111 NORTH ST - BUILDING INSPECTION (3) .f
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The Commonwealth of Massachusetts
1' `t Department of Public Safety
Nlassacluurtls Slrtc liu ilding Cudc(78U C'\IR)
Building Permit Application for any Building other than aOne-or'llvu-Family Dwelling
('This Section For Official Use Only)
Iktilding Permit Ntimbec -_--__ Date Applied: _ Building Official:
SECTION 1: LOG\PION(Please indicate Block M and Lot R for locations for which a street address is not available)
1(L1voAtA s 1-
No and Street City/'Town Zip Code Name of Building(if applicable)_-----
„ SECTION 2:PROPOSED WORK
Edition of NIA Slate Code used.-----_ If Nov Construction lieck here❑or check all that apply in the two rows below
Existing Budding❑ Repair❑ 1 Alteration 0 1 Addition❑ Demolition ❑ (please fill out and submit Appendix 1)
Change u(Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur conslntctiun documents being supplied as part of this permit application? Yes bP No ❑ ---
is an Independent Structural Engineering Pecr Review required? Yes/1�1 No ❑
Brief Description of proposed Work:--- Ael-.4/WIA)/ W,41 /-L/N� ��'�� -�h+'�• --
�Q/LLf.�l�1
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 CNIR 34) ❑
Existing Use Group(s): __— Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing proposed
No.of Flouts/Stories(include basement levels)dr Area Per Floor(sq. ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-I ❑ A-2❑ Nightclub ❑ A-t ❑ A4❑ A-5❑ 1 B: Business ❑ TE: Educational ❑
F: Facto F-I ❑ F2❑ ll: Hi h hazard H-1 ❑ H-2 O. 1I-1 ❑ 11-4❑ 11-i❑
1: lost itutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ NI: Mercantile❑ R: Residential R-10 R-2❑ R-1❑ R4❑
S: Storage 5-1 ❑ S2❑ 1 U: Utility❑ 1 Special Use❑and please describe below:
Special Use
SECTION 6:CONS'rRUC TION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV VA VB ❑
SECTION 7:SITE INFomiATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Wrench Permit Debris Removal:
Public❑ Check if outside Flood lone❑ Indicate numicipal❑
.\ trench will not be Licensed Disposal Site❑
I'm Me❑ or indt-ittify Zonr -___—_-_ or on site System ❑ required ❑or trends or spei ifN:
. permit is one losed❑
Railroad rlght-of-way: Hazards to Air Navigation: "I , 1 . I ' , .. ..
\'ot Applirable❑ Is Strui tore tyithin airport approach area' Is their rn•v ioww.-ontpletrd.' t�
or Consent to Budd onclo.od ❑ )is❑ or.No❑ 1 Yes❑ No ❑
SI[C1lON 8:CON I FN7'OF CFRI IFIC'A'1'L•'OI'OCCUPANCY
I!diUan ut Code: _ - -_ L'w Group( ): , - _ _ . 1\peal CniSlnirlion: 0"upont L.gad Per Iloor -
ILws the building contain.m sprinkler Sy.lem' ;pvt 1,11 Stipulations- _
i � Y
SECTION9: PI(OI'FI(IYOWNFIIAU'l'llOI(IZA'iION
;N"uuc and AdJ«'ss ut Property U viler
fYL<C GLtI T f �4- /Is-
Name(print) No.a d Slrret city/'fawn Zip
properly Ow tier Contact Information:
I isle --- _ — Telephone No.(business) -relephone No. (cell) e-mail address
If" „licable, Ilse properly ocr ierebY authorizes
fw1c� c�1rz�rE ,')v
Nance Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized b• this building ,omit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
1f buildin,is less than 35,0011 cu.ft.of enclowd s,ace and or not under Construction Control then check here❑and.ski St•ctiun 10.1
10.1 Re istered 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
�'nnpany Nauldg
fa.c. r�l�c�6rcI-,c�
Name�yof/Persolt Responsible for Cunstruelion /, License No. and Type if Applicable
?f((J ��W ��2Udt /�/rt-. LOCH 76
Street Address City/T wn State Zip
f7�8j�OS�d
Tole,hone No. business Telephone No. cell a-mail address ---
SECTION 11:t)�_n f l l.,.(k)mwl, t it's t` I nj.\.V_} ):.NJ lil-AVI 1, M.G.L.c.152.1 25C 6
A Workers'Compensation Insurance Affidavit from the h1A 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 a lication? Yes O No
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)-S_
I. Building S ��. P6) Building Permit Fee-Total Construction Cost x_(Insert here
'_. Electrical 5 appropriate municipal factor)-5--.
V Plwnbing S
I. Wchanical (I-IVAC) S Note: Minimum fee-S (contact municipality)
,i. .\Icrh,tniral Other 5
Enclose chtx'k payable to _
n,Total Cost S 3 .o e9 (,onLtA municipality)and w rite,heck number here ---.-__ —_
SECTION 13:SIGNATU F BUILDING PERMIT APPLICANT
IIv entering my n,ut e bylaw, 1 hereby attest unc r he p ti s and pen' tics of perjury that ell of the information contained in this
application is Irut t d/pecuratV to the hest oft y not If;r and un ctandin -
�otM.t6�flstr.��`�
I'lurs tint"tit sup n na pe �^-- title I,Iepttanc o. I. ato
�Ifcct Address Gly/ own i :P.ticl Lip
i
Municipal Inspector Inspector to fill out this section upon application approval:
_—_--- Itate__--
rill
.� AEOlZD® DATE IMMODIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 16 2011
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
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
iIMPORTANT: 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 endorsemen s.
PRODUCER A
I
Eastern Insurance Group LLC - Main PXOxE d� _ FAX
Ar
233 West Central Street N° ' -7 (Ar.NO: - 5 -e
ADD
RESSCSR24CL@easte2minsuranre.com
MA 01760 AA�RESS.
INSURER(S)AFFORDING COVERAGE NAIcC
WSURERA
INSURED 25090 INSURER BSe ec 'v £ 25
Straigbtline Excavation Corp INSURERC:
35 Hillman Street INSURER O:
I Tewksbury MA 01876-1972
i INSURER E:
NSURERF:
COVERAGES CERTIFICATE NUMBER:1882635135 REVISION NUMBER:
j 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.
INSR POLICY EFF 'POLICY EXP
Lni TYPEOFINSURAN($ INSR YJV11 POLICY NUMBER MN) MMID UMRS
A GENERALUABILITY S 1841274 /1/2011 /1,12012 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY P MI N VMI e100,a0a
CWM"ADE OCCUR MEO O(P(Any One person) 510,000
PERSONAL&ADV INJURY S1,0001000
GENERAL AGGREGATE $3,000,000
BENI.AGGREGATE UMIT APPLIES PER PRODUCTS-COMP/OPAGG $3,000,000
POLICY PRO- LOC S -
B AUTOMOBILE LIABILITY A 9091599 /16/2011 /16/2012 Ea acadenl S1 000;000
ANYAUTO BODILY WJURY(Perperson) 5
ALL OWNED SCHEDULED
AUTOS 8 AUTOS BODILY PIJURY(Pmamdeid) S
HIRED AUTOS NON-OWNED
8 x AUTOS PPR�OPe�N DAMAGE S
$
A I UMBREU UAS OCCUR S 1841274 /15/2011 /15/2012
EACH OCCURRENCE 52,000,000
IXDE65lJA8 CUIIMSMADE AGGREGATE S210001000
OED RETENTIONS
S
p WORKERS EMPLOYERS'
LIABILITY
AND C 7264441 /1/2011 /1/2012 WC STATU-MY
YIN
MIV PROPRIEfOR/PARiNER/EXECUnVE EL EACH ACCIDENT
OFACERIMEMBER EXCLUDED? N❑ NIA $500,000
(Mandatory inNN) EL DISEASE-EA EMPLOY $500,000
IIyas thin muter
OESf:RIPTION OFOPERATIONS belim EL DISEASE-POLICY LIMN 1 S500,000
DESCRIPTION OF OPERATIONSI LOCATIONS/VEHICLES(Atdch ACORDICI.Adddlomi Remmim Schedld%ifm mspamism4uiMdI
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.
._ AUTHOR®REPRESENTATIVE
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