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33 NORTHEY ST - BUILDING INSPECTION
Tli `'Ciinimonwealth oFlVtas' i'h-usetts Department of Public Safety + Max"It sLdc Building Cod"(7,41)C,\IR) 7 Building I'lPniit Apphcs't)ufi•Forony Building other than aOne-ur"I': 1,)yvelling. -- (I his Stctwn For Offi,.I,d Use 0111v) Ruildiug Permit Number _ D to \pph!d _ Building Official: SECnON 1: LOCATION(Please indicate Block If and Lut k fur locations for which a street address is nut available) 33../�a277V.ST:. No. and Street Cit}' /rown /ip Code Name of Building(it applicable) SECTION 2:PROPOSED WORK Edition ut MA s611e Cute usrd _ If New Construction chock here❑or check all that apply in the Ilea rtncs below -- I?sisling Building❑ Repair❑ :\Iteration ❑ Addition❑ 1 Demolition ❑ (1'Iease fill oul.unl submit:Appendix 1) Change of Use ❑ Changeof Occupancy ❑ Other ❑ Specify:-__--- Are building plans onJ/ur cunslnnctiun do'ulucnts being supplied as part of this permit application? Yes ❑ No -- ----- Is an Independent Structural Engineering Peer Review myuired? Yes ❑ No Brief Description of Proposed Work!1C7C'owrs5�an� �r.. AL/L, T�yGs.r�! ,YOB t+•e Tryyy _.�LtEr�awr�l/IS.rt�aC�-�n��; �otwssxo 2/errii�ut�/��urr.-s�� w Vt . SECTION J:COM1.!n :rli"171115SECTION IF EXIS"TING_B,UI,LDING,UNDERGOING RENOYA'6ION,AUDITIONr Old CHANGE IN USE OR"OCCUPANCY Check here if an Existing Building Investigation and Evaluation is encloscal (See 780 CNIR.1-I) ❑ Ex is in1 Use Griiii + s ro<` -!•' r h {O _ Proposed Use Gruup(s):__— SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flom:s/Stories(include basement levels)&Area Per Fluor(sy. ft.) Total Area(sq. ft.).md Total Height(tt.) sECrION 5:USE GROUP(Check as applicable) A: Assembly:\-1 ❑ A-2❑ Nightclub ❑ A-1 ❑ A-1 ❑ A-i❑ B: Business ❑ F: Educational ❑ F: Facto F-I ❑ F2❑ 111 High Hazard H-I ❑ H-2❑ -.II-t ❑ li-a❑ I I-i❑ 1: Institutional 1-1 ❑ 1-'_❑ 1-1❑ 1-4 ❑ Mt Mercantile❑ R: Residenti d"RY❑ R-'_❑. R-.1❑ R-4 ❑ s: storage S-I O S_'❑ U: Utility O special Use'l9(iiitC}+leasedescribe l+cluw: sprci,nl Use .,•:.: -. • SECTION b:CONS I'RUCrION TYPE(Check as applicable) 1A ❑ III ❑ I C3 IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VI] ❑ SECTION 7:SITE INFORMATION(refer to 780 CVIR 111.0 for details on each item) Water Supply: flood Zone information: Sewage Disposal: Wrench Permit Debris Removal: Ito hl is❑ Chock it moside Ilo:al Lahr❑ Indicate municipal ❑ A Irrnch will noI be I.icen,rd Pkposal Sit,-❑ I'riv.ue O ar in,lvnlil\ /amp; _.._ ar nn v0.•sc,h,nl ❑ rryuired ❑or trench or spec iIN . ^�N , perlmlt ,l Ill Tit 11 ❑ I 4 Railroad right-of-way: I laiarls hr \u Navigation: . , i Z I \ I.\pph,Jl 1, ❑ I Is.tilruc lure It ill"', ur( art.Ippra.0 h :I n•a? I,Ih,rr it nt it ,mph lad i t to ltu ll.,l uql rJ❑ .,l,cs'C""J'No❑ I 1„❑ \ ❑ SI CI ION S: CON I LNT Uf CIA I'IPIC,\l Ji OF OC C CI;\N( *' .;'•. . ". .. I1 ,Illli n of l Ir- l,r Gn ul(,) I\p, al C. II,Irut nlvl: 0"uPent I.,,.Id per I I,,„r — ll ,. lhrluddinl;,„ntml m�Pr mKI,r tit,tem. p,n,d �lipulalien, S 3 SRA[ON `k I'ROPI[I(I Y IIWNFR AU I I IOHI'ZA I ION ___-_ - :Nottv mitt ;\ddn'ss nl Property Owner Name(Print) No. and Street 'ity/Town Lip I'n+lie rty Owner Ca,I tact III for m.11ioit: I'ille I'claphone No. (business) rcicphone No. (cell) a-retail address It applicable, the properly owner hcrebv authorizes -- -- N une Street Address - -- -City/Tut.n Slate, Lip to li('t{tit rho iriv-•M- "Gwl,cr 4lefiliff, ut irlh5fiattcrs rrlahve to work authorized b [hiy}imiililm kraut a i.lulUVl,. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less Ilion 15,IIW Co.ft If enclosed s,ace and or not under Constnrction Cuiurol then check here❑and.4kip Section III I) 10.1 Registered Professional Responsible for Construction Control Name(Registrant) .. .telephone No. c-mail address Registration Number Sort Address City/rown Stale Zip Discipline -Expiration Dale 'M aL\'N 1i i C Ulllpa❑ 11c1}f�'. 17A M �.JNiutr.� O -- Name of Person Responsible for Construction License No. and Type if A\p_plicable `1 GhSk Aid 37xS$ �: i cs4 t%. 5tre"t Address City/Towne State Zip Tole,hone No. business Telephone No. cell a-mail address SECTIONIl:aI, III-II .( .i �ul-v' IglNl" ul:.l\{'bal111"'1ell M.G.L.c. 152. 25C6 A Workers'Compensation losurmce Affidavlt'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 si coed Affidavit submitted with this a lication? Yes 0 No O SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor Item and Materials) -!oral Construction Cost(from Item 6) S__— I, Building 5 4 O IM-- Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical B /d pyp appropriate municipal factor) .5 1. Plumbing S �w+sr+ nuulici ,amity ;. \lechanit'll (11VAC) 5 Nutt .\minu innl fee=5__(iunLtit 1 ) 3. Nlechanical Other 5 Fndose du•rk payabl" to _ r,. total Cost '5 )Z III- (a,ntad ❑umicipali tv)and write check number lien -- .-. - -- SECTION 13:SIGNAI URE OF BUILDING PERMIT APPLICANT Ill entering ,IN, n.,ne below, I hereby attest under lire p,line•old penalties of perjure' thm all of the information tolo-unvd in [his a I pI it dion is trio. ond actit rate to the best of col WO"lk'dge,cod und"rst coding. I'k- print and .igll mute_. I ille 1'.1"�pltnne Noo. Lila �tn'et Wdrvss 7 z4arA&e7?A)iX• Citl'i 1-,ilvn/'=(I'�9Tr :�tale'f'• Lil9/yf i municipal Inspector to fill out this,"dion ,pill, application approval: __ - � .\', lit e CITY OF S.u.Eal, AuS.ICHL'SETI'S JLtLOI,VG DEP.%AntE%jT I '0 W-UNNGTON STAFBT, 1'O FLCOA rEL k979) 745-9591 1C1Jc3EALfiY ORLSCOLL RAX(979) 749&W .�fAYOk IkG.WISLPIlias . DIfIBLTOL O/Pl8t1C PROPll17Y/gCQ.t7LYC GO\pl(St(OV E!< Construction Debris Dlsp0531 Affidavit (required ror all demolition and renovation work) In accordance with the jixth edition orthe State Building Cade. 790 OUR section 111.J Debris, and the provision of MGL o 401 S J4; Building Permit At is issued with the condition that the debris resulting from this work shell be disposed of in a properly licrosed waste disposal racility as defined by,�IGL c S I JOA. The debris will be transported by; (fl4m0 uf hauler) Tha dde�bris /will ba disposed of in_: !/Vito �CJcS�tpF U•C.aJ u fn�mro or�ermif rpphcnf '� e ��. CCCY OF S.`L.E.Nf, AkSSACHUSETTS t.. ULILOING DEP.h ItrMENT 120 WASHINGTON STREET, ) FLUOR TEL (979) 745-9595 FAA(979) 7N19946 �!>IDE'LL.HY 0AISCOLL �UYO Z TrIOSL\3 ST.PIE.QAB DMUCK 0F PCOLIC PRO PEATY/0L:BA IN,G COJL!,IISS ION EX Worker' Compensation fneurunce ,\ITldavit: UuiltteriJContracturUElectrlc(an..4Plumben t tlleunt Information �r f ass Print Lcaihl Villnc Illmit a+s Urgaronlianlndividu•JI: e�rwrA� !elf Address: 7- 1,-MS14A97ary ST Cily/State/Zip: AAZ4% Phune N: g/� 7fSr37d 7 ,ire you an employer'!Check the appropriate boat I. I am a employer with_ - 4• ❑ 1 arts a general contractor and 1 type of project(required): dmplayees(Hall and/or part-time).* have hired the sub-cantnctars 6' Now cunsuuction 2.❑ I,ran a solo proprietor or parinur- lined on the attached shed t 1• Remodeling ,hip and have no employees These subcontractors have g. Dentalitian working tits main any capacity. workers'camp,insurance. 1No workers',comp, insurance J. ❑ We are a corporation and its y ❑ Building addition required.) officers have exercised their 10.❑Electrical repair$or additions J.❑ 1 mn a homeowner doing all work right of exemption per MGL I I.Q Plumbing repair$or uddidans myself.(so workers'Gump. C. 152,11(4),and we have no 12.Q Raof n pairs insurance required.) 1 vmpluyecs. (No workers' comp. insurance required,) I].QOther '.My applkuill that chticks bat el n,us Ala('1ll am the W11iue below.Aowing their rerk,hi cmnpsnudun pulley mnummion. 'I hvneur tan who+ulhmit Ihis taldavir ind iwtna ihey at doing all work and had hint ualtide eantee:t\m VXlen that rhavk this box moat aaacAud an.WdalueW h.,showing the owns of the mA.vmnctonand helr�rkenacum devil lndicaling.w), p.poltay Interrelation. is ale ON turpluyer that/s provldlnX workers'camprvssalon htsurance far my elnplayers Below/s the policy andfab slrf in�arnrutlaf4 I mururee(:onlpany Name: Policy 4 ur Sel4ios. Liu. it: -----� Expiration Date: lull Sila,Wdruss: CilyiStuted'ip: .tlbcb a copy of Ihd oorktts' compdmatloe pulley ddclarotloll page(showing the policy number and eaplratlon data). I-'ailuru to reeury euverage,as required under.Suction 2JA ut'btGL c. 152 can lead to the imposition orcriminal penalties ofa t tcv up to i l.500.00 and/or one-yearimpri.mnmen4 as Well is civil penalties in Ihd lbrm of a STOP WORK ORDE �:f up in i'_SO.00 s Jay tgainst flit violator. Ile advised that a copy of ihis,falument may bu furwardcd to Ila 01*DER and a lino of I,rr"19Auns.11llw MA Gtr insunnee covaragc veritieuliun. t du hrrrby crrti/y is, ui,u unJ prnelNrr ./pvr/ury rtsur the injunnudan proviJaJ nbuv,r i frar,mJ corrrrl — --- — r1/�irinl mr•fn/y /L,,ref o•rire in f/rr:r:ur,r, Id St emu (rind 5 p y ctry ur lu we ell/Iriu! City ar I...... .. -- i'crmiULlccnse d h+uim; .\uihorily I. ;6ranl ul lleJllh !. IluildGt Ucp.lrlmeut i. l 171 h<r ityll aura CA'rk 1. uefrlc tl lnylerttr i. l'ht�uhim„ lu tpect.tr 4. l.ni1.1.1 , :ntn: `...............�.... ..gyp........... ... . ....... .,..... �T p .. : .• ..+ s Board of Building Rc�rulatiuos and Standards I '"� - ,✓fie iJan:uito/aiaaa o�i/C��raarrc%uae(Ce . Construction Supervisor License # -,' DEPARTMENT OF PUBLIC SAFETY License: CS 46676 Hoisting Engineer License -- _ Number:,HE 068713 s + •' 4 ^- Expires:09/21/2012 Tr.no: 3100 0.. JAMES C SHEEHAN III v i 7 MT WASHINGTON ST f x Restricted 2A EVERETT, MA02149 ,rt' Y' 4 JAMES C SHEEHAN Ilt „ 444 a— - % 7 MT WASHINGTON ST x. Expiration: 9/21/2013 } i c EVERETT, MA 02149 "£ (lnnmi..i,nu.r Tr#: 3882 (( [ Commission- /. 7&ivaeaoau , a�✓�.rtmac�inaeld Office or Consumer Affairs&B siness Regulation ri t s �E HOME IMPROVEMENT CONTRACTOR a Registration ,,111000 .Type -. fi ` Expiration 11/182012 - DBA tv 'True - "5 ` SHEEHAN BUILDING&REMODELING a VY JAMES SHEEHAN III ' _ - ' 7 MT WASHINGTON ST �'� -..k• .re •", o , ' EVERETT,MA 02149 3, ` Gru g r> Undersecretary sa f' SHEEHAN, JAMES C r-�---• �. at� � ��Expires 3 ontmun�ccalth of Massachusetts 26J,UN204` 6 ='3 Department of k , Public Safety lug � { renspoitatlon Workerer Itlentaicati.non Cretlantlal f1 .ertified Building Official _ James C. Sheehan Local Inspector f s i g` `` r = Ado inis9rator Ac RO v® CERTIFICATE OF LIABILITY INSURANCE DATE(MN DD YY 10/14/2011 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. 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 CNAME CT Robert Scrlma R fi R Insurance Agency, Inc. PHONE . (78 � .(791)289-4147 406 Revere Beach Parkway AOA1L INSURER(S)AFFORDING COVERAGE NAIcO Revere MA 02151 INSURERAXS Brokers Insurance Company INSURED INSURER B: Sheehan Consulting and Construction Inc INSURER C: 7 Mount washington Street INSURER 0: ' INSURER E Everett MA 02149 INSURER F: COVERAGES CERTIFICATE NUMBER..CL11101401410 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. IN R TYPE OF INSURANCE POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDD N LIMRS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCULL GENERAL LIABILITY IS Ea oavrren¢TO RENTED $ 50,000 A CLMMS{dADE Fx—]OCCUR 3DG5796 /8/2011 /8/2012 MED EXP(Any one person) $ 1,000 PERSONALAADVINJURY S 1,000,000 GENERAL AGGREGATE S 1,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG S 1,000,000 X1 POLICY JErTPRO- Fj LOC S AUTOMOBILE UASILTIY C0 BSSn'=D SINGLE LIMIT $ ANY AUTO BODILY INJURY(Pw p4rson) $ ALL OWNED SCHEDULED BODILY INJURY Peramtlsaj $ AUTOS AUTOS HIRED AUTOS AUTTOS EO P OPERTYIOAMAGE $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS UAB ' CLAIM�E AGGREGATE S OED I I RETENTIONS $ WORKERS COMPENSATION WC STATU- OH- AND EMPLOYERS'LUBILTY YIN ANY PROPRIETOIUPARTNERIEXECUTIVE E.L EACH ACCIDENT $ OMCEIUMEMBER EXCLUDEDt NIA (Mandatary In NH) EL DISEASE-EA EMPLOYEE S If yyes.das¢be antler DE$CRIP ION OF OPERATIONS Debi EL DISEASE-POLICY LIMIT $ 'DESbRIP,UONOF OPERATIONS LOCATIONS I VEHICLES (Afdcn ACORD 101,Addieonel R. Scbe l%if nmra epa¢I.2quirtd) CERTIFICATE HOLDER CANCELLATION _ - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, N0710E WILL BE DELIVERED IN - ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORD'J n REPRESENTATIVE Ann Brandolini/ANNBRA ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025r,nlmAInl T%.ar:non name an,i rnnn aro roni¢broel...*.of Ar`npn