56 TREMONT ST - BUILDING INSPECTION (3) - - - - -- -- --- - -- --------
The --- -- - --
Colnnionwealth`of Massachusetts, -
{ Department of Public Safety
\ P :\lassachu+otts st6de Build inft Code(741)C.\IIf)
t: Btiildutg Pennit.Apphartion Grany Bruldgigotlrerthan a.One-or'I'wo-Fan)ily Dwelling
��. . •' Y (.fhi+5rchun For O(hcid Use Chdv)
JJJ Building Permit iNomber. _ —.._ Unr Apphcd: -------- Building Official:
SECT[ON l: LOCATION(I'lease indicate Block N and Lot N for locations for which a street address is no
available)
aKD�co�R-------------
---
Nu.,mdStrect City;lowil /ij)Code Name of lluildinf;(it applicable)
SECTION 2: PROPOSED WORK
Edition of AMA Stale Code used If New Cunstrui lion chock here❑or check all that apply in the two rotes below -
--
IisislingiuildinfiX Rcpail`Ar Altaratiun ❑ Addilton❑ Demolition (Ploa.se fill outand Submit Appendi.r 1)
Changioi Use ❑ Change of Occupancy ❑ Other ❑ specify:--_—
\rebuilding plans and/or ronslructiun dtrt'Inucnts being supplied,u part mf this permit application? Yes ❑ No ❑ —_--- -
Is an Independent Structural Eli ill Crin Prcr Review rey�u i�rc�d�? /, Yes ❑ No ❑
Brief Description of Proposed Work:._ QT�L T- ) ))NCO JLPDkTE KITCN0_--
_ RVPA[k �0AjW _
SECTION 3:COMPLETE THIS SGCLION IP EXISTIN.G BUILDING UNDERGOING RENOVATION,AUUI'r1ON,OR
' CHANGE[N USEOR'OGCUPANCY -
Chcck here if an Existing Building Investigation and Evaluation is enclosed (Sec 7311 G\IR.N) ❑
Existing Use Gruup(s): •. _____ '" Proposed Use Gruup(s): _..
SECTION 4: BUILDING IIEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(inclutle basenwnt levels)dr Area Per Fluor(Sol. ft.)
I' Total:\ma(sq, ft.)and Tut.d Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
\: Assembly:\-1 ❑ A-2❑ Nightclub ❑ A-t ❑ A4 ❑ A-5❑ 1 0: Business ❑ Tr•-: Educational ❑
P: facto F-1 ❑ F2❑ If: Ifi h tlazard li-1 ❑ H-2❑ H-.t ❑ li-J❑ F1-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑.1-4❑ \I: Mercantile❑ R: Residential R-ICI R-2❑ R-t❑ R-a ❑
S: Storage 5-1 ❑ S-'_❑ u: Utility❑ Special Use❑and please Jeecribe below:
Special Use
SECTION 6:CONSTRUCTION INIT(Check as applicable)
1:\ ❑ IB ❑ im 71 IIB ❑ III,\ ❑ IIIB ❑ 11 IV ❑ VA ❑ n13SECTION 7:SITE I:NFORM,VLION(refer to 7NBC.MR 1ILO fur details on each item)
Water Supply: Flood Lune Information: Sewage Disposal: Trench Permib DebrisI'u blic lhark if out>iJc Hoof /on hdil ii > .\ Trench�rJelit oat he Lii vn.rd Dt'rnale❑ -,,r inJenlily Lone: or on+nc st.yvm❑ naluin•d S or trench or spe,if\
ItdilnnJ right-uI way: I Iaiarls to Air Navigation:
\ t .\phhr,llh_i� Is�trm low tuthin ❑rl rt.ippro•n It aro,i' I+Ihur to it it vnplehJ
nr C�-inun to lludJ int lu.rd❑ ),s❑ r \ .1VV N
SI:( I[ON 9: CON]E:YI'I)F cTI(I'IFIC'.\TE OFc)C'c UVANC'Y
I ,IiWai ..I t:oJo: C+r Gruu q+f. I\ `r..I C•nnlruchn r l up�urt Ln.iil Irr Flnnr.
lt,m+ ihr but info,,"nlain.m Bpi i nklr rtit.wm' �pn i.d �upu Colons
SIVIION `I: 1'I(OI'If ItTYO%VN1!R ,\Uf1I()1(IL,\IION.___
\ nuu and 1dJn ss ul l'n,psrtt lA,mr
zip
N,nnc (Print) No. and Strsrt city/rmvo LIp
Property Owner Cuntaet Information:
Title ------ fell-phone No. (business) Tcluphone No. (cull) c-mail address
It applicable, the properly owner hcruby authorizes
Name Street.\ddress City/Town .State Lip
to art on the property owner's build!f, in all Ill'i rs rslative to work authorized b lhis:buildin permit a p licatioU: -
SECTION 10:CONsTitUCiION CONTROL(Please fill out Appendix 2)
If building is less than 15•nal cu.ft of enclosed space and ur not under Construction Control then check here O and ski pSection to 1
10.1 Ito pistemd Professional Res onsible for Construction Control
�cerT ou 78/-960-_3. y 'rZNYt260�o_l�-(o o�o� --
Nano(Registrant) Tcluphune rye. e-mail address Registration Number
1 'T'ftwcse.r fzA 4Le,�� , - 419n� iz-14- 13
.. I I Address Cily/Town Slate Zip Discipline Expiration Dote I'
10.2 General Contractor _ ' '
Company Name
a4�lb cs __
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
&L-�b�-r 5g. — —- o 144011 �knt - --
Telc phone No business Telephone No, cell e-mail address
SECTION11: ttt �ittl^. 'ttvub��,:��p,♦ Iv•Igt\.�ir ,uln ,•,\II M.G.L.c.152. 25C6
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 a Iication? Yes O No O
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Gmstnrctiun Cost(from Item 6) 'S_
I, Building 5 Building Permit Fee'Total Construction Cost x—(Insert here
p_. Electrical S appropriate municipal factor)-$
}. Plumbing, S
Kota: \lininunn fee='S--(Contact numieipalilc)
i. \Ierltamical (NVAC) S
i. \luchanical Othvr 5 Enclose chuck pavahle to
n. total Gist S 40 (contact numiopality)and write chuck number here --
SECTfON 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Be suturing inc mope buloty, I hereby attest under the pains.md penalties of perjury that all of the inturnpution nm ne� this
application is truo.md accurate•to the bsst uf'ntp knot,Irdgr;md it tderstand ing.
Please prim t'y dn�-J .i)pt namef ale frlephnnr\'u. Il,tls
A&
�Iresl \ddru+5 C itY; I'otcn ?tote /i p
O
Municipal Inspector to fill out this sediun upon application approva -_- - __. t✓L . - - r/�'�//
N,une I pale
1�
CLTY OF S."d-F-M, NWS.1CHUSETTS
OUILOINO DEPAIMMENT
120 WASHLVG "TON STIEET, ) FL(JOR
TFL (978) 745.9595
FAA(978) 7;0.98.16
1.N13E,U.EY DRISCOLL
NLAYO Z T}{OtL1Y ST.P1EQtt8
DiQECToxoF PLOLIC PROPERTY/BUT-DrNG COSL%l1si[0NER
Workers' Compensatlon Insurance r1ITWavit: Builders/CuntructurliElectricl ins/Plumbers
k 1 Meant Information (case Prhtt Leaihl
V;IInClliutinvsUrg,tmrttionlndividudU: i � A�7!✓ �N!>
City/Sratcizip: A hal 6itA r')14�� Phone N: 9���7`f�{'�/
Are you an employer'!Check the appropriate boa
1.(] 1 a n a employer with �_ 4. El am a general contractor and I Type of project(required):
dmpinyees(hill and/or part-timd).• have hired the sub•conlractors 6. ❑Now cunsu-mlion
2.❑ lain a tole proprietor or patsncr. listed on the alfachcd ahVVL t r• � Remodeling
.hip and have no employees These sub-confinetors have I. Q Demolition
working for me in any capacity, workers'comp,insurance. ,
(No workers:comp, insurance 5. ❑ We are a corporation and its /• ElOuddiug addition
ruquired.) officers have daereised their 10.0 Electrical repairs or additions
J.Cl I tun a homcownur doing ail work right orcxetnption per MOL 11.❑Plumbing rcpuira or uddi(Ions
myself.(No workers'cutup, c. 152, 91(J),and we hove no 12.0 Roof repairs
insurance required.) t employees,(No werkerJ'
sump•insurance reyuin d.J 15•Q Other
•.\uy apphmm dW ah-aks bat II mwl ntu fill nut iht waliuo buluw-hawing chair"ktm'compt"as fun pulley maimradon.
'I lnmvuwft"wha.ubntil this alrletavit indleating they im doing all,wrk.md than him uu4i.4 eonlmstom maul mhmil a new,aattJaril indtaing wah.
t• mn,vtdn Thal chsk this 6vx mutt v avhu i in adrheumd.hatl,hewing IN n" the mb.onfmskae t to'hall warkm'comp.punry Infomutloe.
fain annnp/uyrr shut/s pruv(d/nX rvorkdn'eumprnrur/un buurened�dr my emp/uyres. Brluw!s du po/%y undfub s!!o
in�urnlallnn, � J r�,�✓
In,urume Company Name: ARCED ED 1>....._
Policy our Selr-ins. Lic. d: &S�g Expirilicn 04te: 4 oZo� IoZ _
IVIs Site r\ddll'Ya: ltAol`il T aNa FicOR SA�15M
CityiStute�Zip;
\each a copy of the worker'cotnponlalloa pulley declaration page(thawing the pulley number and expiration data).
F'.,iluru to,eaac eureraga as required under.Seniors 2J,\df StOL e. 152 can ldad to the imposifion of criminal penaitics of t
tiro lip to i I,S0U.U0 ind/ur one-year impriinnmcnt as well as civil penaitids in the farm of a STOP WORK ORDER and a tine
,df up ro 52S0.U0 a Jay iyainv the vidlamr. ile advi a
.+cd lhat a copy of this atcmvnt may Nilr'urwirdcd iu the Oliied of
Id,'e,Il yaliUn.t,rl IIIC Dlr\ 1�)f in.tUratlCe CJvifagd veri llcaliun.
/do/rrrrby t•rrli/y rruJrr the pains it ilpi 6/er -f perjury/but 1/10 hVunnallair pruvided abuvd iv brie• fut currect.
17.
- - - &9
L
0 h/iris!u,e,rely. /h-,n -we ht rhlr "ea, to,.5r cmuplew.1 by"fy ur town"J11,iv!
City nr I'u,r o:
I. ILl:,rd ul Ilcalth !. ILuId Ln; Uc Ltrlmcnr i. '
n. Ulhcr
_ . _ _. _. _-_ . I 1' ityll'pun Clcr,e 1. f•:(.efriell h"pcch'r i, l'lo n'binq Iu spec for
VDAC
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (GS60UB-95231-17-6-11 )
RENEWAL OF (6S60UB-95231-17-6-10)
INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY
NCCI CO CODE: 80411
1.
INSURED: PRODUCER:
CROWN AUTO BODY SUPPLY LLC . GERALD T MCCARTHY INS
45 MASON STREET 92 NORTH STREET
SALEM MA 01970 SALEM MA 01970
Insured is A LIMITED LIABILITY COMPANY
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 10-25-11 to 10-25-12 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
a MA
r
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
p Bodily Injury by Disease: $ 100000 Each Employee
MC. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
D. This policy Includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS. - EXTENSION OF INFO PAGE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information Is subject to verification and change by audit to be made ANNUALLY.
DATE OFISSUE: 09-22-11 WC ST ASSIGN: MA
OFFICE: ORLANDO DA HTFD 05G
PRODUCER: GERALD T MCCARTHY INS 73MBB
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