1 SEWALL ST - BPA-14-565 BUILD BENCHES & INTERIOR WALL { � (
��' ✓ �P 5 � `'f Z S �7y 25 �'
� The Commonwealth of Massachusetts
t ^h�� Department of Public Safety _
�I�( Massachusetts S[ate Building Code(7S0 CbIR)
13uilding Permit Application Eor any Building other than a One-or TwaFamil we ' g �"�
� (This Section Por Official Use Only)��� �
Build'utg Permit Number. � Da[e Applied: �Buil '� �
SECCION 1:LOCA7'ION(Please indicate 61ock#and Lot N for(ocations for which a stree[.addiess is no ��
� S-u+/ � s(- a ot 9 70 �Sc+(��._. Yw,cta
No.and Street _ City/Town Zip Code Name oE Building(if applicable)
SECTION 2•PROPOSED WORK. - � �
Edition of NIA State Code used_ If New Construc[ion check here�or check all tha[�pply in the two rows below
Existing Uuilding❑ Repair❑ Altera[iun ❑ Addition❑ Demoli[ion O (Picase fill out an1 submit Appendix�L)
j
Change uf Use ❑ Change of Occup�incy O Other O Specify: Y
.,
� ,i, Are building plans and/or construction dowments being suppliud as par[uf this permit applica[ion? Ycs ❑ No �
n^ Is an Independen[Stn�ctural Engineering Pcer Review reyuired? Yes ❑ No�','
{ �
6rief Description of Proposed Wurk: �
� ��� �.. 1g�, 1,,._ � 0.� �l�r 2�1�s t!l
SECTION 3�COhiPLETE TEIIS SECTION IF EXISTING tlU1LD[NG UNDERCOING 2ENOVATION,ADDITION,OR
� -- CfIANGE IN USE OR OCCUPANCY . . �� � � �S�
Check h�re if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 3-k) 0 +
Exis[ing Use Group(s): - Proposed Use Croup(s):
SECTION 4:6UILDING HEIGHT AND AREA - �
� Existing Pruposed
� No.of Floors/S[uries(ind�de basement Ievels)&Arca Per Fluor(sq.ft.)
Tot�l Arca(sq.ft.)an1 Total Height(ft.)
� � SECTION 5:USE GROUP(Check as applicable) � � �
A: Assembly A-1 ❑ A-?❑ Nightdub ❑ A-3 ❑ A-!❑ A-5❑ B: Business ❑ E: Educatianal ❑
F: Facto F=l ❑ FZ❑ H: F[i h Flazud H-1 0 H-2❑ H-3 ❑ F[-d❑ H-5❑
1: Institutional Fl ❑ [-2❑ [-3❑ I-�1❑ bL• MercanH(e❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
, S: Srorage S-1 ❑ S2❑ U: Utility❑ Special Use O aiid please describe below:
. Spccial Use: �
� SECCION 6:CONSTRUCTION'I'YPE(Check as applicable) �
IA ❑ 16 ❑ - � [[A ❑ IIB ❑ IIIA ❑ ❑IB ❑ IV ❑ VA ❑ V6 ❑ . .
� SECTION 7:SITE INFORMATION([efer to 780 CbtR 113A for details on each item) ���,�
'french Permit: Debris liemoval: -
YVater Supply: klood Zone InformaHon: Sewage DisposaL• Licensed Dis os il Site�
� ['ublic❑ Check if ou[side Flood Zone�❑ [nJicate tnunicipal❑ A[rench will nut be P ��
reyuired O ur trench or specify:
Pcivate❑ or indentify Zone: or on site system❑ �i�mi[is endosel❑
Railroad righFof-way: Flazards to Air Navigation: �I,�)J ���u �'>,i,i�m� t� n i'r.�a�� � �,:c_s:
�Ioc Applicable❑ Is Strudure within airpurt approach area? Is their review completed? .
� ur Cunsent ro Build rnclosed❑ Yes� or No❑ Yes❑ No ❑ t�
".�,\
SECTION 8:CON'PENT OF CERT[F[CATE OF OCCUYANCY �
EJition of Cudc: Usc Cruup(s): T}'pe of Cunstructiun: Oecup�nt Load per Floor:
Docs thc building iunt.�in on Sprinklcr S}'stem?: Spcei.il Stipuleitions:
� .
n� ��� _.
SECTION 9: PROPER7'Y OWNER AUTIIORIZA'IION - . I
. Name and Address uf Prope�ty Owner - ',
Lj FJ-c/{ �v/LA✓� � �� <Gc/��.2 / /d/JkC
Name(Print) - No.and Strce[ City/"Cown "Lip
Property Owncr Contact Infonnation: (� �n
� � � �J C'��! �li_Z' Q�,C;O y7� �7/ ��. `-V �e'� /�77 .NJRt� S�Ji�OPi1�MG�+,U��
d
�� Title Telephone No.(business) Telephone No. (cell) e-mail nddress � �
� [f a �licable,the prope owner hereby aulhnrizes
,�e ;� ,�✓liti �-, d j �',�v�- /'�c� �S'e% .� � n, �f�s�
Name Street Address City/Tow' Sta[e Zip
to act on the ro er owner's bchalf,in all matters mlative to work authorized b this buildin ermit a lication.
� .. � �SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2J.� . � � �
If buBdin is Icss than 35,000 cu,ft:of enclosed s ace and or not imderConshvction Contml then check here O ond ski Sec[ion 10.1
101 2e istered Professional Res onsible for Constniction Conhol � � � � � �
�: bc+,r/�i'z, `!� S'9� s 9vZ. /9�aiL�o�� G i - oSz� 7 Z
� r N:mie(Registrant) T�•ephone No. e-mail add ss � L Regist�a[ion Number
X, �//G:'✓lirt% ��b�) i'J`clie.s+iL . ivd!'�`.✓JP Ei�'.� r„ cL,•� /�-� / -�S
�,� Street Address City/TiSr�in State Zip Discipline ExpirationDate
0 /"r
102 General Conhactor �� " � � � � � . � � . � �
Con any Name
��e�iGE L ,G� .�ti✓. U G ,$ D � Z�j 7 Z G�✓t/�S/% c/t"�
4. f.
N.mie of Person Responsible for Construction License Na and Type if Applicable '�,
`! / F,.a � 12��� /��v �i.- �v ��yi�""
y� S[met Address City/Tow State 'Zip
� L��-19�S"?dz ���. S' ."� s��z. q��»�zt�d' (����sho�� .��r"r'
,
Tcic hone No. business Tcic hone No. cell e-mail address
�, � SECTION 11:iVOltKfitiS CO�IV1iNS,1ll(h�i INSUK:\:UCF:API'ID;\VCI' M.G.L.c.152. 25C 6 � �
, A Wurkers'Compensation fnsurance Affidavit from the MA Department of Industrial Acciden[s must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the budding permit.
[s a si ned Affidavit submi[ted with this a lication? � Yes❑ No ❑
� � � � � SECTION 12:.CONSTRUCTION COSTS AND PERb[TT FEE��� . � �
Item Estun.ted Cos[s:(Labor
- and Materials) Total Cunstmction Cust(from Item 6)_$
. L 6uilding � Building Permi[Fee=Total Construction Cus[x_(6isert here
� 2.Electrical $ appropriate municip�l factor)_$
. 3. Plun,bing - $
d. �fechanical (HVAC) $ Note:b[inimum fee=$ (mntact municipality)
5. Mechanical Other � Endose chtrk � �ble tu
' Y 6.Total Cost $ P�Y�
/� (�J� � (mntact municiPality)ond write check numbcr hem
� SECTION 13:SIGNATURE OF BUfLDING PERb11T APPLICANT.
6y entering my name below,[hereby attest undcr the pains and penalties uf perjury tha[all of Ihe infurmation cont.iined in this
application is tn�e and accura[e to the best of my knowledge and understanding.
�,t�e,�e� /r�j,,�,� , ,. i�, i , ;v y�s 99d's`�vZ i-�a_ y
Ple.'�print and sign mm�e TitP Tclephune Nu. D,ite
/� Str�t Ad ress � /� City/Town St��te Zip �
�.N�7% J� _ /iJt/� - ���/
iblunicipnl Inspector to fill out this section upon applicatbfi approval:
Neme Date
� 4r „ CITY OF Siu ENf, tiL1SSACHUSET'I'S
t)uiwcstG DEPAR-M&NT
130 WASHNGTON STREET, 3"O DOOR
TEL (978) 745-9595
KIMBERLEY DRISCOLL FALX (978) 740-9845
itifAYO 3 THo.%w ST.PIERRa
DIRECTOR Of AMC PROPERTY/BCII.DCYG CONNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section t 11.5
Debris, and die provisions of N,10,L c 40, S54;
Building Permit k is issued with the condition that the debris resulting from
this work shall be disposcd of in a properly licensed waste disposal facility as defincd by MGL c
I 11, S I SOA.
The debris will be transportcd by:
(name of hauler)
The debris will be disposed of in :
- — - (narne of racdity)
(address of hteility)
»
date
11 Is I
;.4,IL'ORD ® CERTIFICATE OF LIABILITY INSURANCE
`aI
ATE
D01/20IDDIV4
of/2a/za14
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(ies) must 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).
PRODUCER 1-617-723-7775
CONTACT Michael HOlsvert
NAME:
Hays Companies of New England
PHONE FA%
aC No Ext: 617.778.5040 uc No: 617.723.5155
TYPE OF INSURANCE
E-MAIL mboisvert@ha scum anies. com
ADDRESS: Y P
133 Federal Street
INSURERS AFFORDING COVERAGE NAIC9
2nd Floor
Boston, MA 02110
INSURERA: NEW HAMPSHIRE INS CO 23841
INSURED
INSURERS: NATIONAL UNION FIRE INS CO OF PITTS 19445
INSURER C NEW HAMPSHIRE EMPLOYERS INS CO 13083
YMCA of the North Shore
INSURER D:
245 Cabot Street
INSURER E:
Beverly, MA 01915
X
INSURER F
Cr)VFRAr;FS CFRTIFICATE NUMBER: 38212926 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 10 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.
INSRADDLSUBR
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
120 Washington Street; 3rd Fl.
AUTHORIZED REPRESENTATIVE
Salem, MA 01970
POLICY EFF
POLICY E%P
LIMITS
LTR
TYPE OF INSURANCE
NSR
WVQ
POLICY NUMBER
MMIDONYYY
MMIODIYYYY
A
GENERAL LIABILITY
01 -LX -004258427-9
12/29/1
12/29/14
EACHOCCURRENCE $ 1,000,000
X
DAMAGE TOREWED 100,000
PREMISES Es occurrence $
COMMERCIAL GENERAL LIABILITY
MED EXP (Any ane Person) $ 5,000
CLAIMS -MADE FXI OCCUR
PERSONAL& ADV INJURY $ 1,000,000
rGEN'LGGREGATE
GENERAL AGGREGATE $ 2,000,000
LIMIT APPLIES PER:
PRODUCTS-COMPIOP AGG $ 1,000,000FrJ
$
LICY PRO- LOC
1
A
AUTOMOBILE LIABILITY
01 -LX -004258427-9
2 9
Fa aBcideO (SINGLE LIMIT $ 1,000,000
BODILI'INJURY (Per person) $-
ANY AUTO
BODILY INJURY (Per accident) $
ALL OWNEDX SCHEDULED
I
AUTOS AUTOS
NON -OWNED
Pe�acc den) AMAGE $
X X
HIRED AUTOS AUTOS
B
X
UMBRELLA LIABX
OCCUR
29 -UD -004659306-9
12/29/1
12/29/14
EACHOCCURRENCE 5 10,000,000
AGGREGATE $10,000,000
EXCESS LIAB
CLAIMS -MADE
OED I X RETENTIONS 10,000
$
C
WORKERS COMPENSATION
ECC -600-4000020-2014A
Ol/Ol/1�
01/01/15
X WG STATU- OTH-
v
EL EACH ACCIDENT $SOO,000
AND EMPLOYERS' LIABILITY YIN
ANVPROPRIETORIPARTNERIE%ECUTIVE❑
E. L. DISEABE - EA EMPLOYE11 500,000
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH)
NIA
EL.DISEASE - POLICY LIMIT 1 $ 500,000
If yes,deardthe under
OE SC RIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required)
The City of Salem,ris additional insured in accordance with all the terms, conditions, and limitations of the policy and
then only with respect to liability caused by the negligent acts or omissions or the Named Insured.
II
CERTIFICATE HOLDER CANCELLATION
ACORD 25 (2010/05)
mboisvert
38212926
RJ 19a8-ZU1U ACURU CORPORATION. Nal ngois reserved.
The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Salem
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
120 Washington Street; 3rd Fl.
AUTHORIZED REPRESENTATIVE
Salem, MA 01970
USA
ACORD 25 (2010/05)
mboisvert
38212926
RJ 19a8-ZU1U ACURU CORPORATION. Nal ngois reserved.
The ACORD name and logo are registered marks of ACORD