39 NORMAN ST - BUILDING INSPECTION (11) as- 057
The Commonwealth of Massachusetts
D� 1 Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other t a e or Tw amily Dwelli g
(Phis Section For Official Use Only
Building Permit Number: Date Applied: Buil ing Offi -
SECTION 1:LOCATION(Please indicate Block#and
-.Lot#for locations fo a street address is4ot available)
3`1 IVl1Yo"nn a Sear ,
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❑ 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 ❑ No
Is an Independent Structural Engineering Peer Review equired? Yes El No
Brief Description of Proposed Work: phi! A n
�Jr mo ,now we(Is 1 0 0p�_ Q,( npJ,I 2 AS
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): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.),
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ Hazazd H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑
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 ❑ IIIA ❑ IIIB ❑ 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 Di 1: Trench Permit: Debris Removal:
Public]"(` Check if outside Flood Zone❑ indicate municipal A tie h will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system required or trench or specify:
permit' enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review P ess:
Not Applicable Is Structure within airport a proach area? Is their review c mplete
or Consent to Build used❑ Yes❑ or N Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does thebuilding contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Narnq at g Address of Property Owner -
AAJJ&e),A� 35 N, 5 -S v. Ui5
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
'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 budding 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 O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(R gistrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Rwer � `( a� n� rsllnC .
Com any Name
Rtxver p.-T7�ernhka; j�)r,
Na—aPerson Responsible for Construction License No. and Type if Applicable
Ip WONOL1 261 bite. 14 W 00-K)
Street Address - City/Town State Zip
Telephone No. business Telephone No. ee* j 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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ .C1 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (conta t unicipality
111,166
5.Mechanical Other $ Enclose check. payable to
6.Total Cost $ 19 (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 understand' g.
Please int and sign n e Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
Alassactiusetts- Department of Public 5 IfetN ,
Board of Building
�XVl .. Regulations and Standards
Construction Supervisor License
License: CS 53693 -
.'ROGER A TREMBLAY JR
29 HATHAWAY AVE
BEVERLY MA 019
15
i
Expiration: 5/9/2D13
f'ununixsnmer Tr#. t5182
'yam 71. ` 4 License or registration valid for individul use only aas\ Office of Consumer Affairs&D siness Regulation g y
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 445375 Type: Office of Consumer Affairs and Business Regulation
Expiration: 1l1362013 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
20 ER A TREK%EY QiNT A-CT,ORS, INC.
y
tOGER TREMBL,Ey` 0
0 COLONIAL RE)$ll'fE'-4
ALEM, MA 01970 Undersecretar .�figsig
Y of valid without na ure
The Commonwealth ofMassachuselts
Department of Industrial Accidents
Office of Invesdgations
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleciricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/ln(lividual): ��I? Y11s�kQc>74
✓G ''S
pp� � �- f
Address: I � a!U�tlA _ �Q, `��iT� , I
City/State/Zip: 5� rq s� „
e you an employer? Check the appropriate box: Type of project(required):
1. am a employer with-21-) 4. ❑ I am a general contractor and I 6 ❑ New construction.
employees,(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑.Remodeling
ship and have no employees These sub-contractors have g_ ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition.
(No workers' comp.insurance comp.insurance.:
required-1 5. ❑ We area corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their. 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13:0 Other
comp.insurance required.]
•Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,.they must provide their workers'comp.policy number.ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information l
Insurance Company Name: 4tvgol O
Policy#or Self-ins. Lic. +#(( CS O UGr/7 3 5Pq 901 Expiration Date:2 / lZ—
Job Site Address: �1 t/V]tea S� City/State/Zip ✓Cp yr O j 'ZJ
Attach a copy of the workers' compensation policy declaration page(showing the policy number 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$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the.DIA for insurance coverage verification.
I do hereby rC under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: ct Date: ) Z
Phone#: 3 5
Official use only. Do not write in this area, to be completed by city or town ojjiciaL
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
t.nntnet Person- Phone#: .
.4co CIERTiFICATE OF LIABILITY INSURANCE DATEORUCAN""
11/10/2011
THIS CERTIFICATE G ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE.A CONTRACT BETWEEN THE ISSUING INSURER(ft AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER -
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poliry(les)must be endome0. If SUBROGATION US WAIVED,subject to
the terns and condidons of the policy,certain policies may require an endorsement A statement on this DertlRcate does not confer rights to the
certificate holder m lieu of such ends 9).
PROOUOEL - CONTACT Construction -
8astern Insurance Group'LLC °N (508)651-7700 - .(soa)css-eesl
233 West Central Street L10RF88•
° 00031507
Natick MA 01760 BO AFFOROWOCOVEFAGE NAIC0
INSUREr UGURERA$cut:Llus ins. Co.
IxsuREas Arbella Protection Ina. Co.
ROGER A 7MM3LAY CONTRACTORS INC Wsupmc:Hartford Und.-WC Pool
10 COLONIAL RD - IMSURERD:
SUITS 4 - _ W E:
SALEM MA 01970-294.3 xau
COVERAGES CERTIFICATENUMBER*gIiTBR 2011-S - 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. NOTWTHSTANDINO 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. -
rOMERAL
OFINSYRANCE POLICY NUMBER Mm EFF POLICY UNITS
MID EACH OCCURRENCE S 1,000,00 GENERAL LMBILITX P EMI a S loo,000
VDE O OCCUR 186529 - 1/00/2011 1/OB/2012 MEOEXP 0ne S 10,000
PERSONAL a ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000 UNIT APPLIES PER: PRODUCTSJECI
-COIAPlOPAGG f 2,000,000
PRO- LOC - f
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT b 11000,000
(Ea seddem)
ANY ALTO BOWL"INJURY Par
B ALLONNEOAUrOS 9013400004 /15/2011 /1S12012 ( PeMOn) S
BODILY INJURY(Per aWdeno S
X SCHEOULEDAUTOS PROPERTY DAMAGE -
X HIRED AUTOS (Per SCddmQ $
]( Medical pymem S
NONOWNED AUTOS
PIP-Bask g
UMBRELLA LMB OCCUR . - EACH OCCURRENCE b
EXCESS LM CLAIMSAIADE AGGREGATE- S
DEDUCTIBLE b
RETENTION S 0 S
WORKERS COMPENSATION X YMM START- Or14
ANDEMPLOYERS'LMMUTY
ANY PROPRIETORIPARTNERIEXECUTIVE YIN
E.L.EACHACCIDENT $ Sot 000
OFFICERMEMBER EXCLUDED? S60UB473SP98211 /1/2011 /1/2012
(Almdatery In NH) E.L DISEASE-EA EMPLOYE s Soo 000
Nyyee desrrflar urNN E.LDISEASE-
OSVIeF 0%OF OPERATIONS below
- POLICY LIMIT b SOO 000
ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES IANeca ACORD 101•AddWmlal Amuse Schedule.Nmore apace is nyWlM)
ERTIFICATE 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.
AUTHORRED REPRESENTATIVE
. .. Rosemary Fulham/EJM,
:ORD 25(2009109) - 01988.2009 ACORD CORPORATION. All rights reserved.
9025(2obbos) The ACORD name and logo are registered marks of ACORD