31 PERKINS ST - BPA-15-455 RECEIVED
f The Commonwealth of Massa" usetts
WDepartment Public Safety, m A1assachuxtlsStahBuiuiWing Code(780ChT�'� MAY 18 A 4' U 8
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Budding Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block H and Lot t for locations for which a street address is not available)
LN _ Rn-b
t No.and Street City/Town Zip Code Name of Budding(if applicable)
SECTION 2•PROPOSED WORK
Edition of MA State Code used If New Construction check here Cl or check all that apply in the two rows below
Existing Building KI
Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
1 Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
` Is an Independent Structural Engineering Peer Review required? n Yes ❑ No dK
Brief Description ofPropose�tdt�� Work�I:�. rL� � sLeT—CI L�
C LC�.GUL..C.Yrt` c�+'�cvL `J�� I�--I—
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 31) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION4: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 ❑ A4 ClA-5❑ B: Business ❑ E: Educational ❑
F: Facto F-t❑ F2❑ H: Hi h Huard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-I❑ 1-2❑ I-3❑ I-1 CIM: 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 ClIlA ❑ IIB ❑ IIIA ❑ IHB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppii Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public L9' Check if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site❑
Private❑ or indenlify,Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: �L4I liaorii C�imndxfon Rra;ca
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Budd enclosed❑ Yes Cl or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Flour:
Does the building contain an Sprinkler System?: Special Stipulations:
5 12-�
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
lVV'!eJLY_ .rre CILq 2N� gf� CT(.XLC��,Ct/L-. 04yr C!iACL76
Name(Print) No.and Street - City/Town - Zip
n -
Property Owner Contict'1nftirma i6&.
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 owners 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 thin 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(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
t.-XiAAtv&u ccy-t P U1-et^-cvv�
Company Name
�T7r��A catty-rt-n cJ1 _ f .S - O1 (o"�
Name of Person Responsible for Construction License No. and Type if Applicable
G C)) ,f1 SE-.s, YL� Cs-L-CAJr--C-1 rz-L A k a cZ U
Street Address City/Town State Zip
wlw4 ottf 91Cs�om (k/ k - cam
Telephone No. business Telephone No. cell e-mail address
SECTION 11:1V0RKEhS'CObIPFNSAF N 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 0 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Told Construction Cost(from Item 6)_$ ��I QFCX)s
I. Budding $ &Go U Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical $ `1 c5n O appropriate municipal factor)_$
3. Plumbing $ 91, Q
d.Mechanical (HVAQ $ Note:Minimum fee=$ (contact municipality)
5. Mcchanic:il Other $ Enclose cheek payable to
6.Total Cost $ CYCS (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
applications t urate to the best of my knowledge and understanding.
6"c Vr Gll-e- '1- 9W d(f
Pleas(
le ur( r, an0 atneS A .ten u J Title Telephone No. Date
S rcet Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: 5.tI
Name Date
1 The Commonwealth of Massachusetts
5 Department oflndustrialAccidents
1 Congress Street, Suite 100
/ Boston,MA 02114-2017
www.mass.gov/dia
y1'orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information II AA ff Please Print Legibly
Name (Business/Organization/hidividual): V L ,v�p L I (_O-- (l
Address:
City/State/Zip: C�r_GVC5-w/L M30 Phone#: k—FNk-l( (�
Are you an employer?Check the appropriate box: Type of project(required):
L�m a employer with +1 employees(full and/or part-time).• 7, ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in S. remodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
4.7 I am a homeowner and will be hiring contractors to conduct all work on my property. twill 10 ❑ Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'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 are 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. t�,
Insurance Company Name: 1` '„ ,�CC'x
Policy#or Self-ins.Lie.#: �I G G 1' L( \ p Expiration Date: W Q It 1T�
Job Site Address: �Sk City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the patis and penalties ofperjury tyµt the information provided above is true and correct.
Siznature: -- ! � Date:
Phone#: �-
Official use only. Do not write in this area,to be completed by city or town official.
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
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
QTY OF SALEK MASSAC HUSET5
BuiLmNG DEPARTMENT
120 WASH NGTONSTREET,3' ROOR
L.(978)745-9595
FAX AX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLTCPROPERTY/BuIILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work j
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
G COI,
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
gnature of applicant
S (c- - I 1
Date
May 15 Z015 09:13:11 EDT FROM: FZM/1787618032B MSG# 13639366-006-1 PAGE 002 OF BB2
RAY TES DATE(hM/Dluvwv)
CERTIFICATE OF LIABILITY INSURANCE R02z 3/15/2015
-THIS CERTIFICATES 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:H the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. IF SUBROGATIONIS WAIVED,subject to the
terms and conditions of the policy,certain policies may require an endorsement. A statement on this certHlcate does not Confer rights to the
certificate holder in lieu of such endorsement(s).
CONTAZIr
NAME:
PAYCHEX INSURANCE AGENCY INC WCNo,EW: (Kc,Nas (888) 443-6112
210705 P: F: (866) 443-6112 6NAL ADOREee:
PO BOX 33015 INSURERIS)AWORDINO COVERAGE WUCA
SAN ANTONIO TX 78265 INSURERA: Hel OtO 3i Ye Ins Cc 19662
INSURER B:
INSURER C:
WSI LAUNDRY CORPORATION INSURER D:
6 OLD SALEM RD INSURERE:
GLOUCESTER MA C1930 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 POLIO IES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LVSR AOOL SLBR PUL/CYPFF %IUCYPFP
"PE Uf LVSGFANCE WL/CYA'C'MBCR MM/DD/YYYY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE
CLAIM&MADE ❑OCCUR DAMAGE TO REWED
PREMIBEBIES oeeunncel
MEO EXP(AIYY one arson) S
PERSONAL L ADV INJURY
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGOREGAM 0
POLICY JEC-❑LOC PRODUCTS.COMPIOP AGO
OTHER:
AUTOMOBILE LABILITY COMBINED SINGLE LIMB
(En eceldenD S
ANY AUTO BODILY INJURY(Per Puzon)
ALL OWNED 77 SCHEDULED BODILY INJURY(PB/eCdMnD $
AUTOS AUTOS
HIRED AUT08 NON-OWNED PROPERTY DAMAGE S
AUTOS (Per BCCMEMI
6
UMBRELLA LIAB OCCUR EACH OCCURRENCE 5
EXCEEB LIAB CLAIM&MADE AGGREGATE
DEC REMNTIONI 6
WDRNUM LY/MPoNNIT ON PER OTK
.WONMRWY!(N.VlA1dILllY X STATUTE ER
AHY PROPRIETORIPARTNEPJENELImVE YIN E.L.EACH ACCIOEW ElOOr 000
OFFICERWEMSER EXCLUDED?
A (MrINrbNInNH) NIA '/6 WFG PY1869 11/01/2014 11/01/2016 E.LDISEASE-EAEMPLOYEE '100,000
If Vee,dBBOAbB unOer E.L DISEASE.POLICY LIMN 1500000
DESORIPTION OF OPERATIONS below /'
BEOI:RIP/1BN BF (ACORD 101.Ad0ltleDe RFMLMS e611011U%MAY M Mel 11 MAM span Is Mel
Those usual to the Insured's Operations.
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.
CITY OF SALEM AUTHORIZED REPR989NTATNA
120 WASHINGTON ST FL 3
SALEM, MA 01970
®1988.2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
May 15 2015 09:13:01 EDT FEUM: F2M/17876188328 MSG# 13639366-006-1 PAGE 001 OF 002
N
3,. .
THE.
HARTFORD
The Hartford
FAX COVER PAGE
To: James Whitmore
Fax Number: 19782820111
Company: WSI Laundry
From: "Stitt, Terra(Operations)" <terra.stitt"ehartford.com>
Date: 05/15/15 09:12:19 AM
Subject: Certificate of Liability Insurance
Total Pages: 2 including cover page
PRIVILEGED AND CONFIDENTIAL:This electronic communication,including attachments,is for the exclusive use of addressee and may
contain proprietary,confidential andfor privileged information. If you are not the intended recipient,any use,copying,disclosure,
dissemination or distribution is strictly prohibited. If you are not the intended recipient,please notify sender immediately by phone,destroy this
communication and all copies.
Memo:
Terra Stitt
Business Insurance Service Operations
1-877-853-2582 (Agents)
1-866-467-8730 (Policyholders)
1-888-443-6112(Fax)
Email: agency.services@thehartford.com
The Hartford's Small Commercial Call Centers have been recognized by J.D. Paver and Associates for providing
"An Outstanding Customer Service Experience'.Our easy processes and service solutions save time and let your
customers focus on what's important-their business.
For J.D. Power and Associates 2014 Call Center Certification Program' information,visit jdpower.com
We care about meeting your service expectations.Did I provide you with a great Hartford Experience?Please feel
free to send any feedback on my service to sheris.rice@thehartford.com.
Massachusetts Department of RuWic Safety!'
Board of Building Regulations and Standards
Construction Supervisor
License: CS-012622
JAMES H WMT11Jb �.
6 OLD SALEM RD
GLOUCESTERI%A
JwL.,. )PIA]J
-�� Expiration
Commissioner 06/07/2076
a