17 SABLE RD WEST - BUILDING INSPECTION 633 -a)P
Application for Permit to.
Location
Permit Granted
islg �
APp vied
Inspector of Buildings 1
CITY OF S.0 EM, NL--kSSACHUSE-ffS
BU DLNG DEPARTINWNT
\ 120 WASHINGTON STREET, 3' FLOOR
TV-L (978) 745-9595
FAX(978) 740-9846
dC1�ffiER.I.EY Dti%SCOLY.
MAYOR THo&L%s ST.PmaRB
DIRECTOR OF PUBLIC PROPERTY/BU DING CO`LNIISSIONER
APPLICATION FOR THE CONSTRUCTION, REPAID;RENOVATION, CHANGE ON-USE OR
OCCUPANCY, OR DEMOLITION OF ANY BUILDING OR STRUCTURE
This Sectim,for Official Use Only
Builddng Inspectom :-
Esftaft Prafed 08168: Start End:
Conxneniss:
1.0 SITE INFORMATION
LocationNarne- p 7 Budding:
Prop"Address: 1 -7 Sob(p /'k� LZed�
Sc,te Yv\ VV)A
Assessors M Lot/Parcet:
2.1 Owner of Land
Name: G--rovsc ,
Address: 17 Sable I �
vv\A olcj�d
Telephone:
2.2 Owner or lasses of bullding or sf cfvre
Name:
Address:
Telephone:
3.0 AGENCY OR AUTHORITY AUTHORIZING CONSTRUCTION
Agency Name: }�o A'T-re ri b l0. co,+r,c+,--j
Address: L u co love I-Q. Sut4e `1
.SS cor. vvw o lq-i7,
Ipi
gency Project Number.ject AAanager Name: jZo T� my1� �>t Tel: ��8 �y5b
t t
4.0 PROFESSIONAL DESIGN SERVICES;
4.1 Registered Architect: � a
Name: Seal and Signature
Address:
TOW Fax
4.2 ."dwed Professional Engineers, (Use adOlmml dwaft Ifnewsmy and anach M 9
Name N P Seal and ftiatum
Addre
Telephone: Fax
d Respor►sibility: \�
Name: 6sal and Signature
.
Address:
Telephone: Fax
Area of Responsibility:
Name: Seal and Signature
Address:
Telephone: Fax:
Area of responsibility:
5.0 DESIGN AND CONSTRUCTION UTILIZING MGL C 112 SECTION 81R EXEMPTIONS
(See note below)
Contractor
Name:ogT05 A 'l+ esv0blay
Address: (o Caton (MA AJ Su Ae �-1
S<<� m wva a19-7z)
Area of responsibility:
I:icense Number CS 53 �9 3 Date of Expiration 5 j 9 IM
Telephone: �g-)Lf 30 Falc. G '7 t3 7yS 3 a sz
Contractor
Name:
Address:
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fax:
Contractor
Name:
Address:
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fax:
Note: For portions of work uGiizing exemptions of MGL c. 112 s.SIR complete the section above.
Use additional sheets if necessary and attach to application.
6.0 PROFESSIONAL CONSTRUCTION SERVICES:
6A General Contractor 1t� � ,
Address: /D Col o,n taQ 4� Su)- -c `f
Telephone: h Y 9 3 a 6 b Fax:
Responsible in Charge of Construction:
7.6 CONSTRUCTION DOCUMENTS -to be prepared by applicant
Item J as Applicatile
7.1 Plans (Note 1 this page) Submitted Incomplete Not Required
7.1.1 Architectural
7.1.2 Foundation
7.1.3 Structural
7.1.4 Fire Suppression
7.1.5 Fire Alarm
7.1.6 HVAC
7.1.7 Electrical
7.2 Specifications
7.3 Structural Peer Review
7.4 Structural Tests & Inspections
Program
7.5 Fire Protection Narrative Report
7.6 Existing Building Survey
7.7 Workers Compensation Insurance
7.8 Other Documents (Specify)
(Energy Narratives, etc.)
Note 1 Areas of Design or Construction for which Plans are not complete at the time of
this application must be identified herein. Work so identified must not be commenced until this
application has been amended and proposed construction has been approved by the
Department of Public Safety District Building Inspector having Jurisdiction.
8.0 COMPLETE THIS SECTION FOR NOON CONSTRUCTION ONLY
For Existing Buildings Proceed to Section 9.0
Number of Stories above Number of Stories Below
Grade Grade
Story Height Floor Area Per Floor
Total Building Height Total Building Area Above
above Grade Grade
Total Building depth below Total Building Area Below
Grade Grade
Brief Description of Proposed Work:
8.2 USE GROUP AND CONSTRUCTION CLASSIFICATION (Now Construction Only)
USE GROUPW USE GROUP SU®-CA'TEGORY CONSTRUCTION
(J as applicable)- (d as applieabie CLASSIFICATION
A . Ass®mbly A:4 ' A-2 AL-3 A-4 1A
8 Business 1 B
E Educational 2A
F Factory F-1 F-2 26
H High Hazard H-1 H-2 H-3 H-4 2C
I Institutional 1-1 1-2 1-3 3A
M Mercantile 3B
R Residential R-1 R-2 R-3 4
S Storage S-1 S-2 5A
U Utility 5B
Mz Mixed Use Specify:
Sp Special Use Specify:
9.0 COMPLETE THIS SECTION FOR WORK IN EXISTING. BUILDINGS ONLY
For new construction comolete sec- on 8.0,
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building Now
Brief Description of Proposed Work:
9.1, USE CROUP AND CONSTRUCTION CLASSIFICATION (Existing SuIldln Only)
EXISTING PROPOSED Change. CONSTROCTION
USE Groups) in CLASSIFICATION
Use Hazard Use _ Hazard Y Hazard
(note sub-category) Group Index 'Group Index Index" (J as appttcab9s)
A Assembly IA
B Business is
E Educational 2A
F Factory 28"
H High Hazard 2C
I Institutional 3A-
* Mercantile 3B
R Residential 4
S Storage: 5A
U Utility 5B
Mx Mixed Use Hazard Index
Sp Special Use
Note: Include Hazard Index Modifier for Construction Type as applicable
1
9.0 CONSTRUCTION COSTS (See Tao CMR Appendix L)
Total Construction Cost Building Permit Fee Check Number
(1 D = (1)x $0.401
10.® AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR!®UIL.DING
PERMIT (wheat applicable)
i, Rucjsw ya—THem`o�v `�'� on behalf of the State
Agency or Authority, hereby authorize, -22- !! 1� to apply
for the building permit for project number,
4r.� A 1-�
Sign tore Date
11.0 SIGNATURE OF BUILDING PERMIT APPLICANT
A, -
Nam
Signature Date
12. Certificate of Occupancy required on completion of project? Yea No
Inspector's Notes:
- n Shr$iA1"el'1t�sd,F-Li 'd`ft�e_ I
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q`�mrssl.P
1 _
3 �
G 1�Ly'1lames
Failurie to i 0ftItas a ClirrenUedltto, .of1he-
Masgac fit-it1.:5$ta'te Buddtn Code „4
is CaudA-f'ot're'uueatiou d'tbrssAieepse. 3
T1. T0691+MOft..a a/1 �imecrc/umek3
q� Board of Building Regulations'and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
ReplsttfloA' ._ 5375 One Ashburton Place Rm 1301
/n3/2009 Tt# 126164 Boston,Ma.02108
��1_Gto Corpora0on
r
ROGER A TREU)3 TORS,INC. /f
ROGER TREMBILG�- -
1 O COLONIAL RD S�Ii'"33+ --
SALEM,MA 01970 Administrator Not valid witho t si nature
p,.e CO,.v onweaZth of Massachusetts
om_ Depmvne ,.oflndurtral fiecidents
yt.._ pffzrx ofZnvestig�ans
r 600 Washington Sneer
' Boston MA 02111
�' WoskeEs' C r eat oa In unaa°C Affidavit
y�
uy..r2, s<fx`. %'2=d am'>x i""r• %-r. >-.av'a*:i: %;9k%
q -- -
property Owner Name: .
_ job Comm: -
'
City' ..
❑ I am a bomcowner"perfvmrmg all work myscl£ '
Proprietor and have no ant w°�ing in My=PAY•
I am a sole .. MR,
:° -. _ - - "may:' <°'> :. :xr;.,. .e.;..�•,::>
❑ PCOPn asxx ,
�.'�F^'"..::—LT-•r Zqs-'as '� s'x l ccs wor�o on this job.
CmPl°)rar Pr°viding waakers-LOIII(1C9zZhLD lor my—1p °y .
Company Name-
Address D. C� SvNA� 2. ..
Phone
• P oltcy# W����'/5 I
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NUT5 - "�re f.%4C� �-� � m�:::h,:.�r>,.' �:r, d�S wdua.u..:x.•. •..^ -
.. .. ......:_�»..�. .- ...w. - �..•� """"` •- .,..t,-.ryr..�lirtr3bdow who havc the fouDwing wows'
�,�'[am a sole pm e,or ho�cvwne(Uncle one)and havc hued the .
eompeosa=a polices: . .
CompanyNamc: .
fddress: _ Phone#
City Policy#
ee Co. ... ... .<.�Y`6::5}.£:.Y''^'A"InSln:an ::v.:fx:;�x:�;,�^:.u: .:�_'t.;i>x: .:a»'r,:x:<:C'..,:'�a�:ar".ir•-o".�,^i',,"jfz
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Company Name
Address Phone#
City Policy#
Insurance Co.
_.. ::,w:<.'::>A��x „a£....'»:"^; <6X.<.crri:3a.�i�.s»R< ',;:.•:�.w^.::>. . .,n.`Y:..-���--"aa�'t ,
y3>': •.. .......rf e...: >5 �.o cnalties of a fine vp to understand
and or. ..
Faih, io sleare=VtZ39c as regnircd trade Seaim the of .,f a .TC mn rOF iD the imPosffiaa of eominal p
me yea,impx3mr�ent as wen as civil penalties is the fv�-of a tions of Oe DLA for coverage vCri5c2EK'anfi a fine of Ito00.D0 a day against roc. L mderatand that a
copy of this saotmml may be forwarded to the Office of Iavesfiga
I do bcrcby ertifY Under the pains and Pmaltics of pejvry that the is vmtatioa provided above is true and marst
Date z 7
Sipsatnrc /L.t9�(1^ L1' �w t �n
Pn.
7
vt Name. -2-7— p
Ef5jjInly. Do nut write in this area,to be eompladbyatYartowno�rial ❑Bi g Dcpartmmt
P ❑ Limsing-Board
: ❑ Selectmens Ogee
❑Q Health Dcpartmrnt
mmr-diatr..r_cnnnse is rccu'red ❑ Other
s _ phone
I~JUL-02-2007 MON 1.1 ;40 AM JENKINS .INS. FAX NO, 7812459563 P. 01/01
ACORD,„ CERTIFICATE OF. LIABILITY INSURANCE DATE/2/07
PRODUCER THIS CERRFICATE IS ISSUED ASA MATTER OF INFORMATION
Wayne C. Jenkins Insurance ill3y ONLYAND CONFERSNO RIGHTS UPON T HECERTIFICATE
50 Salem St HOLDER THIS CERTINCATEDOESNOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 69
Lynnfield, MA 01940 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: Safety Insurance
Tremblay Contractors, Inc. INSURERB: Ohio Casualty
10 Colonial Rd Ste. $4 INSURER C:AIG
Salem, MA 01970 INsuRER 0:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTCO BELOW HAVE BEEN 191 NED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRA., T OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIIII 1 DESCRIBED HEREIN 15 SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REIII JCED BY PAID CLAIMS.TRY,
SR OD' - •.. _....—.. %0AUCYEFFECi bE WUCY IRATgN .-
S fYP_E�r e+sUR POLICY JMBER � LIMITS
GENERALLIASILRY EACHOCCURRENCE S 1,000,000
}(
pRffmL ETD-RENTED
B COMMERCIAL GENERPL LIASILRY BKF7525198i1 2 4/15/07 4/15/08 PRFs.II6 E6(Ee AEEWei,EA ? 50.000
— CL MSMAOE Fx OCCUR MEO E%P(Anyone pe,eap !F 5,000
X bfpd, xcu, cont .- PERSONAL&ADV INJURY S 1,000,OOQ
7( Contr. Protecti. GENERAL AGGREGATE,_ $ Q�Doo,o00_
GEN'LACGREG_ATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG S 11_000 000
POLICY X JE�I' LOC —
AUTOMOBILE LIPSILITY COMBINED SINGLE LIMIT
p ANYAUTO 1500143 4/19/07 4/19/08 (EAMCIdant) $ 1,000,000
X ALLOANEDAVTOS BODILY INJURY
[ 9CH FOULED AUTOS CPU p&con) $ —
HIRED AUTOS BGD ILY INJURY
](— NON-OMFD AUTOS IF.,arrJtlenp
PROPFRTYOAMAGE $
-- '" (Pa wddeSt)
GARAGELIABILITY _AUTO ONLY-EA ACCIDENT $
ANY AUTO OTYIER THAN _EAACC $
AUTOONLY. AGG $
F ESSRIMBRELLALIAOILITY EACH OCCURRENCE $
_ICCCUR CIAIMSMADE AGGREGATE S
$ I
DEDUCTIBLE S
RETENTION $ S
WO RK FRS COMPENSATION AND q TORT UMRS
C EMPLOYERS'UI ILRY WC 687465? 7/1/07 7/1/0B EL EACH ACCIDENT $ 100 ,000 '
ANY PROHR IETORIPAR TNERIFXECUTIVE
OFFICERIMEMSERD(OLUDE07 E•L DISEASE-EAEMPLOYEE $ 500.000
ules,apcc beaodv S.L.DISEASE-POLICY LIMIT $ 100,000
SPECIAL PROVISION S Eohw
OTHER
UMCRIPTIONOFOPERATIONS/LOCATIONSIVEHELESIEXCLVSIONSL IOEO BYENOCRSEMENTI SPECIAL PROVISIONS
Contracting Operations:
cERrIFIC ATE HOLDER CANCELLATION
BHOU LD ANYOF THEAEOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THFISSUWGINSUREll FND6AVORT0 MAIL 30 OAYSWRITTE•N
NOTED ETC THE CERTIFICATE HOLDER NAMED TO THE LEFT,OUT FAILURE TO OOZO SHALL
I MPOSFNO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORI EO EPRES
ACORD 25(2001108) O AC RD CORPORATION 1988