18 TREMONT ST - BUILDING INSPECTION 'p.�-�� GK e� t 53�
� t o�v. '
� The Commonwealth of Massachusetts
^ Board of Building Regulations and Standards CITY OF
, � Massachusetts State Building Code, 780 CMR SALEM
�� Revised Mar 2011
,^� B�iiding Permit Application To Construct, Repair, Renovate Or Demolish a
�r� One-or 71vo-Family Dwelling
' This Section For Official Use Only .
Building PermitNumber: Date Applied:
�����, %��� ��� 3 5 /Z
� Building Official(Print Name) Signature Date
SECTTON 1:SITE INFORMATION
1.1 Property Address: 1.2 pssessors Map&Parcel Numbers
� , � l.la Is this an accepted stree[?yes no Map Number Parcel Number
1.3 Zoning Iuformation: 1.4 Property Dimensions:
'Loning District Proposed Use Lot Area(sq ft) Fmn[age(ft)
1.5 Bailding Setbacks(ft)
Fron[Yazd � Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: t.8 Sewage Disposal System:
Public❑ Private❑ 'Lone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check if yesO
SECTION2: PROPERTYOWNERSHiP'
Owner'o Record•
�i�ca+_� ��c� �a1 �w� �/I W 6 t���
Name(Prini) City,State,ZIP
1`3'� '(�r�c�G�_ 5�- � � `110 [��3 R-ua� c� � V� 6k5 v� . �b��
No.and Street Telephone Email Add�ess
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Exis[ing Building 1'� Owner-Occupied ❑ Repairs(s) � Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units `Z. O[her ❑ Specify:
Brief Descr' tion of Proposed WorkZ:
� �arC.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
ltem Estimated Cos[s: Offieial Use Only
Labor and Mazerials
1.Building $ �Q, ��� 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application.Fee
2.Elecvical $ I G� •O OO ❑Total Project Cost�(Item 6)x multiplier x
3.Plumbing $ � �00 2. Other Fees: $
4. Mechanica( (HVAC) $ � `L O QQ List:
5.Mechanical (Fire $ Total All Fees: $
. Su ression
/,� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $�5 �OO� ❑paid in Fult ❑Outstanding Balance Due:
C� � / `�- �� �'��� _
�
SECTION 5: CONSTRUCTION SERVICES
5.1 C�onstruct4on Supervisor License(CSL) ��(7 G Yll1 ( \� � Z
���'�1� �(� �C^ �[' � � Licen e Number/ \ Expira[ion Date
Name of CSL Holder
�A �u���,l V1 C 5� List CSL Type(see below)
No.and Sheet T pe Description
(� � ` q U Unrestricted(Buildin s u to 35,000 cu.ft. .
�V�P 'n i��"Q. N\ � �Z� � � Res[ricted 1&2 Famil Dwellin
CiTyl1'own,State,ZIP M Mason
RC Roofin Coverin •
WS Window and Sidin
SF Solid Fuel Burning Appliances
� I O O'�3 Q�cur 1�� Q��egu�x.��4 < <�uiat�o�
Tele hone Emai]address D Demoli[ion
5.2 Registered Home Improvement Contractor(FI.IC) 158 n 1� p � I d
` ' )4 �1
�� ����� 'V�.��-�] ��—N�����C ���� HICRegis[rntionNumber ExpirationDate
HIC Cpmpany N o�WC egistr Name
� 4 ���CAV�� �j� �ICCAJ� � ��Ej\CM.�jI�
Ni���tren�°'� � /n �2� /b �/�1� �D�FiV /� Emailaddress �—
PI
Ci /I'own,State,ZIP Tele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAV IT(M.G.L.c. 152.§ 25C(6))
� Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the deniat ofthe Issuance of the building permit.
Signed Affidavit Attached? Yes ..........7.Q No ...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Elechonic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penal[ies of perjury that atl of the information
con[ained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized AgenPs Name(Electronic Signature) Da[e
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home [mprovemen[Contractor(HiC)Program),will nat have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Progam can be found at
www.mass.gov/oca Infortnation on the Construction Supervisor License can be found at www.mass.eov/dos
2. W hen substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemenUattics,decks or porch)
Gross Iiving azea(sq.ft.) Habitable room count �
Numbe�of fireplaces — Number of bedrooms G�
Number of bathrooms Z Number oFhalf/baths
Type of heating system � Number of decks/porohes �
Type of cooling system �p�� ��� Enclosed Open
3. "Total Project Square Footage"may be substi[uted for"Total Project CosY'
d!:•.\ '.•� •,••••••••••n..cuss.� vJ trtuJaucnuJe!!J
,.� Department ojlndustrialAccidents �� � �, `�
� u Ojfice ojlnvesrigations I � (��2
600 Washington Street
, Boston, MA 02111
" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Iaformation Please Print Le ibl
N3IT1C (Business/Organization/Individual): � �� �C� � C��µ,,a � .�,��n
�' �ddress• � ��—�3�� cQ tiP �
City/State/Zi : Phone #:
Are you an employer? C6eCk the appropriate box: Type of project(required):
1.� ] am a employer with 4• ❑ 1 am a general contractor and I 6. ❑ New construction
employees (full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. [�Remodeling
ship and have no employees These sub-contractors have g, � Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.= 9• ❑ Building addition
required.) ., 5. � We are a corporation and ia �0.� Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their � �.� p�umbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.❑ Roofrepairs
insurance required.] 1 c. 152, §1(4), and we have no
employees. (No worken' 13•� Other
comp. insurance required.]
•Any applicant that checks box NI mus�also fill out�he section below showing lheir workers'compensation policy infortnuion.
t Homeowners who submit this andavit indicating thry are doing ell work and ihen hire outside convactors must submit a new afTidavit indicating such.
�Convactors that check tfiis box must atteched an additionel sheet showing the neme ot the sub-contrac[ors and state whether or not those entities havc
employees. If[he sub�contractors heve employees,they must provide their woricers'comp.policy number.
I am an employei[hat is praviding worke�s'compensation insurance jo�my employees. Below is the policy and job site
injormation.
Insurance Company Name:_ � 1(���I ^Q 1� 1�
Policy N or Self-ins. Lic. #: � � � � �� . � �jq �}�8 Expiration Date: Ic� 1 � I I 2
Job Site Address: �� � C°`� vLC.c7 rj � �' City/State/Zip: � ,�
Attach s copy of the workers' compensation policy declaration page (showing t6e policy number and expiration date).
Failure to sewre coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-yeaz imprisonment, as well as civil penalties in the fortn of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereb ce fy un r the pains aqnd penalties ojperjury th�the injormation provided abave is aue and correct
� " 21 � J iZ
Si ature: Date:
Phone#: � 2� �
Ojficia/use only. Do nor write in this area, to be complered by ciry or rown ojficiaL
City or Town: Permit/I,icense#
Issuing Authority(circle one):
1. Board of Health 2. Building Departmeot 3. City/I'own Clerk 4. Electrical Inspector 5. Plumbing Iaspecror
6. Other
Cootact Person: Phone#:
: : <a � : = =- w �,; ... � i��tiruC�lu�t�
, : orken' compensation for their employees� '
� •- -_r- : ir •.n, service of another under any contract of hire,
;,:... ; ,. ..,,,,,,,,;,,,, ,,;,�- �r.icion or other legal entiry, or any two or more
, ,,i � ,_;�r�sentatives of a deceased employer, or the
-.- ' �ntiry, employing employees. However the
� ` uho resides therein, or the occupant of the
. , ,__,
,: .
� - „ -- uion or repair work on such dwelling house
_ ,. .,._. .,�.
� � �. , , + ��.,pinyment be deemed to be an employer."
� , .:;_,,, ,:: :. , i,-ti agency shall withhold the issusnce or
L-;;,,.; ,, :,., . .. ':�uiiJings in the commonwealth for any
,;, :,�.���r::: ,,:' :,,i,:�•;iar.c; �:ith the insurance coverage required„
'� - ,, . , � ::f�l-. nor any of iu political subdivisions shall
� :.:�t '�
�„ ��,: .,,:,, , �_p�.::ni� .::iclence of compliance with the insurance
. _ . . . . .. _. . ._��:„ .
..
.
' • . i.;,i: .�..;rml:,.V � '.�. :irctiing the boxes that apply io your situation and, if
. , � ; . I � �.unb.rte; along with their certificate(s)of
! � �;�. ; ,,, ; .i..!,�Ir'. .�,�n-r',hips (LLP)with no employees other than the
, ,;;,� ,:ni., ;n�o� i:r ur�nce. lf an LLC or LLP does have
- �„ �idvi,�ci tiiat this aft'ida�it may be submitted to the Department of Industrial
�,,,.��r;mce cuverage. Also be sure to sign aod date the affidavit. The affidavit should
�.��e ;:�plication I'ur �he ^enni� or license is being requested, not the Department of
' ,,.;; �m yuesiions re,_artiim_ the la�� or if}ou are required to obtain a workers'
• . ,;i C�cpanment a!the nu�ni�cr lisied t�rlow. Self-insured companies should enter their
� .. , :, .. .��:� .^I�propriate Jine.
,�„�, , . � . ,:;;i� ,.,i'i, �, '?:r a-tment has provided a space at the bottom
, to contact you regarding the applicant.
�.,;; „ . . ; � , . _r�nce number. In addition, an applicant
, ,,,,.� � _d �,nly submit one affidavit indicating current
� n` .y ,. �_
ci or
. � � , ; ;hnuld write "all locations in ( ty
, � � ;_. ,� � ;. �.� the ciry or town may be provided to the
, „, , , , ;,, : � . . .:c�. A new affidavit must kx filled out each
,:� , ,�, .i.�ted [o an business or cornmercial venture
. i i_ . �i Y
� ,i� , �. .� -:•! to complete this affidavit.
� � , ,, .,..• -, - •.:,- - - -,eration and should you have any questions,
. . �._ �r.:: i:>. n.:c-�i:::� ,
.,: � �'': .. . . ..,.�LY. . . !'� . ......:tCI1::SCLtS
, "1„e'.t -. -�`.. '*�?' _'..'.�nC$
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:. i-_:,'7_^.g'i'v �::� =0� c�r 1-K��-MASSAFE
,
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A�� DATE�MMIDD/YVYY)
CERTIFICATE OF LIABILITY INSURANCE 1i13i2o12
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRAAATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CEI3TIFICAT� OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S), AUTHORIZED
REPRESENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certiflcate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGA710N IS WAIVED,subject to
the terms and conditions�of the policy,certain policies may require an endorsemeM. A sfatement on this eertificate does not confer rights to the
certifiwte holder in lieu of sueh endoreemen s .
PRODUCER CONTACT �9B MUnOz
NAME:
W1180II Insurance .�@I1C]� PNONE , (7BS)GGS-1034 F� . (�BS),662-0301
109 West Foater Street E-MAII
INSURER S AFFORDING COVERAGE NAIC M
Melrose MA 02176 INSURERA:E9S6X Inaurance Co.
INSURED iNsursene:Travelers Pro ert Casualt
Ricardo Garcia, DBA: R S Design S Construction iNsunenc:Commerce Inaurance Com an
14 Oakland Street INSURERD:
. INSURER E:
M61TOSe MP. O2S7G INSURERF:
COVERAGES CERTIFICATE NUMBER:CL1211300519 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTMTHSTANDING ANV REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR O7HER 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 SHONM MAY HAVE BEEN REDUCED BY PAID CLAIMS.
�NgR TYVE OF INSURANCE p VOLICY NUMBER PoLICY EFF PO�1L�Y EXP UMRS
LTR
GENERAL LIABRJTV EACH OCCURRENCE $ 1�OOO�000
COMMERCIAL GENERAL LIABILI7V PREM SES rrence S 50,OOO
A CLAIMS+AAOE ❑OCCUR DJ2637 0/26/201110/26/2012 MEDEXP M ona rson $ 1.00�
� PERSONNL 8 ADV INJURV $ 1�OOO�O00
GENERAL AGGREGA7E $ Z�OOO�OOO
GEN'L AGGREGATE LIMR APPIIES PER: PRODUCTS-COMP/OP AGG 8 1�OOO�OOO
X POLICV PR� lOC $
AUTOMOBILEIIABIIJTY 9R9G5 /30/2011 /30/2012 COMBINEO SINGLE LIMIT
Ee eccide
L. ANVAUTO BODILVINJURV(Perpersan) S 100 000
ALLONMED X SCHEDULED BODILVINJURV(Peraccitlent) $ 3O0 OOO
AUTOS AUTOS
NON-ONMED PR�OPER�DAMAGE g lO0 OOO
HIREDAUTOS AIIrOS .
g
UMBRELLALIAB OCCUR EACH OCCURRENCE $
���Up8 CLAIMS-MADE ' AGGREGATE E
DED RETENTION$ $
$ WORKERSCOMPENSA710N WCSTATU- OTH-
AND EMPLOYER$'LIABILJTY
ANVPROPRIETOR/PARTNERIFJ(EQIrIVEY� N�p E.L.EACHACCI�ENT $ SOOOOO
OFFICERIMEMBERE%CLUDED9 p.7[Tg-0590N88-2-11 6/5/2011 6/5/2012 E.L.DISEASE-FAEMPLOVE $ 50O 000
�MenCaWry In NX)
Hyea,Aeacribe untler
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500 OOO
.DESCRIPTION OF OPERATONS/LOCATON51 VEHICLES(Attneh ACORD 101,ACEltlonal Rema�lca Schetlule,Hmore apace Is requlree)
Tremont Investora, L.P and BPG Management Company, L.P. are named as Additional Insureds
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE 7HEREOF, NO710E WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Tremont Investora, L.P.
C/o BPG Mangement Company, L.P.
� 460 Totten Pond Road AUTXORIZEDREPRESENTATIVE
Suite 101
� Waltham, MP. 02451
Reith Bowden/ROSE .
ACORD 25(2010/O5) OO 1988-2010 ACORD CORPORATION. All rights reserved.
INS025(2oioos�.oi The ACORD name and logo are registered marks of ACORD
� X?(`��1p.1 nll—.ni.. V 7GC ���ry... .. , Q i . i �Ar�_ / , _�ri�/4fI' ,
!f �Q
O�ce of Consumer Affairs and iiusiness Regulation
, ' 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
.� -.
Home Improvement Contractor Registration
='_`--� Reqistration: 158774
�� r , Typet DBA
r,':; ���y,,�,J Expiration: 3/3/2014 Tr# 220686 -.
RS DESIGN & CONSTRUCTION ���` _ ,� �;,�� � � �
RICARDO GARCIA
14 OAKLAND STREET ��' � � � �
MELROSE, MA 02176 � '� � �s
l� � - � �- �r
7J\ f�
. �:�y��'-�'e/`, Update Address and retum card.Mark reason for ehange. .
� . . - `L._J'' � Address � Renewal � Employment � Lost Card
OPS�CA1 fi 50M-OC/04G101216 -
__ �j�-��_�,�_���.__�_ . ."__--__—'_._ . _ --___--__'_'_--___—
� � Office��o�me°'���r'�is 8i'Ba�ioess'"�eguTaeon�b License or registration valid for individul use only
_ HOME IMPROVEMENT CONiRACTOR betore the e=piratioo date. If found retum to: .
_ � RegisUaUon ,,.158774 . Type: - O�ce of Consumer Affairs and Busiuess Regulstion
;� Expiration 3/3/2014 DBA 10 Park Plaza-Suite 5170 - , '
. -_= Boston,MA 02116 -
R �SIGN&CONSTRUCTION< " �
'�"�p_ ��.�'. � . . . .
RICARDO GARCI9 �,.-' � . � -
14 OAKLAND STREET � � Q�_ _
MELROSE,MA02176�,,.'?:-i':'_.;;.:.'� � .
� Underucrcmry Nat valid without signature
f�t Massachusetts - Department of Public Safety
. � Board of Building Regulations and Standards
. � , Cunstructiun Supcni+ur -
License: CS-095771
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Drawing Title: ae�;s�o�:
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� P.O. Box 781204 Melrose,MA 02176 Ph.781 720 8073 ,
Project Name: s��e sns��=,�-o�
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Drawing Title: ae��5�o�:
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