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23-25 WARD ST - BUILDING INSPECTION - �) The Commonwealth of Massachusetts y tr Department of Public Safety 1 Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling A�U M.•'.- T°F ft +x g(This Section For Official Use Only) t2,,t Buildin Permit Number"�, c—"� _.� Applied: g Date SECTION 1:LOCATION(Please indicate Block#and Lot#for location's for which a street address is not available) ��4rv1 �fZ1M `Z:� No.and Street City/Town .Zip Code Name of Building(if applicable) , ".^ `;,=, SECTION 2.PROPOSED WORK ,. ,. Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair Alteration ❑ I Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No - Is an Independent Structural Engineering Peer.Review required? Yes ❑ No 4a J Brief Description of Proposed Work: i U �� V,7 n ni I ---.on a' SECTION 3:COMPLETETHIS SECTION IF EXISTING BUILDING VNDERGOING:RENOVATION;ADDITION,OR€.z: t� M+t. ; CHANGE IN USE OR OCCUPANCY r. .:' ,ai Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): Zw;,".SECTION 4:BUILDING HEIGHT AND AREA;;. . ,Ia„_ v# Existing Proposed No.of Floors/Stories jinelude basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) a F$.x'SECTION S:.USE GROUP(Check as applicable)a" 4 ,t c F A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto- F-1 ❑ F2❑ _ _H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R. Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S•2❑ U. Utility❑ Special Use❑and please describe below: Special Use: V'-A'�SECTION 6:CONSTRUCTION TYPE(Check as applicable) '. " ..., ITAr _ ' ' IA ❑ IB ❑ IIA [3 IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑ I'SECTION 7:SITE INFORMATION(refer to 780 CMR411.0 for details on eachitem) m Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: A trench will not be Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: - permit is,enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Conunission Review Process: Not Applicable❑ Is Structure within airport approach area _ Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION'8:CONTENT OFCERTIFICATk.OFOCCUPANCY44 Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: \ Special Stipulations: r �yce L di7- SECTION 9: PROPERTY OWNERAUTHORIZATION Name and Address of Property Owner - i�ovr� "\ \-P. C)1�t 1y Name(Print) No.and Stree City/Town Zip Property Owner Contact Information: om e Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes - �i a Street Address City/Tov5l State IZip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. ABAr£, p,&, TIOIV 10 CONSTRUCTION CONTROL(Please fill out Appendix 2) . ,t bml m 3s less than 35,000 cuPEt oYencloseds ace and/ormot under Conknaction Cdntrol then chi tic here O and sla 9eehron.10.1 ?' _.. . . 10.1 nstruction Control ' .w ,` ,„ '. ,fit, -r',,0 Name(Regis nt) Telephone No. .e-mail address Registration Number a 'MrRmS V)au<�_-.Ne— M f� f4) �1loQ all. Street Address City/To vn State Zip Discipline Expiration Date '10n2,GenealCoritiactor A,; $"$"' ^,ova P.i�: � -: � :`�� ; �- ,==xu..rnw's'. xT�i ah..pr3F`*',` tvNO— Company Nam Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip - - Telephone No.(business) Telephone No. cell e-mail address !Akk :;";., ,< ','�- SECTION'Il:,WORKERS�CONIPENS.4TTONdNSURANCE:'AFM-'AYCf, 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'ipuance of the building permit Is a signed Affidavit submitted with this application? Yesi6' No ❑ .SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE °s l,",'T,�+ Item Estimated Costs:(Labor_ and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ — 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost - $ �. (contact municipality)and write check number here ��n SECTION 13 SIGNATURE OF BUILDING PERMIT APPLICANT 'r , By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information con 'ed in this application is-true and accurate to the best o my knowledge and understanding. Ple rint and sign n e Title Tele a No Date - In I Ex Street Address City/ wn Sta ip 1 ye ✓' ? .�: 'Ip+ "a?6r, .Y ?' n3`y hk4�^, +Ir .-j..'dR sip�S' `Mumcipal Inspector to:fill out this section upon application approval r ' �p r:rg �s,,, CITY OF S,3LE%1, l'LNSSACHU1rF-1'TS BL'IImmr,DEPkP.T% NT�OOR 120 WASHLVGTON STREET, L Tm- (979)745-9595 oY FAx(978) 740-980 <�GRT F_Y pjZj$COLL THONW ST.PIER" jLS YDR DIRECTOR OF PUBLIC PROPERLY/B UULDi,4r CON L%ffSSl0NFR Construction Debris Disposal Affidavit (required for all demolition and.renovation work) In accordance with the sixth edition of the State Building Code,790 CMR section l l l.5 Debris, and the provisions of MGL c 40,S 54; is issued with the condition that the debris resulting from Building Permit# eri licensed waste disposal facility as defined by MGL c this work shall be disposed of in a prop Y 111,S 150A. The debris will be transported by. (name of hauler) The debris will be disposed of in (name of facility) (address of facrlLLy) Sig tune of p mit applicant date debrisaffAm t Two Adams Place vaNTAGE Suite 100 `<>RAA r 1U Quincy, MA 02169 FAM4"t� .aa Hk nx c ,s as ?iz "maa � �1Jal� uG...,.s 7/2'•.Q/201"�.,u.'�a�a`�... AGENCY: Action for Boston Community Development, Inc. ABCD 178 Tremont St. Boston, MA 02111 HOMEOWNER: TOTAL Salem Street Properties PROPOSAL $7r285 23,25 Ward St Salem MA Mg I n Da te of,walk throughs:f4/20/11 NJngg WE Joli Cost # 14037c .r a +use s } w+ 5�.. a�.. TR 3 a DESCRIPTION QTY. UNIT UNIT PRICE TOTAL PRICE DOORS Weatherstrip w/Q-Ion or equal 12 ea $43.00 $516 Automatic Sweep 12 ea $22.00 $264 MISC. MEASURES Basement air sealing 8 man/hr $75.00 $600 Building Permit 0 LS $318 $0 BASEMENT INSULATION Basement overhead insulation (Dense pack-9.5" - R32) 1,522 sq.ft. $3.75 $5,708 Strapping/ Sheet Rock,taped &coat-for holes in ceiling 32 sq.ft. $5.28 $169 Page 1 of 1 NOTICE TO PROCEED Action for Boston Community Development(ABCD),administrator of the DOE Expiring Use energy efficiency program for low-income multifamily properties, is hereby authorized to have its contractors,employees, and other representatives access the property and perform the work contained in the attached Work Order, including final inspections.A copy of this document shall be carried by ABCD's contractors, employees, or representatives and presented upon request. By signing this Notice to Proceed,the applicant acknowledges that the benefits to the clients will be delivered as stated in the attached document. Applicant Information II q n Site Name: 0 r�4 A 0 C 11 l l' O N4 LP Street,City/Town, Zip: 10 STn S kAA 61 50 Contact Name&(Phone at Site: C1 C O Y-) R1V-1.Ct_� 01 — S� - OG O- Signature: Printed Name: (Vl1 C�Q t 1 ly o l�n Cum F� Title: Organization: 00(4{ 1 S41nre mc- Date: $ + I Acknowledeed by ABCD's representative: U, John Wells,Vice President for Real Estate and Energy Services, ABCD Please sign and date two originals. Retain one for your records and return the other to: Grace Park ABCD 178 Tremont St Boston, MA 02111 fax: 617-357-4661 parknabostonabcd.or¢ ' t The Continonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston,MA 02111 wwminass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/orgmization/Indlvidual): �\\t: ( \ag \1Jec� lie•r�z0.- �.,<� \n' Address: i City/State/Zip: C k ( nA. C \ Phone.#: \_L 03) \c Are you an employer?Check the appropriate boa: Type of project(required):, 1.[A I am a employer with 16 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a'sale proprietor or partner- listed on the'attached sheet. 7. ❑ Remodeling shipand have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. employees and have workers'_._. ._ y a co insurance.$ 9;"❑Building addition [No workers comp,insurance comp. . required.] 5. ❑ We area corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11•❑Plumbing repairs or additions myself. [No workers'comp. right 6f exemption per MGL 12.❑Roofrepairs insurance required.]t c• 152,§1(4),and we have no . employees.[No workers' 13.0 Other comp,insurance required.] *Any applicant that checks box Nl must also fill out the section below showing their workers'compensafion policy information, t Homeowners who submit this affidavit indicatlng they are doing all work and then hire outside contractors must submit a new affidavit indicating such. •Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entitles have employees. If the subconhaotorshave employees,theymustpmvido their workers'comp,policy number. I ant art employer that is pi•oyidiitg workers'compensation insurance for my employees. Below is the policy and fob site Information. �\ Insurance Company Name: Policy#or Self-ins.Lie.#: Cb��} �ui Expiration Date: IQZOp1G}-,j Job Site Address: �a Ad �� City/State/Zip: �\YY� , Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Fallure,to secure coverage as required under Section 25A of MGL e• 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$25000 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby carli y under the pains"and penalties of erf that the inforutation provided above Is true and correct Si atute: Data \� \� Phone Official use only. Do not write In thi a ea, to be completed by city or town official j City or Town: Peemit/License# Issuing Authority(circle one): I 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector 6.Other Contact Persou: Phone#: i I i i aco CERTIFICATE OF LIABILITY INSURANCE o6/Zo/zo,MhVDD 7YYY) 11i THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement($). - PRODUCER CONTACT Diane Shaw Fred C.Church,Inc. NAME: 41 Wellman Street PHONE 9783227272 FAX (978)454-1865 Lowell,MA 01851 AIC Ne E#: AIC No: EMAIL dshaw@fmdcchumh.com (800)225-1865 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Cation Insurance Company 40274 INSURED INSURER 13: National Union Fire Insurance Company of Pittsburgh,PA 19445 Advantage Wealherization,Inc. INSURER C Navigators Insurance Company 42307 Two Adams Place,Suite 100 Gemini Insurance Company 10833 Quincy,MA 02169 INSURER D: INSURER E: Stan Indemnity S Liability Company - 38318 INSURER F COVERAGES CERTIFICATE NUMBER: 18s41 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. 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. INSR ADDLTYPE OF INSURANCE INSR MD SUER POLICY NUMBER MMIDDPOLICYIYYYY MMIDDIIY YY LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 OAMAG O X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,000 CLAIMS-MADE �OCCUR VIED EXP(Any one person) $ 5,000 O VUMA0000890 4QI2011 402012 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY X PEP LOC $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ 1,000,000 ANYAUTO BODILY INJURY(Per person) $ A ALL OWNED X SCHEDULED BBNT98 4212011 412/2012 BODILY INJURY(Per accident) $ AUTOS AUTOS X X AUTOS NON-OWNED PROPERTY Y DAMAGE $ HIRED AUTOS AUTOS Peramident X UMBRELLA LIAR XJ OCCUR EACH OCCURRENCE $ 5,000,000 E EXCESS LIAB CLAIMS-MADE BINDER 620/2011 61202012 AGGREGATE $ 5,000,000 DED I X RETENTION$0 $ WORKERS COMPENSATION X WC STATU- .OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER B ANY PROPRIETO 006430048 6I20I2011 6120I2012 RIPARTNEPoEXECUTIVE❑ E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED] N/A (Mandatory in I E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe antler 7 p00,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ - $1 a,aa9,6oa x or$s,00D,oga C Umbrella NYIIEXC711193IV 622012017 6/2012012 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) As required by Contract,Action,Inc.Keyspan Energy Deliveries and it's subsidiaries,National Grid USA and it's subsidiaries antl NSTAR are included as Additional Insureds with respect to general liability only. Weathedzation Projects, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Iwo ! Cgent# 31461 Met# 18b41 Cent Holder# 2IJ1112 ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD n_ }1 s,:�t#rnsttls Drimrimtol of P4011k B+�ixit I Butidio Ra ulaW-ui An<# 4s ai3 erri�. j Ltcanw CS 102978 Reautcred to:._00 BRIAN MACHADO,- - 47 MALBONE ROAD _ ASSONET, MA02702 Eapunva(o 5/26120/3 r ,teftti+=i;ner 7rt I M78 j i r I 4 i. '✓fre{na>rmncow�ea�d c�.�aausc�«eelld Office of Consumer Affairs&Business Regulation License or registration valid for individul use only 410ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: .. Office of Consumer Affairs and Business Regulation a` Registration 166075 Type: 10 Park Plaza-Suite 5170 Expiration 412 112 01 2 Supplement Card Boston,MA 02116 ADVANTAGE WEATMERIZATION INC. - - BRIAN MACHADO TWO ADAMS PLAQE - QUINCY, MA02169 ---.._ - Undersecretary Not valid without signature