7 OAK ST - BUILDING INSPECTION t ,
I' The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(Ibis 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)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK
Edition of MA State Code used If New Constructiomcheck-here.❑or check all that apply in the two rows below ^+
Existing Building Repair Pj Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No fll�
Is an Independent Structural Engineering Peer Review required? Yes ❑ No dd�--
Brief Description of Proposed Work: C� i 17 G
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❑ 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 Sl❑ S-2❑ U. Utility❑` Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ HIB ❑ 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 Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8: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 Address of Property Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) a-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 building 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 0 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
10.22 General Contractor
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Comp y Name
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Name of Perrpn Responsible f93'Construction License No. and Type if Applicable
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Street Address ice- City/Town State Zip
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Telephone No.(business) Telephone No. cell e-m ' 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 most 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
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)_$ 08
1.Building $ •60 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee—$ (contact mum'cjpali_ty) \
5.Mechanical Other $ Z/�J(�/)
Enclose check payable to
6.Total Cost $ Ste,O� (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.
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Please print and sign name Title Telephone o. Date
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:7 Q , ST {�I a
Street Address City/Town., State
Municipal Inspector to fill out this section upon application approval: 7
Name 61Date
UGONEJOHNSON INS.AGCY.INC.7 Grove Street Suite To:Kevin(19783568591) 08:54 1 111 6111GMT-06 Fig 02-02
� l ® GATE(MWOdYVYq
s►`c� 'CERTIFICATE OF LIABILITY INSURANCE 11/16/2011
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.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les) mW 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). CONTACT
PRODUCER NAME:
UGONE-JOHNSON INS.AGENCY, INC PHONE 978-887-8304 FA°c No�978-887-5517
DALEJOHNSON AE RIESS:DALE_JOHNSON@FARMFAMILY.COM
7 GROVE STREET,STE 201 INSURER(S)AFFOROING COVERAGE NAICA
TOPSFIELD,MA 01983 INSURERA:FARM FAMILY CASUALTY INSURANCE
INSURED INSURER B
PARK WOODBURY CONSTRUCTORS LLC INSURER C:
75 COUNTRY CLUB WAY INSURER D:
IPSW ICH,MA 01938 INSURER 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.
POLICYEFF POLICYEXP LIMITS
INS TYPE OF INSURANCE OMICYHUMBER MMIDDIVVYY MWDa'YYYY GENERALLIABILITV 2005XD368 11/25/10 11/25/11 EACHOCCURRENCE s 1000000
A
X COMMERCIALGENERALLMBIL" IS S SO DDD
CIAIMSMADE a OCCUR NED UP(Am,ono person) S 5000
CONTRACTORS SPECIAL PERSONAL A ADV INJURY s 1,000,000
GENERALAGGREGATE $ 2,000,000
GEN'LAGGREGATE UNIT APPLES PER: PRODUCTS-COMPIOPAGG S 2,000,000
X POLICY PRO LOC S
A AUTOMMLLELABIL" 2005C39700A 11/25/10 11/25/11 Ea aMidon
11/25/2011 11/25/2012 BODILY INJURY(Per person) S 1,000,000
ALL OWNED SCHEDULED BODILY INJURY(Per aoioom) 5 1000000
AUTOS X AUTOS
NON OWNED Pei aden0 S 100,000
HIREDAUTOS AUTOS
S
UMBRELLA LIAR OCCUR EACHOCCURRENCE S
EXCESS LIPS CLAIMS-MADE AGGREGATE S
S
DED I I RETENTION
A WORKERS COMPENSATION WC STATU- OTH-
ANDEMPLOYERS'LIABILRY' 2D01 W6652 02/D6/2D71 D2/O6/2D72 X
ANY PROPRIETORPARTNEWEXECUTNE YIN EL.SIGH ACCIDENT S SOO DDD
OFFICERMEMBEREXCLUOED? Y NIA EL.DISEASE-EA EMPLOYEES 500000
I Mandatory In NN)
Ryyesdesarl-0wFO' EL DISEASE-POLICY LIMIT S 500,000
DESGIRIPTX)N OF OPERATIONS below
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,11 more apace is required)
LIABILITY POLICY INCLUDES GENERAL RESIDENTIAL CARPENTRY,INCLUDES CONSTRUCTION,RECONSTRUCTION AND MASONRY
KEVIN MCGINNESS IS NOT COVERED UNDER WORKERS COMPENSATION
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF SALEM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
BUILDING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS.
SALEM, MA 01970
AUTMORREOREPRESENTATIVE
tG DALE E JOHNSON
®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 42010/05) The ACORD name and loco are realstered marks of ACORD
a
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ow
�7k LOov/NRd/rU/eGrbf/L oy✓ M48�6
Office of Consumer.4ftairs&B siness Regulation
kTHOME IMPROVEMENT CONTRACTOR
Registration: '107297 Type:
Expiration 7/30/2012 Ltd Liability Corpoi
PAWCODEURYC6N9TRUCTIONLLC.
F
Kevin McGinness` -
75 COUNTRY CLUBWAY,.
IPSWICH,MA 01938 - -
Undersecretary
1
Massachusetts- Dcpaitrncnt of Public Safet'
Board of Building Rc_ulations and Standards
Construction Supervisor License,
License: CS 32857
KEVIN E MCGINNESS
75 COUNTRY CLUB WAY ` 4
IPSWICH, MA 01938 ..
Expiration: 11/26/2013
('onmiissioner Tr#: 8256
CITY OF S,V-F.`f, AkSS.kcjjL'SETI'S
St;UZLVC OEP.1ATtLVT
120 W.t3HLVGT0N STUST, }iO FLOOA
Tht (978) 745-9595
KJAMERLSY ORMOLL FAX(978) 7449846
MAYOR rRomm ST.PMUA
DIREcroAOppL9UCpROPEATy/9t;pLVGCO-NallSSIONEA
Construction Debris Disposal Attidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MCL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting from
this work shall be disposed of in a p
I 11, S 1 SOA. roperly licensed waste disposal facility as dcfincd by MILL c
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
Ctti55�( � Cz� _
(name of faulbly)
(�Jd �a of f�mliy)
uynamre ofpermrt ip u4nt
1 — —
nnvd h�