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6 ROSLYN ST - BUILDING INSPECTION (2) -' The Commonwealth of Massachusetts ►: t Department of Public Safety 9� /© ',IaNN.tchusv1I,State Budding Cody 1%SO CNIR)Se%enth Edition /City of Salem Building PermApplication it A lication for an Buildin other than a 1- or 2-Fam•f D 1 rhis tirctiun For Official Use Only) Budding Permit Number. Date Applied: 4 Zq4e)— I Building Inspector: SECTION 1: LOCATION (Please indicate Block I and Lot I for locations for which a street address is not available) KOSL Iyj YAL-ero a19 u No. and Street City /Town Zip Code Name of Budding(if applicably) SECTION 2:PROPOSED WORK It New Construction check here 0 arr check all that apply in the two rows below, Existing Building 0 Repair Alteration O 1 Addition 0 1 Demolition 0 (Please fill out and submit Appendix 1) ChangvofUse 0 Change of Occupancy 0 - Other ❑ Specify: Are building plans and/ur cumtruction ducuments bring supplied as part of this permit application? Yes 0 No 0 Is an Independent Structural Engineering Peer Review required? Yes 0 No 0 Brief Description of Proposed Wur�l: K�M U1/4 -('�{ /N4C1?S '�C? ♦°� w0 0 '� Re c'N/ ✓ace-, � SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) O Existing Use Group(s): Proposed Use Group(s)- Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flours/Stories(include basement levels)6:Area Per Floor(sq.ft.) Total Area(sq. ft.)and Total Height(ft.) SECTION St USE GROUP(Check as applicable) A. Assembly A-10 A-2r O A-Inc❑ A-3 0 A40 A-50 1 8: Business 0 E: Educational 0 F: Facto F-1 O F2 0 H= 'Hi Hazard H-1 ❑ H-2 0 H-3 ❑ H-4 0 H-5 0 1: Institutional 1-1 0 1-2 0 1-3 O 14 0 M: Mercantile 0 R: Resldentlal R-10 R-2❑ R-3 0 R4 0 S: Storage SI 0 S-2 0 U: Utility 0 Special Use 0 and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 ISO IIA 0 11813 IIIA D IIIB O IV 0 VA O VB O SECTION 7:SITE INFORMATION (refer to 780 CNIR 111.0 for details on each item) 1Vater Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Put+Lc 0 Check tl uuhtdv Fit a,.l Lune 0 Inalicate mumcnpal ❑ A trench will not be Ltcvn.ed Di>ptt.,d Site 0 required 0 Air trench ur,pte4A.: I'ncah❑ ur malvnldy Lunr:_ or tin Nrtr Nc,trm ❑ permit is vnclo. d 0 Railroad right-of-way: Hazards to Air.Navigation: ll\ I t •nnnn—t,..t Rv,u o 1'r, \.,l %pphca01v0 IN?tructun•tcnhm.nrpurt epprna.h area` L their re%ivty onoplcted.' r l ntwnl lit 11udJ cndnvvl 0 )v 0 nr No 0 1'a•N❑ \n 0 SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY I dawn .,i l ��dv. L,v l;rnuplo rt pen,lon,irucotm: lkcupant Luaal pvr I Lour I h ,, 0w bwlditig onmunen Sprinkler Slax'tal?tii+u latn+nN� SECTION 9: PROPERTY OWNER AUTHORIZATION .tme anJ .\d.lross of 11roperiv Owner plIR U &LAt,,/ XAn/rOKIsS1)Jk1 6a (is Cyi.J SpCeM . y 1't'It4 - a1�7U Na v(Print) .No.and Street Cih'/ ruwn Gp 1' rj t-rty (h.fie (-intact Inl Hnm: ?it � elvpltonrr No. (busmen%) relrphonv No. (cell) r-mad addnos If ap) tcablr, the property occnerherrbv.utthunzrs �AGG G, d?a ✓AWN/A/� ;7-1 )naG-0c1N AVE ynL,DFoit rn/1 62(55 Name Street Address City/Town State Zip to act"n the jwr,,jerI% ocrner•s behalf, in all matters relatne to work authorized by this buddin ,ermtt a , +lication. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If t+uddin is Iess thin 35,tW c u.mot encluvd s ace anJ/or nut undw Construction Conln+l then check here C3and4uP Sacuun IU.1) 1 .1 Re islered Professional Res onsibl �forConstruction Control ���1c L. 1�2R✓i)2iga_)¢I i/9- Y/85 pAVCJF�y3tsfymcmru , /�/C12Qy amr(Registrant) Tel �hone No. e-mail address Registration Number ZZ Jll - 7 MalroUu A� /�h 9FoKU /hA aztSS 9� Street Address ;/Lily/Town State Zip Discipline Expiration Date 10.2 General Contractor CrUt1714kriCS COi✓tZTeuc7-1aN Company Name: P /8/s Name of Person Res tr�.viblp for Construction License No. and T if Applicable '1 7 /rlA(rOU�N fiV hILfU R� yam P 421$ t Address City/Town fate Zip St72/9_ uly9 57B _L3.G_ 7z�� 2T Telephone No.(business) Telephone No. cell -r e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT IM.G.L.a 1S2.§ 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 oft i issuance of the building permit. Is a signed Affidavit submitted with this application7 Yee NOD SECTION 12:CONSTRUCTION COSTS AND PERMIT FE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)=f 1. Building .(,'Ul S Building Permit Fee-Total Construction Custla`1)nsert here 2. Electrical f appropriate municipal factor)-f 3. Plumbingf Note: Minimum fee f (contact unfci alit 4. Mechanical ( f P Y) 5. Mechanical (Other) f � Enep>.tir check payable to 6; Total Cunt f (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT fly entering my name below, I hereby altva under the pains and prnalttes of perjury th.ti all of the informationn cohttnral in this applicatin •C/ � 'I., Irur and accurate to the bra ut my knowlralgi:and undrrvtanding. ZC{/ / / a+14e L.e9-e ✓/7,c-rp /f) (,Ce u -1-Au C,Tro..-J SVPI!k 1'I4!01 }e ,riot and sign name rrtlr rvle +hone.No. Date ) Strea•t .\J.In•.. CityI Tu+c st,l to p Municipal Inspeclur to fill out this section upon application approval: JA �V Name or , \ CITY OF S.u.E.«, ISS.XCHUSETTS BLMDLNG DFP.%W.lE1T 120 1W.\311MTON STRMM. 1"FLOGR TM. (978) 145-9599 F.uc(97it► 1�49A•1� KJM®EA"V ORJSCOLL 11iW tASST-FMMA UAYOA plRlCWR OF rL eLIC PAOPGRTV/K MDLHG CO%"SS'CL%EX Wurkers' Coalpelas idea Insurance Allldavit: Guilders/Contraction/Eloet►iclensll Plum ban t Ilesnt InformsdOMIL Please Print Lla t Valndliu.,,.n.OryarrarlewlrMb.rslWl: RO17►Z�II�O 6C/IIxNRAISS Address: Z I IS A t_ COMB f-r cily/stictyzip: S I)L e. W\ M 14 6j9 7(3 rnon. \r Yee to employer?Cheek the appropriate bass Type of preiese(regsiredE @. Q 1 an a coaarts"or and 1 I. 1 am•cmpkryf with hired I el a ❑Now construction .Inpieyese(Rd anWW pul-dor).o have hLted lira erkearlaacaors ad rs putrea lislad as lhsasaehad shaet= 7. ❑RensolMling i.Q I an a sob prepri Thus st/beoatnoom have R ❑Otmolilias .hip and have no employee working far nw is ally capaeiry. wt1A@n'comp`inwaasoa 9. Q Building addition (No wwk*W camp inerance f. Q We we a cegsred=and it I O.Q Electrical repairs or additiarw re quire .1 otlknrs howaatreiatl thrai ).Q 1 am a homenwoor doing a0 work right dt;ultpion par MGI' I t.Q PhunUV repairs or addickma myself NO weAme'comp t: 13Z f 1(4X and we Aare no 12.13 Reef rspsirs insurance required)r `mplelrae Ilse arms' 13.0 Odur comp installation legaired.l ANY sneer than rllrake hell el sew asw M w uw ram sd..I..6ta tkab webs'anga�+e PaWr i.e.ttt.r.. 'l6wwwtea rb piked clls Nllrrr+eYdlw dust So doing A wed ae tMa No NAVA easeee seM wdseb r see amrr.b wrlc+r MA l..e.eiw dr.Yeb W r.wu atledrd a aYliwl sh"rbeYy ee eMr dab tl&e..States ref'hest w.&M."OF Panel Irwne d o. /rue ce elry/elw rMr tr prerl/bR trerfers'rear'rwradra/w@areaaw/ir q catlpde�nws Sdeer tr rAr/Nlep ee/p1 s/sr in�Marelllra Insurance Company-Name: rnlicy s or Self ins.tie.A' Expiration Due )ub Site AdthsC Ciry/StaWtipe .\Clock a copy of tb workers'compowe bs policy dotkastke pep(skewheg Ills Pe"su=br and aspltrulee dow)6 failure to%"we coverop a requited under 3alloa 23A of MGL a 152 can lewd to the impoai im ofcriminal ponsldes of a fine up IQ 11I.500.00 snd/a ona-year imprison"Iend,a we0 sa civil Panama is the tarot of a STOP WORK ORDER and a fine Of up to 5_20.00 a day ayainsl the violator. lie advised thus cupy of this siatrrrlr d maybe larwardad to the 011Iee of In.c.try+Iiurr of the nIA for insurance cowralp.vilkidwta /de herear Certify un/ss Ilse Oci"#ad yene/ds of per/rq M r the io/irwonde prori"wlere is rend,real a erred ••n.nurC I)Yf1: P`jire a: O/Jtrief ne md/t De wW i.riM iw/hill rrrq/c Ele•rrwP/e/d lsj rill a/iaw.I/�/tir/ cityorfut.n: Issuang.\mhonly Icirch noel: I Huard of li.allb I. Huddleg B.•pa•tmsni I. Ciy/fo.o Clerk I. Electrical Inspector S. Plumbing In4pceror 6.111 her _ t. ..ttAct Per on: Phan@ a. Nf assachusctts - Dcpar merit of Public Safe(N Board nt NuildinL Rc_ulations and Standards Construction Supervisor License License: CS 84815 Restricted to: 00 PAUL L DERVARTANIAN 27 MAGOUN AVE MEDFORD, MA 02155 Expiration: 5/31/2011 - '('onnoissloner Trp: 17682 67 MEREEM ORice of Consumer Attdra A Baaiaeaa Regulation HOME IMPROVEMENT CONTRACTOR - Re9istratlon 1. 1402iyi Tr# 289506 Expiration 9 ? �I Type;! Ind Nidual — J• DIVERSIFIED BUILDERSI PAUL DERVARTANIAN� - =� r� S'I 27 MAGOUN AVES`tR Undersecretary MEDFORD,MA 021552�= CITY- OF SALEM PUBLIC PROPRERTY DEPARTMENT � yI 1.11: NO " "NIA „I1 I:Cu'�.te. •,t��wiyrleFltr. ris isposal construction.yuired1 all demolition D sit uyj renovation ion work) In accurdanee with the sixth edition of the State Building Code, 730 CM section 111.5 pebris, and the provisions of MGL c 40,S.54: MGL e is issued with the condition that the debris resulting{ f}om Building{ Permit N��_: 1 Geealsed waste diVaSW facility as defined by this work shall he disposed of to a p P�Y I 11. S 131)A. The debris will be transported by: - 1 n.ma of hauler) The debris will be disposed of in S#}U CrUS �1s 190ACAL pr.trna ut AI Iry SP6AG US ) .ul'r-Wa11ly) .Iproture nl lwrinit/pplm M � /l 2 U l d date RightFax N1-1 6/14/2010 6: 55 : 21 AM PAGE 2/002 Fax Server ACORD. CERTIFICATE OF INSURANCE DATE(MWDMYY) 06-14-10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE LAURANZANO INS AGCY HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 107 DODGE STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE BEVERLY,MA 01915 COMPANY 7242D A TRAVELERS DIRECT ASSIGNMENT INSURED COMPANY B GUIMARAES RODRIGO DBA GUIMARAES CONSTRUCTION COMPANY 21 BALCOMB STREET C SALEM,MA 01970 COMPANY D COVERAGES 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 PENTAX THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFF POLICY EXP LTR TYPEOFINSURANCE POLICY NUMBER DATE(MMrDD\YY) DATE(MMODWY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ CLAIMS MADE OCCUR. PERSONAL&&AOV.INJURY $ OWNER'S&&CONTRACTOR'S PRO 1. EACH OCCURRENCE $ FIRE DAMAGE(Any one tire) $ MED.EXPENSE(Any one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Per Person) $ SCHEDULEAUTOS BODILY INJURY(Per Accident) $ HIRED AUTOS PROPERTY DAMAGE $ NON-OWNED AUTOS GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY UB-9851MS97-09 07-30-09 07-30-10 STATUTORY LIMITS X THE PROPRIETOR/ EACH ACCIDENT $ 100,000 PARTNERS/EXECUTIVE INCL DISEASE-POLICY LIMIT $ 500,000 OFFICERS ARE: X EXCL DISEASE-EACH EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIRESTRICTIONS!SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFPECPING WORKERS COW COVERAGE THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR OWMARALS RODRIOO. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF SALEM DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE 120 WASHINGTON STREET SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. SALEM,MA 01970 AUTHORIZED REPRESENTATIVE ACORD 25-5(3193) Charles J Clark To:City of Salem Page 2 of 3 2010-06-11 13:28:38(GMT) 19783365533 From:Larry Lauranzano ACORDr CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODNYYY) 05/24/2010 PRODUCER (978) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Lauranzano Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE g y HOLDER.. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Beverly NA 01915- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Underwriters At Lloyd's Rodrigo Guimaraes INSURER B.Traveler's Guimaraes Construction INSURER C. 21 Balcomb Street wsuRER o. Salem MA 01970- INSURERS 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 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD-LINSRO IYPEOFINSURANCE POLICYNUMBER DAM MMIDDNY) POLICY DATE EXPIRATION LTR NSRD ( TIV DATE(MMIDEXPIRATION LIMBS A GENERAL LIABILITY LM0817408 07/28/2009 07/28/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES To occurrence) $ 100,000 CLAIMS MADE OCCUR / / / / MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUr_TS-COMPIOP AGG $ 2,000,000 X POLICY PECT AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANYAUTO (Ea accident) $ ALL OWNED AUTOS / / / / BODILY INJURY SCHEDULED AUTOS (Per person) '$ HIRED AUTOS / / / / BODILY INJURY - NON OWNED AUTOS (Peraccldent) $ PROPERTY DAMAGE (Peraccldent) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHER THAN EA ACC $ A-PO ONLY'. AGO $ EXCESSIUMBRELLALIABILITY / / / / EACH OCCURRENCE $ OCCUR F-IOLAIMS MADE AGGREGATE $ DEDUCTIBLE / / / / $ RETENTION $ WORKERS COMPENSATIONAND / / / / WCSTAIN OTH EMPLOYERS'LIABILITY TORV LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVE EL.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? / / EL DISEASE-EA EMPLOYEE$ ryes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICYLIMIT $ OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLEVEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION I'.. (978) 745-9595 5641 (978) 740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL l 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City of Salem FAILURE TO DO SC SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE Public Properties Department INSURER,ITS AGENTS OR REPRESENTATIVES. 120 Washington Street AUTHORIZED REPRESENTATIVE Salem NA 01970- A�pC, ORD 25(2001108) ©ACORD CORPORATION 1988 I'G.1-INS025pioq.05 ELECTRONIC LASER FORMS,INC.-(S00)327-0545 Page 1of2 To:City of Salem Page 3 of 3 2010-06-11 13:28:38(GMT) 19783365533 From:Larry Lauranzano IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) {,,;INS025(01oe)o5 Page 2of2