36 PERKINS ST - BUILDING INSPECTION (2) 03/24/2011 06:09PM 7815957810 PRO TECH PAGE 02/04
1 A�3O � �a
The Commonwealth of Massachusetts
(r�r Department of Public Safety
J lU Massachusetts State Building Code(780 CbIR)
Ghl Building Permit Application for any Building other than a One-or Two-Family wel
hisSectiiyti•For,OFficial'.Use:Only : :
Build tiigPertgitNuon 6n. :.DateApplied: BittIdmgOffiFial "'
SECTION I::LQ,CA7.TON(P.(easefndicate;BlpckNandLot for locatioitsfo'rwhfeh'ssheetad'dxe"ssisno waiIabCr _
No.and Street City/Town Zip Code Name of Building(if applicable)
..:..::$EC7I0N 2.PROPOSED:WOTUC`i�`;^'.:;t::'.;`i` ,.; ;';::.:;,r •�';. ..::.',;'::L .,.. .
Edition of MA State Code used_ .Jf New Construction check here 0 or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration f] I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify-
Are building plans and/or construction documents being supplied as part of this permit application? Yes M No 0
Is an Independent Structural Engineering Peer Review required? Yes Cl No IV
Brief Description of Proposed Work: L�MLt%t /�iNcl /�d�iyiC+ f&W y 6 ley �Cii✓r Sf
SECTION M COMPLETE-THIS SECTION.IF EXISTING BUILDING.UNDERGOING RENOVATION:ADDITI ON. Oti
'CHANGE INUSE'.OI(OCCUPANGl'
Check here if an Existing Building Investigation and Evaluation is enclosed(See.780 CMR 34) 0
Existing Use Croup(s): Proposed Use Group(s):
•.-SEGTION'4:.BUILDING HEIGHTAND
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,(Checkasa-_plicable)j",_ ;�.'
A: Assembly A-1 ❑ A-2❑ Nightclub 0 A-3 0 A-4 0 A-S❑ B: Business 0 E: Educational 4
F: Facto F-1 11 F2❑ H: Hf Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 0 H-5❑
I: Institutional I-1 CII-2.❑ I-3❑ [-0❑ 114: Mercantile❑ R: Residential R-10 R-2❑ R3❑ R-4❑
S: Storage S-1 0 9-2 0 1-U: Utility❑ Special Use 0 and please describe below:
Special Use: x
SECTION 6:.CONSTRUCIION TYPE Check at applivable
IA O IB 0 IIA 0 IIH 0 IIIA 0 UIB O IV ❑ VA O VB 0
SECI'IONxS1781NFORMATTON(iefer.tn 780 CMR 111.0 Eord'ekatls`an each item)� -
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal
Public❑ Check if outside Flood Zone❑ Indieate municipal❑ A trench will not be Licensed Disposal Site❑
i +i", required❑or trench or specify
Private❑ or indentify Zone: or on site system
❑ permit is enclosed 0
Railroad right-of-way:,' ^' Hazards to Air Navigation: J4 HiYh'rir('y nnnis.iun Revi,avyn�•r9a;
Not Applicable❑ Is Structure within airport approach area? is their review completed?
or Consent to Build enclosed❑ Yes 0 or No❑ Yes❑ No ❑
SECTION 8;CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code; Use Group(s): Type of Construction: Occupant Loud per Floor:
Does the building contain an Sprinkler System?; Special Stipulations:
03/24/2011 06:07PM 7015957810 PRO TECH PAGE 03/04
.. of.. . ; ... _ .. ..._... ..
Name and Address of Property Ow err
A3RQWlc/f*1 ,�42 Z"rso2 _J P c9,t.,i/ cf C.f�EA ,,sue Cyl.r r�
Name(Print) No,and Street City/Town Zip
Property Owner Contact Information:
f4,yee&Wf,4"{iuiY4vlt Cb�•
Title Telephone Ni;.(business) Telephone No. (eap) email address
If applicable, the property owner hereby authorizes
�✓w.a-a.� T�f.;v+. � c.9olrto//sf C�rF/sirs+ /�//
Name Street Address City/Tow, State Zip
to act on the ro er owner's behalf,in all matters relative to work authorized by this buflding permit ap lication.
;§ECTIOhI�lOi CONSTRUCI`.IQN CONTROL,(I'ferse'.1.01'oiit A-',:eiidfi�f 2"i:':'.`it: ;:;,..::5.';;.'`•.:';.<..:..': ..
IfbuQdln ssle§sthan35000rii:R,dfencldse'd's d&&h': /oraotundeiCv�whuchoiYCnhtro7-4lencheekflex U:andrki Sechon101
10;I Re steied Professional'Res onsible for Conitrnctf'oicConiiof�•s "" `:''•;,i`-:;: .": > s:i= -
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
.. . ..
40.2 GeneialCli'nti'acton:'.:•
Company Name '
�06ri4A,A Tat4r�_«•,
Name of Person Responsible for Construction license No. and Type if Applicable
.,Street Address City/Town State Zip
Tele hone No. business Telephone No, cell e-mail address
SECTION II:MRKERS COMPENSATION IN
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 sigUd Affidavit submitted with this a lication? Yes O No 0
. .. .. ..SEC
ON12:.CONS'CRUC'ITONCOS'I'S.AND.EERMITFL13`-.:.�1:'::f_"!':: :`:'; .
Item' ' Estimated Costs.(Labor
and Materials) Total Construction Cost(from Item 6)
1. Building_ _v+:: $ C _GV
_ B -
utldin Permit 2.Electrical.. $ g
rtrut Fee-Total Construction Cost x_ Invert here
appropriate
mgnlci el factor) '$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=S. (contact municipality)
5.hlechanital Other $ e' , ,
Enclose check payable to
6.Total Cost $ Cf ? �� (contact municipality)and write checl number here
SEmol`4.13:SIGNATURE OF BUILDING PERMIT'APt;LICANT;;,:`•
By entering my name below,I hereby attest under the pairs and penalties of perjury that all of the information contained in this
application is true and accurate to the est of my owledge and understanding,
Please print and sign nam Title Telephone No. Date
Adfu_0
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon appliegHon.approvat
Name: Date
i
..P
r
?2-� T
03/24/2011 06:09PM 7815957810 PRO TECH PAGE 04/04
a
CITY OF S.U..E.1, .NL L-1SSACHusETCS
• 8v=L\,G DEP.1RT%MNT
q r�• 120 WASHCVGTON STREET, 3-FCOOR
b" T EL(978) 745-9595
1
F.ALX(978) 740-9846
!CINCBERLEY DRISCOLL
MAYOR Tm%us ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/HCII;DW(;CO\LUISSIO.iER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by;
�k
(nam6 of healer)
The debris will be disposed of in
(name of facility) {�
,. (address of I'acilily) T
signature y emut applicant
/ /7 /2
date
dc0n�afr,l.k
03/24/2011 06:09PM 7815957810 PRO TECH PAGE 03/04
' �wrSuaG Gu.
CITY OF S:UaNL 1, NUSSACHUSETfS
• BUILD LNG DEPARTWUNT
y 120 WASI-INGTON STREET,Yes Mom
TEL(978)745-9595
F.+-x(978)740-9846
K].\[BF.RL11Y DRISCOLL
VUYOR 'R4ob1As Sr.PIERRIi DtRECCOROF PUBLIC PROPERTY/BUILDUNG Cosa IS.SIONER
Workers' Compensation Insurance Afrldavit: Duilders/ContracterslElectrlclans/Ptumberg
Anollcant Infahrroatlnn Please Print, Leelifty
Va111C(Ousilw"sa.Ur�a,tiraliaNlndividuN): '✓A!l-� !L r.vc�-✓t,
Address: h� e'W11Ac9
City/StatdZip: �� &.d 9,atdy Phone#: 6-7 2 —30�Y /
Are you ties employer?Cheek the appraprlate bast Type of project(required):
1.❑ 1 am a amployor witb 4. ❑ 1 am a ge mml contractor and 1 6. aNew construction
e,nployees(fufl aud/or pert-lime).• have hired the sutecontraeton
2.❑ I am a sole proprietor or pamn listed on the attached slice[t 7. ❑RCmodeling
.Alp and have no cmploycoe Thies sub•enntractors have g. 13 Demolition
working fur mo In any capacity. workers'comp.insurance, q. 0 Building addition
(No workers'comp.insurance S. ❑We are a corpomrlan and its
rcgturcd.) OfRcers have exercieod their 10.0 Electrical repaus or additions
3.0 1 am a homeowner doing all work fight ofaxempliun per MGL I1.0 Plumbing repairs orudditlons
myself.[No svorkcra'comp• C. 151,§1(4y,and we have no 11.0 Roof repain
insurancomquind.) t .mployew.IN*workers' I7.Q00ter
comp inwmnca required.)
•Mr applrranl dat Owlia beast rows,a1w ml Wd the sixties bdswahawins thstr r,kM-earopmaadue pansy into ma eas,
'I F.ro awnaww who sehmlt this affidavit indimslne ih.y andeirel sit"wart and Than him wuielo"nneatps rami auhroh a esw amdawk indicaana mwk
:twu oaten that xtwek ihia its;Rewtsaachedara ukLiduesl ah4t Auv i"S the Raise a(the rubcdnirsom and theft worken'anep.puticy inresmaooe,
l are an employer that b,prov/dfnt,ivorkses'compertsaden hrsamnee for my emplayerr; Below Lr the polfry andJob site
htJormarldiL /j _r� 1
Insuavnee Company Yam*: 1 ,- / t eLk1*1
Policy 4 or Self-ins.Lie,It, (`W C h Ul bA del [)1 QP/a Expiration Date.
Job Site AJalnss: . 2 b �Kti�tty t S7 ,Cily/Stale/Z(p:_
mtsch a copy or the svorhen'compensation policy declarallon page(showing the policy number and expiration data).
Eai(um to secure coverage as required und¢rSeedon 2$A of,MGL a. 131 can lead to the(mposilien of ctiminal penaltles of a
rinc up to S1.500,00 un,Var one-year Imprisomnent as well as civil pcaahies in the(bra of 4 STOP WORK ORDER and a tine
Of up to S250.00 a day against the viotamr. Ile advised that a COPY of this smtemunt n,ay be forwarded to the Offica of
Invus6gmians of the DIA for insurance coverage vcdelcution.
l des hereby crrrlf rot the puull °anst rna/t/es of perJary that Mht H Jurmradon proYldeJobua ry truer end correct
IM
Cho ,• y�
I (7/)icia/us'e umlyt Oa nor rvrih in Ihls ono,re be ramrp/rled by city ar sown.iJJh•%!
City nr'fmrn: ____ Parmlt/1.kcnre s _-__�
Issuing Aulisority(circle one):
1. heard of Ilculth 2.Building nepartlnem I.City/rown Clerk 4.Electrical inspector S.Plumbing Inspector
6.Other _
funlact Person: Phone p:
i
- ao♦ coca RURALSAY INS. AGENCY 0001
aco& CERTIFICATE OF LIABI4ITY INSURANCE °"'�'°""°°""T'
1/17 13
THIS CERTIFIGATE 19 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFUMArMLY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NDT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURI R(S), AUTHORIZED
REPRESEWA71VE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: R the Certificate holder hi an ADDITIONAL INSURED,the poficyges)must be andomed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the pogey.certain policies may require an endorsement A slatement on this certificate does not carrier Atha to the
carbficate holder in lieu ofsuch endorsemen
PRODUCER
• T
Richard A. Kowalsky Insurance vRnNR - 781I 231-2020 i OUCN (7a11 231-2o2a
544 Lincoln Avenue MELas: RK@XowalskyInsurance.com
P.O. Box 999 INSUIERSIAFFORoaIG COVERAIf wNcs _
Saugus, MA 01906_ - INSIIRBRA;Essex Insurance ComRgm' _ ._
MUR® Imues e:Aaeociated Industries Of PIA 1411
E 6 R Construction Inc. INSURPA C:
SS Carroll Street INsuRDi D:
Chelsea, MA 02150 IN$uR9RE:
INSURER F:
I
COVERAGES CERTIFICATE NUMBER- REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE USTED 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 i
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES OESCRI13ED HEREN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS ANDCONDITIONS OFSUO_i POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS
LYR TYPE OF INSURANCE ADIM OO POUWKUNDM w�� NOW UNITS .�..
A GENERALUIUMUIY 3DR9629 4/11/12 4/21/13 EAcHoccuRRENCE s 1,000.000
X COMMFACIALGENER4LLW9WTY UfdMGE TO RE Eo
USES fEe I E 50,OO.QJ
GUUr$MAOE O OCCUR AED EW(AM.M )- 'a O
PERSOMLA ADV INJURY E 1.000.000
_ GENERAL AGGREGATE S 2 000,00o
GEN'LAGGREGATE LADTAPPLES PER PRODUCTS_mMPJOP PG S 1,000.000
POLICY F1
p LOC S
F
"OMLE U MIT
NTAVTO 90DIlYINIURTIPePRM) S
ATADSCHELD BODILY INJURYpaismL N SNRED
O PIR AUTO
...-�
IIL14(iE S ...
E I
UNBREIIAUAB OCCUR EACH OCCURRENCE S_ _
8(06SUA9 CLAIM&MIA ..
AGGREGATE _ E
DED RETENTION 1
$ WORKS COMPENSATOR 10/27/12 10/27/13
AND EMPLOYERS LABARI Y 6016262012012 we sraTu an-
LL
OLFILERAEAEEA E7(CL1OW
ANYPROPREGVPARMUiIE'I+a AfINE � , ZO .O000MIA . CO _
(N, bymNHl EL.OL4EASE- ePL E 100,000 ;
tt awci WOF O
Ds`CRIPTnN ff OPERATpNSbMOw EL_o EASE-poLRCv LMTr E 500,000
R
09SMPIM oeovERAIwrSILOCATIONSIVeSCLES (Ate hACORDTM.AURO"RMDRAs Sd Mft,ifu sM.ft equMI
I
CERTIFICATE HOLDER CANCELLATION
1
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE "DELIVERED N
36-36 Berki s; St Condo Assoeia ACCORDANCE WITH THE POLICY PROVISIONS.
36 Perkins Street
Salem, I91 01970 AUTHOWED RERIESENLSTIVa
I
.„ Richard iCOwal97cy
®1988-2010AGORD CORPORATION. All rights reserved.
ACORD 25(2010105) The AC ORD name and logo are registered marks of ACORO
Phone: Fax: (617) 466-0329 E-Mail:
03/24/2011 06:07PM 7815957810 PRO TECH PAGE 04/04
r J .
I
I � I
I
i
T
cr R
Z
L
a k �
yX6 Xio Rf
Y \I
� k
1
a
i
r � j
i