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39 NORMAN ST - BUILDING INSPECTION (10) The Commonwealth of uasM{I Ie V►CESI Department ofPubliq,$4fety Massachusetts State Building C1 (f 1 q��� '' 0Building Permit Application for any Building other than a One-or Ai A'al&gy Dwelling 0 (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) l No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 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 19 No ❑ 60 6 Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: ��t.�7� ✓I�o i�VT L,9�L 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): I Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors Stories include basement levels &Area Per Floor .ft. / ( ) (sq. ) Total Area(s9.f.)and Total Height(£.) SECTION 5:USE GROUP(Check as applicable) 3 A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 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❑ I-4❑ M: Mercantile❑ R: Residential R-10 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 applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ 1 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 trench will not be Licensed Disposal Site El El Check if outside Flood Zone❑ Indicate municipal❑ required❑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❑ Is Structure within airport approach area? Is their review completed? r or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY r� Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: `;•i';=;a;; c ay \f[ 1 NOTES p,Y.."`$'R,, nary, , n, F � ✓n,t-..;= RECEIPTwy ra No ` +. "� c",;DATE ©� �o � 3 8 0191 ` (tnrf�ar;.� C�` e V� lVi,W �Iy W� fRECEIVED FROM .= " ' i ! ADDRESS r(4� Y w,N 1 t 1P >✓`E.iV`C d + J"°'m^.!v h3 �Y" ' t` y.}W A� Y+A�' �lyN E 00 f F_� CtOFOR {?jLoU 'Y '�YYTlT FOIE vC1L3Mr>^OMWE—DcLTII`�aia. .� �* m b� a'+ Fb .� .y i .' r . V �'WCL` ACCOUNT HOW PAID �+�- rr ! a >OYC AMT.OF °Fyn` �?,d dp ! Q (�,.G ACCOUNT 4a sAkv CASH iyr�y�_, ��s GKQ� �4am'4I e�Y,tNd`„`ri2}`y w m, AMT CHECK n �' � � PAID t� as � jV (1 d1. � . �i♦ ����\ BALANCE �y R `r MONEYBY 'DUE ORDER T SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner / jglzil?� 9/ft.es45N)UL 7,1 Name(Print) No.and Street City/Town Zip Pro erty Owner Contact Information: v�y7 EA,I— ' V -60- 07oV 135I,a4sa 49f/"w14 `r674-bX.r�y Title Telephone No.(business) Telephone No. (cell) e-mail address 7If plicable,,tthe property owner hereby authorizes (,.R," /_ q &X/c, St - SwPin &v7- A4j9 019a 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) f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑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 Company Namt CA rL vb !{V-o MLnd L S 'O b / y/i / Name of Person Responsible for Construction License No. and Type if Applicable Street �C / ��� /�Address City/Town State Zip tr Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVrr 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❑ No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 0 r) WD b 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 $ Enclose check payable to 6.Total Cost $ DJ, D0 (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 a ' ation is true qxlWcurate to the best of my knj ledge and understanding. K- - l s� atf �it�s,o Iry r �2 Please print a d sign name (� Title Telephone No. Date t ,w ?• Iw/Y+�7J,�a � � 07 O Street Address City/Town ,,J � State Zip Municipal Inspector to fill out this section upon application approval: "'�'+'� Name Dat _ Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-061061 Construction Supervisor - CARLO E CAPONIGRO L, �•� CJ�xe t0amrmzan+aemr!!/z o�C-Yl�aeaac/zuoa!!d 159 BURRILL ST, � "- OrPce of Consumer Affairs&Business Regulation _ SWAMPSCOTT yA 7 -- OME IMPROVEMENT CONTRACTOR egistration �qgg Type: ':� ":.. ,�/ • xpiration: DBA /� CAPONIGRO CONSIr I Expiration: Commissioner 07/25/2017 CARLO CAPONIGR 159 BURRILL ST _ SWAMPSCOTT, MA.019 'S`'p Undersecretary • r OP ID: LK CERTIFICATE OF LIABILITY INSURANCE DAT9/25/2015v) 09/25)2015 . THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED JREPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: DeSanctis Insurance Agcy,Inc. PHONE FA% 100 Unicorn Park Drive A/c Nn E.T: A/c No: Woburn,MA 01801 E-MAIL ADDRESS' PRODUCER CAPON-2 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIL# INSURED Caponigro Construction Co.,inc INSURERA:Pilgrim Insurance Company 159 Burrill Street INSURER 0:Associated Employers Swampscott, MA 01907 INSURER C INSRER D' INSUURER E' INSURER F' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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 OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IITR TYPE OF INSURANCE ADDL U POLICY EFF POLICY EXP N VJV POLICY NUMBER MM/DDM MM/DD IJMfrs GENERAL LIABILITY EACH OCCURRENCE $ GE to HEN I ED COMMERCIAL GENERAL LIABILITY PRREMISES Ea o rren $ CLAIMS-MADE ❑OCCUR MED EXP(Any one Pemn) $ PERSONAL$ADV INJURY $ GENERAL AGGREGATE $ GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- El LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea amident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per aoradent) $ A X SCHEDULED AUTOS PRC00001003551 06/06/2015 06/06/2016 PROPERTY DAMAGE X HIREDAUTOS (PER ACCIDENT) $ X NON-OWNEDAUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LMB CLAIMS-MADE - AGGREGATE $ DEDUCTIBLE $ RETENTION $ E WORI(ERS COMPENSATION X I_PCTUTU - OTM- AND EMPLOYERS'LIABILITY IR B ANYPROPRIETOR/PARTNEWEXECUTIVE YIN CC5005013890201 SA 09123/2015 09/2312016. E.L EACH ACCIDENT E 1,000,000 OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) (MA) EL DISEASE-EA EMPLOYE $ 1,000,000 If yes,&e ,be under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 1,000,000 1 CERTIFICATE HOLDER CANCELLATION - _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVES 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD d ',yµi,4. CEO TIFIC AVF Or`LIA#ILITY INSl3 ANC DACE( �YYYYr ' -�-• - 1/12/2016 .�F THIS CERTIFICATE IS ISSUED As A MATTER OF.INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ' CERTIFICATE DOES NOT AFFIRMATIVELY ORNEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE :AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:.tithe cenificate holder is an ADDITIONAL INSURED,the poficy(ies)must be endorsed. If SVQROGATION'IS WAIVED,Subject to . the.lerins and conditions of the,policy,certain policies may require an endorsement. A statemept.on this certificate does not confer rights to the, certificate holder Wlieu of such endorsemedt(s). - :PRODUCER _. .. - _. CONTACT COIa40r01fl1 Line6 . . .. :_. NAME: Prescott:and, Pon Insurance Agency,Inc. PHONE. (781)322-,2350 9.63 EastetA Avenue - : .- :' E+naL : ._ _. . .. . . _. ADDRE INSURER(S)AFFORDING COVERAGE - NAICI Ffa"ldea - MAC: 0214;8' �msURER j:7+r}iella. Protee£iCsn :Ins Co 42.3ISO INSURED.- ... "". INSUREn:B: .. .. .. Ca.pgA7Lgro Constructon. Co. inc.. - iN.::suRER c.: - ..,.. .. . 159 BurrS,ll SE.. . • INSURER D: ... .. !!TA D1907 F: COVIMA0129 -- -- - CERTIFICATE-NUMBERCCL1471b18938 'REVISIONHUMBER: . THIS is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW IJAVEBF,F-N ISSUED TO THE INSURED NAMED ABOVE FOR-THE POLICY PERIOD'- INDIC6TED'. NOTVATHSTANOING ANY IIG REOVIREMENf.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT.TO WHICH THIS OURITIOCATE MAY BE ISSUED OR MAY P£RTNU.THE INSURANCE AFFORDED BY THE POES DESCRIBED HEREIN IS SUB.IEOT TO ALL.THE;TERMS, ' EXCLi r l(..)NS ANI)OONOfT10N$OFSUGH POUGEs.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - m5D O •. ...... . ;-: .POMY:Eff POLICY E%P .. . Tta,eof OISUURANCE ... WE PCUCY eR1BER NrtIWYY klloarrr uigR5 '. . GENE)tACLfA6IDTY -- ... .. ; ' EACH OCCURRENCE '.. 5. X COkTAERGIFL GE,NEnAI LN[0111Y - ' I - 1 PREMI _So NoavdlrMee.. a 50,000 'A ,ci O is-,ihE -Txn. OCCUR �. 500061810 /z7/zG15 /27JZ036 ' MED:rJ2Pf aiexrser0 E .5 Goo /101,6 /27/2017 000,000.. PERSONALAADV kUURY " $• 1, i - - GENERA,AGOREOATE-- a 2s:000,Goo GErrL AGOREGATE.LMIT APPLIES PER: - PRODuCrs. cc.m A7P AGO 6 -2,000.,000' ... . .... AVLOYdeO.E LNaltliY- •. -.:. :.f. - .... COMBI�NE,DI61NGIE LIMIT . - ANVAUTO .- aw"INJURY(Pa.Par ) 5. AMNIINFD $CtIE04AED : :. _ BODILY DLAIRY tPer aaiaaal S AUTOS Fan[O.AVTO.a .. NONovmEO - AUTOS ttaafCcrAl .. JXUFeeFELLRLIA :M- OCGUFi ... .. EAC occuRRENCE S00LIAe' 60006Z466- - /?]/z015 /27/2016 -"' '-'xxAM&btADE AGGREGATEs5:,00:DED: nEiENTio'Ni - - /37%1.D16 L12f/2027 .: S . WOR.SEitS'lbE1PEN$Am5 N' Zw2N1PLOYER5l1fiBILITY' TIN AHYPeGPEuDe L"CulENE%EGVIhE.❑ - ELEAOH ACCIDENT . ORTCERM.EMBER Fi{cUJIIED7 E4 DISEASE EA EIAPL _ YYcccz .. 9 ' OE.MR. II'nONLF.OPERATION$Eeloiv _ ... - •...�".' .'. - E.L DISEASE-POLICY LIMIT 6 :.... .... , DESCRIPTIONOFOPERATIONS/LOCATIONS/VEHICLE.^. (Attach ACORD 110I,AdMonal Remarks Schedwe,N more space lsrequired) - - CERTIFICATE HOLDER CANCELLATION .':SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN - ACCORDANCE WITH THEPOLICY PROVISIONS.' - AUTHORIZED REPRESENTATIVE - J S Scholnick/MPB ACORD 25(2010/05) - - --- 01988-2010 ACORD CORPORATION. All rights reserved WS025 fJn1M.5Tnt_ - :. Th.A(:(lgrl name anA innn pre runietnrod mar4c of AC(TRA