The URL can be used to link to this page

3 TRADERS WAY - BUILDING INSPECTION (4) � I/ The Commonwealth of Massachusetts t 'd' •.1�' Department of Public Safety ..\IassaChusrtlsSt•ucl4uildingCurie(78UC\�{)�� - ISuilding Permit Application for any Building other than a On r'1 h,f Mfy D el ii (This Section For Official Use Only) Building Permit Number Dale Applied: __ Building Offi SECTION 1: LOCATION(Please indicate Block It and Lot N for locations for which a street address' not ailabie � dot - City Zip Code Name of Building (if applicable) + Street ----- SECI ION 2: PROPOSED WORK Edition'If MA Slate Cotle used If New Construction check here❑or check all that apply in the two nn.:s below Exi.stinf; Building❑ Rapair❑ 1 Alteration ❑ 1 Addition❑ I Denwlition ❑ (Please till out and submit Appendix 1) Change of Use ❑ Change of OCCupancy ❑ Other ❑ Specify:-- Are building plans and/or const ruCt ion dtx'unhents being supplied as pert of this permit appi ication? Yes ❑ No ❑ --- Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Descry ion of Proposed IVork:"_- 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 CNIR 3.4) ❑ Existing Use Group(s): . __ Proposed Use Group(s): _ SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basenhent levels)&Area Per Floor Is% ft.) Total Area(sq. ft.)and Total Height(ft-) SECTION 5:USE GROUP(Check as applicable) :\: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-1 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ P: I-veto F-I ❑ F'_Cl H: Ili h Haz rd H-1 ❑ H-2❑ 11-3 ❑ FI--4❑ 11-5❑ 1: Institutional 1-1 ❑ 1.2❑ 1-1❑ 14 ❑ >'1: Alercantile❑ R: Residential R-I❑ R-2❑ R-i❑ R-a❑ S: Storage S-I ❑ S-_2❑ U: Utility Cl Special Use❑and please describe below: Special Use SECTION 6:CONSTRUCTION TYPE(Check as applicable) I.\ ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV Cl I VA ❑ V11 ❑ SECTION 7:SITE INFORMATION(refer to 780 CbIR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Cheek if outside Flood Lune Cl Indicate municipal ❑ .1 trench will not be lr,pvtrd Disposal Site❑ n•yuinvl ❑ur trench ar specify:_. "- I'ricale❑ or indenlily Luna ar on site system❑ perautis enclosed ❑ Railroad right-of-way: ilamrds to Air Navigation: Not Applicable❑ Is tit virtu rr within airport appmdrh an•,i.' Is Choir rt•v it'" nmhplrlvd' ur 6n1sd111 to Ile ri n d rrlosr d ❑ )vs ❑ or.No❑ 1't'a Cl No ❑ SF("IION 8:CONTFNI'OF CPR'1'IIICA IT OF OCCUPANCY ISdinun nl Cudr: _ -..C'sr Group(Ny . .. I\-pc Id C11111MrhUlt: 0 t upant Lead per I loot: I tors lhr building c onuain,m sprinkler Syswm': tiprCial �npulations: _ _ t ' SECTION 9: I'It011i:lt'I'Y OWNTR AU'I'1IOl2IZA I[ON Name and :\ty_l ress ul Propvrh Opener r — � ��-�G -------------- -------- - ,une w(Print) No. and Street City/Ton Zip Vroperty Owner Contact Information: I ille ---- ----- Telephone No. (business) Telephone No. (evil) c-mail address If applica Iv, the properly u v to hereby authorizes Name Street Address City/Town State Zip to act on the pro pert owner's behalf, in all matters relative to work authorized by this building, permit a plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) 1f bit ild in•is less than 15,0011 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.l ❑.1 Registered Professional Responsible for Construction Control Nance(Registrant) relephone No. a-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 Gener I Contractor <PoQ/—�� pang ame � q (T/� Name of Person spr�for Cove/instruction License No. and Type if Applicable Street Address _ City/Town State Zip 'role phone No. business Telephone No. cell e-nail address SECTION 11: t\t 11, .t,rr, t twin IN i,u,,_ul:.\.Xt I \e[n ,\\]I M.G.L.c. 157-§ 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 O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and \laterials) Total Construction Cost(from Item b)-S_ I. Building $ Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical 5 appropriate municipal factor)=5 t. Numbing 5 J. ..MeChanical (HVAC) 5 Note: \linnoum fee-S (Contact municipality) \ S. \Icchanical Other `5 Fncluse check payable tok_ —CZ/!J� C/!-��\I n. Tidal Cost '.+ (Contact numiCipalih),uml write Cun wr her-- c7 _:.__,-_ SECTION 13:SIGNA"I'URE OF BUILDING PERMIT APPLICANT liv vutering nay name below, I hercbv altcSt under the pains and penalties of perjury that all of the information Conteinrd in this ,application is true and accurate to the best of my know ledge,and understanding. 19ease print ,md Sit;n Halite Title Iolcphone No. hate 9lrral Address Cily/Town State /IV \lunicipal Inspector to fill out this section upon application approval: Name 17a1e __ CITY OF SM-ENis A%Lkss,kcj-;C'SETTS ©t't DOW DEPAMLL\T 110 V7.l3NGVGT0N STXV", Jw Rccit rEL (978) 743.9599 KI\3EALBy DUWOL L FVc(978) 144984 ,b(AYOR 1140MAS ST.PMUA 01mcres OP PLSLIC PROPEA y/SL•QDNG COSLNISSIO.VE1t Construction Debris Disposal Atltdavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 130 CMR section 111.S Debris, and the provisions of MGL a 40, S 54; Building Permit p is issued with the condition this work shall be disposed of in a that the debris resulting from 1 11, S IJOA. properly licensed waste disposal facility as defined by,yGL c The debris will be transported by: x � i ( t auler / The debris will be disposed of in : na uli�y) ( ddnri of f�nhcy) + gn.rmre ofpermit �pplwmt f CITY OF S�U.ENI iNLXSSACHLSETTS • BUILDING DEPART%(ENT p• 120 WASHINGTON STREET,3-FLOOR TEL. (978)745-9595 FA..c(978) 740-9846 Kl\tBERLEY DRISCOLL ,L1t►YOR THObfAS Sr.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIONER Workers' Compensation Ins ranee Affidavit: Br iJdens/Contractors/Elect ricians/Plumbers Applicant Information Please Print Leffibil e Name(BusinesaiOrganintion/Individual): Address: 21 G��/ U 1 City/State/ZiPCCC_[/7 e6YAO/Va(/2 Phone#: CI-7i�r 't you 2! m an employer?Check the appropriate box: Type of project(required): 1 a a tartployer with 4. ❑ 1 am a general contractor and 1 6. El New construction employees(full and/or part-cone).• have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached shcet.: 7• ❑Remodeling ❑ P P shipand have no eon loyees These sub-contractors have 8. ❑Demolition P working for me in any capacity, workers'comp.insurance. 9. Building addition Now rk 'co i 5. ❑ We are a corporation and its ( o ers rap. insurance rP required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§I(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13 ❑Other comp. insurance required.] *Any applicarn that checks box sl must also fill not the section below showing their workers'wmpmswkm policy infomution, t I h eoue,ners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new,amdavit indianing such. ;Contractors that cheek this boa most attached an mWitiord sheet showing The name of the mb,omntetors and their worker'camp.policy faro mmiat. 1 am an employer that is providing workers'compensadon insurance for my employees Below Is the pulley and Job slue information. Insurance Company?lame: a-Vf 9 Policy#or Self-ins.Li�c.j#•' /, / Expiration Date• - 3 Job Site Address / �(/ 7 N/��wY City/State/Zip' Attach a copy of the workers'compensatioo policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Scction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advi.ed that a copy of this statement may be forwarded to the Office of Investigalions of the DIA for insurance coverage verification. 1 do hereby certljy and r the pains and penahl s of perjury that the information provided above Is truuee and correct Siena I tre• Date: b P on # Official use only. Do not write in this urea,to he completed by city or town official City or Town: _ Permit/License# __ Issuing Authority(circle one): I. Board of Ilealth 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: - _ Phone#: Massachusetts - Department of Public Safetc Board of Building Regulations and Standards Construction Supervisor License License: CS 91242 Restrictedto: 00 . PETER NGETH 35 RUTH AVE'.' DRACUT, MA 01826 -•� �y—� Expiration: 5/5/2012 ('nmmiseioner Tr#: 23692 Office o( amer frr"s Nci+�i en ss egu a-libu HOME IMPROVEMENT CONTRACTOR T_ Registration: 129474 Type: Expiration. 9/9/2013 DBA Ko geth RemodelmwContractor. PETER NGETH 35 Ruth Ave. Dracut,MA 01826 r - Undersecretary .,n;y� er c O / J / LV 11 J : LO : VT r-IVI 0Y1)0 VL / VL CERTIFICATE OF LIABILITY INSURANCE DATE08 03/2011 TRIG CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS HO RIGHTS UPON THE CEATIFICATE MOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES HOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(5) , 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 t0 the terms and Conditions Of the policy, Cextain pOlieieS may require an endorsement. A Statement On th1S Certificate dOBS not Confer rights to the Certificate holder in lieu of such endorsement(s). PPODVRP 0..' Byam Brothers-Mahoney ' Insurance:Agency Inc LiIASY 191 Pawtucket Blvd ADDACSS: PPD.. Lowell, MA 01854 INS RYD IASVPLD I51 .' EusIRG C.Wtss L pAl[ R Peter Ngeth x..u. A: A.I.M. Mutual Insurance Co dba�'K9 General Construction Ruth 35 th Ave INSURER D: Dracut, MA 01826 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED SELON HAUN e0 ISSUED TO TWE INSURED NAWEO ABOYE FOR THE POLICY PERIOD =DICATLO. NOTWITHSTANDING MY BEQUIRQQTIT, TERM OR CONDITION OF MY CONTSMT OR OTHER OOCUMIDIT WITH RESPECT TD WHICH THIS CERTIFICATE MAY WE ISSUED M MY PERTAIN, THE INSURANCE N 001) BY TWE POLICIES DESCRIBED HOEIN I3 SUBJECT TO "I THE TERMS, EMCLOSIONS NEW CONDITIONS OF SOCK POLICIES. LIMITS SHOWN HAY HAVE BEEN REDUCED BY PAID CLAIMS. - we TYPE OP INSURANCE POLICY eVAIDEP POLICY EFF POLICY GAP LINITr NDATn lumnnevn GENERAL LIABILITY San, OCCVAANCC 6 OMPRCIgL GQNQFAL LIPpII IIY pSksur xD msp . PRIMISCSIEe.ae[ussence) G OOcLIN9 IMoe ❑OC YP WPL e6 1-❑ Y °ne Pen°nl 6 ❑ rrnsaw.a m G N'L wcc qII PLS[x [P. puGNA. A6pP .S fi ❑POLICY COO PPOSICI ❑LCC - °�/°P K• b e AUTOMOBILE LIABILITY LIxIx OANY AVID I�eceidentl� fi OBODILY IETM ('11 se-11 b NS Otul:[P wci05 OSCHEDULCD APcs CDOSLY INTm (w awfaPtl 6 O NIPeO APLp3 PROP CP}Y pL1A6L IPa au'faay fi O AOw O.aeD AvxOs e v OOMBPPLLR LIAD IXCOR EARN OCeVPDEH CE b OQYCESS LIAR ❑ CLAIN9 MADE AGGREGATE b ODADUCTISLL G ORETEDIIVN 6 WORKENS COMPENSATION AND EMPLOYERS LIABILITY THE PROPRIETOR/PARTNERS/ IXECUTIVE OFFICERS ARE C.L. PJex A[CTDCPx 6 1DD,QOQ A ❑ inci ® ex<1 601454R012011 e.L. Dlswu -PpLsss LIMIT s 500,000 07/31/2011 07/31/2012 .L. ....A.. - R.®WL.YR. A 100,000 CEp 1 / DesaIDTlax or RPI ART.S. as LRcaxxpxs: PETER NGEPH IS NOT COVERED BY THE WORKERS'COMPENSATION POLICY. CERTIFICATE HOLDER CANCELLATION CITY OF LOWELL ATTN: BUILDING INSPECTOR SHOULD ANY OF THE ABOVE DESCRIBED eOLlcxe6 BE CANC -- SWORE THIS eNeIRATTON DAYS Tvascor, NOTION =,I BE DrixVERRE a Are...ANce HI" THE 375 MERRIMACK STREET POLICY PROVISIONS. LOWELL, MA 01E52 WONRRIML IGPPEsatarne _ I ()A A