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667-3B NORTON TERRACE - BUILDING INSPECTION W The Commonwealth of Massachusetts Department Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (Phis 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) 0 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 y iv Existing Building❑ Repair Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Existing Building0j Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes M-' No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No Er� Brief Description of Proposed Worry 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❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2 O 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-113 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 ❑ 1 IIIA ❑ 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: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Conmussion Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed?or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ - SECTION8:CONTENT OF CERTIFICATE OF OCCUPANCY - - Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Ad ress of Property Owner 1 Name(Print) _ No.and Street City/Town Zip Property Owner Contact Information/J��li+rg��IOC 6pu7r7 Title Telephone No.(business) Telephone No. (cell) -mail address J If applicable,the property owner hereby authorizes Ab �1r Name �eet Xddress City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building ern-it 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 0 and skip Section 10.1) - 10.1 Registered Professional Responsible for Construction Control - /�1 N ( 3eo3 L R is a T ephon N am Re istra ' Numberon (5 c Sl 1 Street Addr ss City/Town State Zip Discipline Expiration Date 102..1Genera/l Contractor - - K YI/OABN r/ LQq�� ✓1 /n/O oy}pony Name D. &.war 3 yillq Name of Person Responsible for Construction,/ n/! / Lidcsense No. and Type if Applicable W 7X (A f�7C 7Q �Jf f�Lf�v�7 �S�etr et Addreessss—/ City/Town A State Zip /l - Tele hone No. business Telephone No. cell e-mail addr s SECTION 11:WORRERB'COMPENSATION INSURANCE AFFIDAVrT 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 ysssuance of the building permit. Is a signed Affidavit submitted with this application? Yes Or No ❑ SECTION12:CONSTRUCTION COSTS AND PERMIT FEE'. Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 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 1 $ I (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 understanding. Please print and sign name Title Teleph e No. Date Street Address City/Town S IF Municipal Inspector to fill out this section upon application approval: ame V Date • J. Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot# for locations for which a street address is not available) No. and Street City /Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark'Y'where a licable No. Item Submitted Incomplete Not Required 1 Architectural 1/ 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other V'_ 10 Surve ed Site Plan(Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review - t/ 13 Structural Tests&Inspections Program - 14 Fire Protection Narrative Report 15 Existing Building Survey/Investi ation 16 Energy Conservation Report ✓ 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance - 19 Hazardous Material Mitigation Documentation 20 Other(Specify) - 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for.which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original pennit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address9�40 Registration Number ',et ress City/Town� /Tre Zip y �`F Discipline Expiration Date Stn Stat Name(Registrant) Telephone No. e-mail address Registration Number Street Address Ci /Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date Dep;irtment of Pufilic Sate% - Board of �.B �i .t Idin� Rt i _ulatiom and S_t.mdard> con struction Su ervisor Lic ense cense License: cs 42144 CARLO DUMAS 10 BROOKHEAD AVE BEVE RLY MA 01 915 'oat, f Expiration: 6/29/2013 111 (linm�isi.ner Tr': 17037 Office of Consumer Affairs and Ifusiness Regulation 10 Park Plaza - Suite 5170 w Boston, Massac - setts 02116 Home Improvement or Registration Registration: 113869 Type: Private Corporation _ _ W Expiration: 7/1 912 01 3 Trk 216609 KNEELAND CONSTRUCTION CO w CARL DUMAS o 407 R MYSTIC AVE #34B W MEDFORD, MA 02155 x m� Tc'oyM S�e�' Update Address and return card.Mark reason for change. . Address ❑ Renewal ❑ Employment Lost Card DPS-CAI 0 50M-04I04-G101216 Officeaoo�me°" r 2 iars&Bu'"5iness egu ation " License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR - before the expiration date. If found return to: Registration: , 13869 Type _ Office of Consumer Affairs and Business Regulation Expiration: jUbP13 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 TKNDCON S) - �m CARL DUMAS 407 R MYSTIC AVER MEDFORD, MA 0215 M / .Undersecretary Not valid without signature A�"AC a DATE(MMIDD/YYYY) lY CERTIFICATE OF LIABILITY INSURANCE 12/28/2012 PRODUCER Phone: (979)562-5652 Fax 978-562-7120 - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION WELSH&PARKER INSURANCE AGENCY,INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 131 COOLIDGE STREET,SUITE 100 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR HUDSON MA 01749 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: All America Insurance Company 20222 KNEELAND CONSTRUCTION,INC. INSURER B: Commerce Insurance Company 34754 407 R MYSTIC AVENUE SUITE 34B INSURER C: Torus National Ins Co/Quaker Special Risk MEDFORD MA 02155 INSURER D: Quaker Special Risk INSURER E: COVERAGES 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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSR pATE MM/OD/YY OATS MM/nD/YY GENERAL LIABILITY CLP 7998068 08/01/12 08/01/13 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY - OPREMHMAGE To RENTED occurence $ 300,000 Ee ISES CLAIMS MADE❑ OCCUR MED.EXP(Any one person) $ 10,000 A YES - PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO-FCT LOC $ AUTOMOBILE LIABILITY - RNY760 01/04/13 01/04/14 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ B ES X HIRED AUTOS BODILY INJURY $ X NON-OWNEDAUTOS (Per aceident) PROPERTY DAMAGE $ (Per aoodI GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY 71184E120AL7 08/29/12 08/01/13 EACHOCCURRENCE $ 2,000,000 X OCCUR ❑CLAIMS MADE AGGREGATE $ 2,000,000 C $ DEDUCTIBLE $ X RETENTION$ 10,000 $ u WCST OTHER WORKERS COMPENSATION AND TORY mrtS , EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ (Menddlory In NH) Il yes.describe under E.L.DISEASE-POLICY LIMIT $ SPECIAL PROVISIONS belmv OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION KNEELAND CONSTRUCTION, INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOREHE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS 407 R MYSTIC AVENUE SUITE 34B WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO MEDFORD MA 02155 DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OFANY KIND UPON THE INSURER,IT'S AGENTS OR REPRESENTATIVES. ` AUTHORIZED REPRESENTATIVE `else-! Attention: Karen Gedenberg ACORD 25(2009/01) Certificate# 51759 ©1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD . . . �I //G 0 ���