTED
CITY OF SALEM
V )
.� o 3 .l 6. 0S
No. Date
Is Property Located In Location of
the Historic District? Yes No_ ftilding S6 Mario, S�.
Is Property Located in
aw CortserveUon Area? Yes No_
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other: In+or,or keKova��s
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name Salem t45toN rorttbtc 5h'ec+ 14L-A C"r&LfC6rt, —
Address & Phone 'Po fox 110 , ga6m, VA Ot 9-7o (iIS) -1 q o So 0
' Architect's Name +rea�- itt4Likeys , CK .
~� Address & Phone 209 l5igW q-, 1 �aleuA, MA& oi970(R?8`) 7,lq. 7371
Mechanics Name Ke I le h er S 6d zG k 6 /st e-
Address & Phone ?r32 FlsSC>< a. , verly, 1.(h 0191 S (9741) q Z f - a a go
Whet Is the purpose of IWIMI ag?
MraMdel of bul ding? NdSMACg
\/ oo B a dwelIN,for Prow many famble?
WE bAdlrag corAtNm to law? 725 Asbestos? a! eo_ 4 rfi Qr
Estimated cosIM600, 00 o Gty ucerwe r N P' slate uowm r
�50s 0- now Iaproveeent
� • Lie. r i
sec Signature o pii i
() SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE r
• Ne.0 iMT���or�iNtSkaSLrydal� , eedt. s , Tloor couert,ae51
n yyaN �Lt' foowt5 4 0-%0C *AU UU O(UVAbt' rr f I� w w-"6,t•.a-fie
Sprtwk�r, t:! Vs}enw 0 • Now (et� c�teus • View 4 C,
���� • New I.vV`�AowS .• Mtge . Gun•e.r-a.� 12e9atc'S
MAIL PERMIT TO: GCt�/che2 Co.,aa/ C'b
z3z F��S'£Ksr..
/1'IIq /
,f7A( �rch4x-.1 Scuv +45Qe- �,
Fl
M ' �
t.
APPLICATION FOR
PERMR TO
P,� n�Qul uS fe.�✓s
7�
LOCATION-
PERMIT GRANTED
APPROV�D
SP OR OF BUILDINGS
CONSTRUCTION CONTROL AFFIDAVIT
Project Number: 0179.004 Date: 03/03/05
Project Title: Salem Mission Seeds of Hope Campus—Shelter Renovation
Project Location: Salem, Massachusetts
Name of Building: 56 Margin street
Scope of Project: Interior/Exterior Renovations
IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUIDING CODE, I
MARK MECHE, MASS. REGISTRATION NO. 7083, ARCHITECT HEREBY CERTIFY THAT I HAVE
PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS,
COMPUTATIONS, AND SPECIFICATIONS CONCERNING:
Entire Project Architectural X Structural Mechanical
Electrical Fire Protection Other(specify)
FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH
PLANS, COMPUTATIONS, AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE
MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND
ALL APPLICABLE LAWS FOR THE PROPOSED PROJECT.
I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES
AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO
DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS
APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING
AS SPECIFIED IN SECTION 116.2.2.
1. Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for building permit, and approval for conformance to the design concept.
2. Review and approval of the quality control procedures for all code required control materials.
3. Special architectural or engineering professional inspection of critical construction components requiring
controlled materials or construction specified in the accepted engineering practice standards listed in
Appendix I.
PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTOR. UPON COMPLETION
OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS fl THE SAT SFACTORY COMPLETION
AND READINESS OF THE PROJECT FOR OCCUPANCY. A `
Signature
Y
SUBSCRIB AND SWORN TO BEFORE ME THIS Third DAY OF March_ 2005
My commission Expires: DD
otary Pu c
AFFIDAVIT
ELECTRICAL DESIGN
Permit No.
To the Commissioner,Inspectional Services Department:
I certify that to the best of my knowledge, information and belief,the plans and computations accompanying the attached
application concerning the locus at
S�kC.E�n V-1"I A
LAA V& V t�'� Ward S1tCcM, ItiA are in accordance
with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances.
Stephen J. Sullivan -27913
"OF y � ENGINEER- MASS. REG. NO.
e h n J. BLW Engineers Inc.
$ U ' COMPANY
le
311 Great Road, Post Office Box 1551, Littleton, MA 01460
ADDRESS
SS�ONALE�6� 978A86,4301
PHONE
Commonwealth of Massachusetts
County of Pt I DUL017"
On this day of Hker-4 2005 , before me, the undersigned notary public, personally appeared
Stephen J. Sullivan proved to me through satisfactory evidence of identification, which were
Personal Knowledge to be the person whose name is signed on the preceding or attached
document, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of
his/her knowledge and belief.
B ft me,
LOUIS J.L.BERNARD,jNotary PublicCmnmaweaab of Massach My Commission expires
MyComnl�iahEIIpYeeFeb24
.a
R.t5aGy41Ly 2 4 700(
t
Electrical Desgin;Aindavit.doe
ISO AF 1
AFFIDAVIT
FIRE PROTECTION
Permit No.
To the Commissioner, Inspectional Services Department:
I certify that to the best of my knowledge,information and belief,the plans and computations accompanying the attached
application concerning the locus at
SJ1Ccw. 1✓15SioN I S<. r4r►Tt �(%A %-TTlt ErT
'"Mr`^ r 410110%A C 147c) Ward SACZ 'r WA6 are in accordance
with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances.
William J. Scanlon -45449
ENGINEER -MASS. REG. NO.
Et•,LTM OF r'd
BLW Engineers Inc.
Wto ,�„ - COMPANY
J
MEC . EN ON « 311 Great Road, Post Office Box 1551, Littleton, MA 01460
454 NEEq ADDRESS
e9o,�9E0 ,cp
f'�roMAL EMOTw`-" 978.486.4301
PHONE
Commonwealth of Massachusetts
Countyof IVItOVLBE r-. f
On this_day of MAa264 2005 , before me,the undersigned notary public,
personally appeared William J. Scanlon proved to me through satisfactory evidence of
identification, which were Personal Knowledge ,to be the person whose name is signed on
the preceding or attached document, and who swore or affirmed to me that the contents of the document are truthful
and accurate to the best of his/her knowledge and belief.
Before
LOUIS J.L.BERNARD,JR.
Notary Public
caiuimoullb of Massachusetts
MyCpmt4ebn00sis feb24,20M My Commission expires
t _ `r
Fire Protection U.sgin Affidn"L bs.doc
ISO AF 1
AFFIDAVIT
MECHANICAL DESIGN
Permit No.
To the Commissioner, Inspectional Services Department:
I certify that to the best of my knowledge,information and belief,the plans and computations accompanying the attached
application concerning the locus at
S)q Qje ... w S-4s i a tr. 54 w4A�61�. sttR2E'�
SAL6kA^r 1W44 0%4q10 Ward UOQC � rlI are in accordance
with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances.
William J. Scanlon -45449
ENGINEER-MASS. REG. NO.
s
oar BLW Engineers, Inc.
WILLIq ,�„ COMPANY
N N w M
No. EEq NGIN
No. 311 Great Road, Post Office Box 1551, Littleton, MA 01460
ADDRESS
4L Epa�`�P 978.486.4301
PHONE
Commonwealth of Massachusetts
County of '' %Vgj zsEK
On this Lr'�day of 2005 , before me, the undersigned notary public,
personally appeared William J. Scanlon proved to me through satisfactory evidence of
identification, which were Personal Knowledge , to be the person whose name is signed on
the preceding or attached document, and who swore or affirmed to me that the contents of the document are truthful
and accurate to the best of his/her knowledge and belief.
Before e,
LOUIS J.L.BERNARD,JR.
Notary Public
CamndnwepA,pt Massachusetts
litOg irtlelmE OseFeb24,2006 My Commission expires
V f E aww—Y Z4, too
r .
Mechanical Desgin Affidavit bs.doc
`IfILITtES 517-L
S� MA eM �T'Z'5t r
i
s
0
O
Ing
�83 .y` Mckf ER�vENTtr� �� �YA
Tyg
�sr.P �
RiVFtUAV G T n '
NEB 6�C1 FikEPQo7� - �
DM„ G NATER LINeU/�xl
o .._
WMH �` AC
I
REPAVE s TRi p -AR
v�
g C
JOSEPH
D.o
'r r
c
F� rNAI-
JOB Li� ►JItc-rw &mam ,Sari/
Joseph Georgis, P.E. SHEET NO. OF
9 Taft Drive
WINCHESTER, MA 01890 CALCULATEDBY Nj t4- DATE 20 Z
TEL & FAX (781) 729.4646 CHECKED BY /Y DATE
✓IY 1 SCALE +
GENERAL NOTES:
1. UTILITY LINES LOCATION SHOWN ON THE SKETCH ARE APPROXIMATE.THE --
CONTRACTOR SHALL VERIFY,.
1CALL DIG-SAVE PRIOR TO.START WORK.
30 ALL'WORK SHALL BE MADE IN ACCORDANCE WITH THE;CITY REQUIREMENTS.
4. WATER LINE SHALL BE 4 FEET MINIMUM BELOW GRADE
5, CUT IN RQAD AND DRIVEWAY PAVEMENTS SHALL BE RESTORED TO_ITS ,
ORIGINAL CONDITION.
...ABBRIVIATIONS:
G GAS
GG GAS°GATE
W ...WATER._
WMH WATER MANHOLE
WG WATER GATE
_D DRAIN .... ,
DMH .. DRAIN-MANHOLE
S SEWER:
SMH SEWER MANHOLE
E ELECTRIC
EMH ELECTRICMANHOLE ... 104
... .al�� FORGI5
.... ... 2
ON '.......
iAA0LC110L1ltryesne�Mi VkAet�
r
FIRE PROTECTION NARRATIVE
Salem Mission
Building Renovations
SALEM, MASSACHUSMS
DATE: MARCH 3,2005
TO: City of Salem
Fire Prevention Office, Salem Fire Department
FROM: David Catanzaro
BLW Engineers
SUBJECT: SALEM MISSION
56 Margin Street
Salem,MA
COPIES TO: File
Gentlemen, in accordance with the Massachusetts State Building Code 60' edition chapter
9, we respectfully submit for your review this narrative on the proposed new fire
protection systems at the Salem Mission project located at 55 Margin Street in Salem,
Massachusetts.
SECTION 1—BUILDING DESCRIPTION
1. Building Use Group—RI
2. Total Square Footage of renovated space:
a) Basement - 4,500 sf
b) First Floor - 4,500 sf
3. Building Height—2 stories total
4. Number of Floors Above Grade— 1 Stories
5. Number of Floor Below Grade— 1 Story, Basement
6. Attic Spaces - none
7. Building Construction—Existing non-combustible
8. Types of Occupancies Within Building—Rl
9. Hazardous Material Storage—not applicable
10. High Piles Storage Over 12 Feet—not applicable
11. Site Access for Emergency Vehicles—No Change, site access shall not be altered
Page 1 of 6
FIRE PROTECTION NARRATIVE
Salem Mission
Building Renovations
SALEM, MASSACHUSETTS
SECTION 2—APPLICABLE LAWS, REGULATIONS AND STANDARDS
1. 780 CMR THE MASSACHUSETTS STATE BUILDING CODE, 6ch edition
2. 780 CMR CHAPTER 9, "FIRE PROTECTION SYSTEMS"
3. NFPA 13 "STANDARD FOR THE INSTALLATION OF SPRINKLER
SYSTEMS"latest edition
4. NFPA 25 "STANDARD FOR THE INSPECTION, TESTING, AND
MAINTENANCE OF WATER-BASED FIRE PROTECTION
SYSTEMS"latest edition
5. M.G.L. 148 MASSACHUSETTS GENERAL LAW CHAPTER 148 "FIRE
PREVENTION" (as applicable)
6. 527 CMR FIRE PREVENTION REGULATIONS (as applicable)
7. All applicable regulations and criteria of the local fire department and the owners
insurance authority.
9. All applicable sections and regulations of OSHA and ADA.
10. NFPA 70 NATIONAL ELECTRIC CODE
11. NFPA 72 NATIONAL FIRE.ALARM CODE
12. NFPA 24 "STANDARD FOR THE INSTALLATION OF PRIVATE
SERVICE MAINS" latest edition
SECTION 3—DESIGN RESPONSIBILITY FOR FIRE PROTECTION SYSTEMS
1. The sprinkler contractor shall provide a registered professional engineer (PE) who
shall produce a complete set of hydraulically calculated sprinkler systems
drawings as required by NFPA-13 latest accepted edition. The sprinkler
contractors registered engineer shall make the drawings complete in every respect
and shall show all piping runs, lengths, dimensions, fittings, elevations call-outs,
sprinkler head locations, pipe sizing, equipment layouts, hydraulic nodes and all
appropriate details. The shop drawings shall also show the existing sprinkler
systems and the points of new connection to the existing piping systems. The
sprinkler contractors registered engineer shall provide all hydraulic calculations to
verify the pipe sizing of the sprinkler and standpipe system. The sprinkler
contractors registered engineer shall stamp all sprinkler drawings and hydraulic
calculations and shall submit these to the fire department and owners insurance
authority for approval and permit. No work fire protection work shall begin until
the sprinkler contractor has obtained the approval for all sprinkler and standpipe
Page 2 of 6
FIRE PROTECTION NARRATIVE
Salem Mission
Building Renovations
SALEM, MASSACHUSETTS
systems from the fire department and the owners insurance authority. The
sprinkler contractor shall perform a new fire pump test in order to obtain current
flow and pressure data.
SECTION 4—FIRE PROTECTION SYSTEMS TO BE INSTALLED
Existing Building
The existing building will be provided with fire sprinkler systems for 100% of the
building interior spaces. All fire sprinkler systems will be designed in accordance with
NFPA-13. All fire sprinkler systems will be new and will be automatic wet pipe systems.
Sprinkler heads will be provided for all interior rooms, closets, toilet rooms and all spaces
as required by NFPA-13. Due to the fact that the existing building is non-combustible
construction, sprinkler heads will not be located in concealed spaces above ceilings.
There are no attic spaces in the building.
A new underground fire service main will be brought into the building mechanical room
in the basement. The sprinkler contractor will be responsible for installing the entire
underground fire service main up to and including the connection to the city water main
in the street. The new fire service entrance into the mechanical room will be provided
with a double check valve backflow preventer that will be registered with the
Massachusetts D.E.P. by the sprinkler contractor. A wet alarm check valve and trim will
be installed on the building side of the backflow preventer. A fire department connection
will be provided on the outside wall of the mechanical room and at a location of vehicle
access. The fire department connection will have the ability to charge all of the new fire
sprinkler systems in the building. A water motor gong will be provided on the outside of
the building in close proximity to the fire department connection. A master water flow
switch will be located on the sprinkler riser for the building. Due to the floor area of the
building, a single sprinkler riser will be used to supply all of the new fire sprinkler
systems in the building. Sprinkler heads will be connected to the sprinkler riser with
sprinkler mains and branch piping for both floors of the building. Sprinkler heads
throughout the building will be quick response type. Temperature ratings for sprinkler
heads will be ordinary temperature for general building areas and high temperatures for
mechanical rooms, electric rooms and kitchen areas. Temperature ratings for all sprinkler
heads shall be in accordance with NFPA-13.
Page 3 of 6
FIRE PROTECTION NARRATIVE
Salem Mission
Building Renovations
SALEM, MASSACHUSMS
General
The sprinkler systems will be hydraulically calculated per the requirements of NFPA-13.
General building areas will be hydraulically calculated per NFPA-13 at a light hazard
occupancy, with a density of .10 gpm per remote 1500 square feet. A 100 gpm hose
stream allowance will be provided. Kitchen areas will be hydraulically calculated per
NFPA-13 at an Ordinary Hazard Occupancy Group 1, with a density of .15 gpm per
remote 1500 square feet. A 250 gpm hose stream allowance will be provided.
All sprinkler systems will be designed, tested and installed in accordance with the
applicable sections of the Massachusetts State Building Code 6ch edition and NFPA-13
and NFPA-24 latest accepted editions as well as the regulations and guidelines of the
local authority. All sprinkler systems equipment, materials, piping, sprinkler heads and
devices shall be UL listed or FM approved for fire protection service and shall be rated at
175 psi working pressure. All applicable sprinkler piping shall be seismically braced in
accordance with the Massachusetts State Building Code 61h edition and NFPA-13.
The sprinkler contractor will conduct a new hydrant flow test in order to obtain current
flow and pressure data at the site. The flow test will be conducted in accordance with
NFPA-13. The sprinkler contractor will coordinate with the local water authority for the
requirements of the test and for opening and closing the fire hydrants in the street.
Sequence of Operation
A. In the event of a fire, heat will be produced and will build at the ceiling. Upon a
sufficient buildup of heat, an automatic sprinkler head over the area of fire will be
activated via its fusible link element, and water in the wet sprinkler piping will flow out
of the orifice. Heat and smoke will also trigger the buildings smoke detectors which will
activate the existing building fire alarm systems. Upon the flow of water from any
sprinkler head in the building, water will flow through the sprinkler systems alarm check
valve, and up the sprinkler riser, to the sprinkler system and through the sprinkler system
branch piping. Water will also flow into the alarm check valve alarm trim, and will
activate the master water flow switch which will send a fire alarm signal to the building
fire alarm system. Water will also flow to the water motor gong and an audible alarm
signal outside the building will be activated.
Page 4 of 6
FIRE PROTECTION NARRATIVE
Salem Mission
Building Renovations
SALEM, MASSACHUSMS
SECTION 5—FEATURES USED IN THE DESIGN METHODOLOGY
FIRE ALARM SYSTEM
1. A new fire alarm control panel and complete fire alarm system is being provided.
Manual pull stations shall be provided at all exit doors on all floors. Smoke detectors
shall be provided in common areas and electrical/mechanical rooms. Audio/visual
devices shall be provided throughout. Sprinkler tamper and flow switches shall be
tied into the new FACP. The control panel , when tripped, shall report to the Salem
Fire Department,via an existing Masterbox..
2. The emergency lighting shall be provided utilizing self contained battery units with
dual heads and exit signs with battery backup. Exit signs will be located at all
exitways, and emergency lights will illuminate all means of egress with a minimum of
1 footcandle at the floor leve.
SECTION 6—TESTING CRITERIA
1. All Testing of the sprinkler systems devices, piping, heads and valves, shall be
performed by a licensed sprinkler contractor, experienced in the installation and
testing of fire sprinkler systems in the state of Massachusetts. This sprinkler
contractor shall provide all coordination of the sprinkler tests with the fire
department. All sprinkler and standpipe systems tests shall be witnessed by the
fire department, owners representative, owners insurance authority. The sprinkler
contractor shall give notification to the local fire department, owners
representative, owners insurance authority and all other authorities, prior to the
conducting of any sprinkler and standpipe tests.
2. All sprinkler systems testing shall be performed in strict accordance with NFPA-
13,NFPA-24 and NFPA-25, latest accepted editions.
3. The sprinkler contractor shall provide all equipment, water, pumps, labor, etc.,
necessary to conduct all testing required by NFPA-13, NFPA-24 and NFPA-25,
and shall obtain all required approvals from the fire department, building code
official, owners insurance authority, and all other authorities upon completion of
the sprinkler systems testing. All dates and times of the sprinkler systems testing
shall be coordinated by the sprinkler contractor with the fire department, owners
representative, and the owners insurance authority.
Page 5 of 6
FIRE PROTECTION NARRATIVE
Salem Mission
Building Renovations
SALEM, MASSACHUSMS
SECTION 7—EQUIPMENT AND TOOLS
1. The sprinkler contractor shall have at the site, at the time of sprinkler installation
and testing, and readily available for use and inspections, all tools, equipment,
permits, hoists, scaffolding, piping, fittings, valves and all required tools and
equipment necessary for the complete installation of all fire protection systems.
2. The sprinkler contractor shall provide all gauges, valves, hoses, smoke, etc.,
required for an operational test of the installed fire sprinkler system. Remote test
and drain stations shall be provided for system performance testing.
3. The sprinkler contractor shall have, at the site, the manufacturers instructions and
nameplate data for all fire sprinkler equipment, and devices being used in the
sprinkler systems installation.
SECTION 8—APPROVAL REOUIREMENTS
1. Upon successful inspection and testing of all fire sprinkler systems, the sprinkler
contractor shall obtain written approval of the completed fire sprinkler system
from the fire department, owners insurance authority, and all other code officials.
Copies of all written approvals shall be turned over to the owner representative.
2. If a code official should find cause to reject any portion of the fire sprinkler
system installation or testing, the sprinkler contractor shall be responsible for
correcting the problem in a timely manner. Upon completion of all corrective
measures undertaken by the sprinkler contractor, a new test and inspection shall
be again coordinated by the sprinkler contractor, and witnessed by the fire
department and all other authorities as previously stated.
3. The sprinkler contractor shall submit stamped and signed sprinkler design
drawings and hydraulic calculations and obtain all required permits prior to the
installation of any fire sprinkler systems. The sprinkler plans shall be in
accordance with the Massachusetts State Building Code, 6`h edition, chapter 9, as
well as the requirements in NFPA-13, latest accepted edition.
4. The sprinkler contractor shall obtain all document of acceptance as required by the
Massachusetts State Building Code, 61h edition,chapter 903.4, and shall submit all
such documents as required, to the owners representative and building code
officials.
Page 6 of 6
Richard W.Southgate Jr.
Vice President
Operations;
, Kelleher 232 Essex Street,Beverly MA 01915
Construction Managers'; Direct:978.998.6153
'General Contractors Main:978.921.0080
Established 1912 Fax:978.922.6087
�'" E-mail:rsouthgate@kelleherconst.com
KELLEHER - LETTER OF TRANSMITTAL
232 Essex Street
Beverly, Massachusetts o1915
Date: Job No.
(978) 921-0080 03-16-05 SalemMission
FAX (978) 922-0087 Attention:
Joseph Barbeau
Re:
TO: City of Salem Public Property Dept Building Permit Application for
120 Washington Street Salem Mission Seeds of Hope Campus
Salem,MA 01970 56 Margin Street
WE ARE SENDING YOU _ X Attached Under separate cover via the following items:
Shop Drawings Prints X Plans Samples X Specifications
Copy of Letter Change Order
Copies Date No. DESCRIPTION
3 11-18-04 Full Set Construction Plans
1 03-16-05 Building Permit Application
1 Disposal of Debris Affadavit
1 Insurance Affadavit
1 03-03-05 Construction Control Affadavit
1 02-24-06 Electrical Design Affadavit
1 02-24-05 Fire Protection Design Affadavit
1 02-24-05 Mechanical Design Affadavit
1 02-28-05 Utilities Site Plan
_ 1 02-28-05 Utilities Notes
1 03-03-05 Fire Protection Narrative
THESE ARE TRANSMITTED as checked below:
X For approval Approved as submitted Resubmit copies for approval
For your use Approved as noted Submit copies for distribution
As requested Returned for corrections Return corrected prints
For review and comment
FOR BIDS DUE PRINTS RETURNED AFTER LOANED TO US
COPY TO: 1160KORTEC SIGNED: Rick Southgate
o CITY OF SALEM� MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA 01 970
TEL. (978)745-9595 EXT. 380
FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition
of Building Permit# , all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility, as defined by MGL c III, S 150A. I
The debris will be disposed of at: �jy�v� 4y.Cr AAA
Location of Facility
3 . l g. 5
Signatureoft!ITitAppli6fim Date
FULLY complete the following information:
(PLEASE PRINT CLEARLY)
I`ly�.Ml-A <GJa4a �e1�
Name of Permit Applicant
Firm Name,if any
232 6 '->k. , 13e✓e-r . MA- of
Address, City & Sta e�
The above statute requires that debris from the demolition,renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL clII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
The Commonwealth of Massachusetts
p. 3
Department of Industrial Accidents
la -= OHIeeBllnvesflgetloaa
600 Washington Street, ra Floor
Boston,Mass. 02111
v 'Workers'Compensation Insurance Affidavit: Buildin lumbing/Electrical Contractors
AnnR' `ucaa w rmat[ona '+.` x',a€'a� *+�ra�t=in§en�cflHlL�i6'" -XV? .0,
name:
address:
city state: zip: phone#
work site location(full address):
❑ 1 am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel
[�-I am a sole proprietor and have no one working in any capacity. ❑Building Addition
1 am an employer providing workers'�compensation for my employees working on this lob .�t
R_G��Gk. r�✓�.OK '"'4,"F``� ' ifi
compapv name !.J' t-%a °'' N:L t a Pi t'i r'address:, GX �ll' +rr
ciri; JCYIY
insprxps€co� �7 •. face-t t/`cl.)/fi��G1'S
❑ 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'compensation polices:
e mm mate•.<. - - IT
address:
city:
in nc
company name• . n' _
YSAE p T:i�.''v-°`�£'Y41411
'y
777777
r,' x r
n 4 rt me+r�6-b'. x?Siy`xyt� gtask a'h xr.3',+4: ..�"4w 4
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a Rue up to SI,50a.00 and/or
one yesn'Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
l do hereby certify under the pains andd ppenalti of penrjury thal!t ormation provided above is true and correct`
Signature !/✓ r�r`' Date 3. 14, ✓ psi
Print name Rl, � �O V t Or. Phone 0 0
official use only do not write in this area to be completed by city or town official
city or town: permil/Iicense a ❑Build(ng Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's OMm
❑Health Department
contact Person: phone a; ❑Other
Ire.used Sepi.axnl
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law",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 section 25 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, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation. Please
supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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.
City or Towns
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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
� m
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Me of un►est ISUIee
600 Washington Street,7h Floor
Boston, Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext.406