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41-43 WARD ST - BUILDING INSPECTION (2) V The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use 'Building Permit Number: Date Applied: - Building 0fficral., ^ SECTION 1-LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) ` LII- 0-\ ,nC SAA- eo �vcrr-rta 6o 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 El or check all that apply in the two rows below l Existing Building❑ Repair Q Alteration ❑ 1 Addition❑ I 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 d XY' Is an Independent Structural Engineering Peer Review required? Yes ❑ No ri_ _ Brief Description of Proposed Work: C =� s SECTION3: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 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): ` - SECTION 4:BUILDING HEIGHT AND AREA.. Existing Proposed No.of Floors/Stories-(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) ^ + - SECTION SF.USE GROUP(Check as applicable). A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ 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 1-1❑ I-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use ❑and please describe below: Special Use: ., `•' ` . ..: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ - IIIB ❑ 1 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site Cl 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 Commission 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 OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): - Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION.9: PROPERTY.OWNER AUTHORIZATION Name and Address of Property Owner - Nalne(Print) No.and ;reet City/Town Zip Property Owner Contact Information: .Qn Poop lb _2LQ_ �a Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes VacT�t iU�lak�loAya un [391am5�)2ck Q' .c )D�)L - �lI eme - Street Address City/To State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. ,: ,'SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix'2),. building is less than 35,000 co:fr of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1 10.1-Registered.Professional'Res p onsible for Construction Control 1 ` , \ adVcrviec� '�1s(3t��C,A y..�ra�'fY�nVQ�tyl Name(Regis ant) Telephone No. e-mail addreuY —� Registration Number R 'yyxm-�, Vau wl t\c.C. O SpC� cell Street Address City/To vn State Zip Discipline Expiration Date �16.2\General Contractor 1-fJdCRn�t�D.�\\�2Q�Y\DAv�CaV:�,r� Company N=60 Name of Person _Responsible for Construction License No. and Type if Applicable -\ Y1 � 1 10.��'JUM �b4. 1�' Y1�:�1`v�➢�"S 1��Yt `�C31� Street Address - City/Town State Zip - Telephone No. (business) Telephone No. cell e-mail address _7 SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT-M.G.L.c.152.§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/]'S��lance of the building permit. Is a signed Affidavit submitted with this application? YesZ iV 0 ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE 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 - $ Ca appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ kQ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ 9 Z.lo3 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information ntained in this application is-true and accurate to the best ot my knowledge and understanding. PleaI4,int and sign n e ` Title elepho a Date - - n ti\ 6 \ Street Address City/ wn - State 'p Municipal Inspector to fill out this section upon application approval: ` Name 7, Date i CITY OF &U&N1, NL-kSSACHUSET rS BL'u,DING DEP ARTNMNT \ 120 WASHNGTON STREET,3" FLOOR TEL. (978) 745-9595 Fnx(978) 740-9846 KISIBERL.EY DRISCOLL MAYOR THo&w ST.PmRRE DIRECTOR OF PuBuc PROPERTY/5uaDNG CONMSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name of facility) (address of facility) sig ature of p� it applicant date Jc6rivilLJx , 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 n Site Name: 0r4-k 6 0-fe Street,City/Town, Zip: b S S MA Contact Name&Phone at Site: — C z O-yq �, -a — O Signature: Printed Name: `m 1 Ck r I Title: - Pe htiII Organization: 006- 1 stlom cocG Date: ` - Acknowledged 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 park(a),bostonabcd.org P--I > Two Adams Place GOADVANTAGE Suite 100 ®®1NC " ` ` ' "'" Quincy, MA 02169 . m - "Date. V T x j/28%2011� .� AGENCY: Action for Boston Community Development, Inc. ABCD 178 Tremont St. Boston, MA 02111 HOMEOWNER: TOTAL Salem Street Properties WORK ORDER $9,263 41-43 Ward St Salem Date-of walk-throQ1i 4/20/1V a % w Job Cost # 14037 s -x=ij' �a _ - r 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 21 man/hr $75.00 $1,575 Building Permit 1 LS $177 $177 BASEMENT INSULATION Basement overhead insulation (Dense pack- 9.5"- R32) 1,750 sq.ft. $3.75 $6,563 Strapping/ Sheet Rock, taped & coat -for holes in ceiling 32 32 $5.28 $169 Page 1 of 1 ' The Cornrnonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigations x' d 600 Washington Street Boston,MA 02111 www.mass.gov/dia j Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): . kcoc\y �1�cc� fler�ZR.�\ \nL Address: City/State/Zip: ` (' 'k C \< Phone.#i U\1 03n \bqL� Are you an employer?Check the appropriate box: `Type of protect(required)':. 1.EA I am a employer with 16 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sob-contractors 6. El New construction 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑ Remodeling - ship and have no employees These sub-contractors bave g, ❑Demolition workingfor me in an capacity. .. employees and have workers'._._ Y P tY• 9: Bnilding addition [No workers'comp.insurance comp,insurance.# required.) S. ❑ We are"a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other comp,insurance required'.] *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-cohtractors and state whether or not those entities have employees. If the sub-contractors hale employees,they must provide their workers'comp,policy number. I ant an entployer'that lsproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Policy#or Self-ins.L(ic,#: Cbo1 \Cl_1.� ` ' Expiration Date: Ql>z. ZO�p�GI�� Job Site Address: `\\ - kA� \YND r\Il�� City/State/Zip: (Y 1 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure,to secure 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-year imprisonment,as well as civil penalties in the form 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pates and pen1aIt�' of erj that the information provided above is true and correct Si ature: t "\f`" Date <�5\ \\\ Phone#; -T a. )" )EAD Official use only. Do not write in thr a ea, to be completed by city or town official City or Town: Permit/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 Person: )'hone#: i A� CERTIFICATE OF LIABILITY INSURANCE 061Z 12o 1MM0131YYYY' - 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 endomement(s). PRODUCER CONTACT Diane Shaw NAME: Fred C.Church,Inc. PHONE 9783227272 FAX (978)454-1865 41 Wellman Street AIC No EH: AIC No Lowell,MA 01857 E-MAIL dshawQfredcchumh.com (800)225-1865 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL# INSURER A: Coal Insurance Company 40274 INSURED INSURER B: National Union Fire Insurance Company of Pittsburgh,PA IN45 Advantage Weather¢ation,Inc. INSURER C; Navigators Insurance Company 42307 Two Adams Place,Suke 100 Gemini Insurance Company 10833 Quincy,MA 02169 INSURER D INSURER E: Stan Indemnity S Liability Company 3831E INSURER F: COVERAGES CERTIFICATE NUMBER: 18sa1 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 TYPE OF INSURANCE ADDL SUER R POLICY NUMBER MOLICY EFF POLICYIYMIDDri YVY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X DA AGE TO RE T ° 1on,000 COMMERCIAL GENERAL LIABILITY PREMISES Its occurrence $ CLAIMS-MADE I X I OCCUR VIED EXP(Any one person) $ 5.000 D VUMA0000890 4122011 4/2/2012 PERSONAL B ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PET TOO S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident S IX ANY AUTO BODILY INJURY(Per person) S A AALL UTOS OWNED X SCHEDULED SSNT98 4/212011 4/212012 BODILY INJURY(Per accident) S AUTOS X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Paraccident $ X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 5,000,000 E EXCESS LIAR CLAIMS-MADE BINDER 620/2011 620/2012 AGGREGATE $ 5,000,000 DED X I RETENTION$0 $ WORKERS COMPENSATION % WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMIT ER ANY PROPRIETOR/PARTNEMEXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? N/A OOfi430048 6I20I2011 fi/20I2012 (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ 1,000,000 It yyes,describe under 1,000.000 DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ $10,000,000 X of$5,000,000 C Umbrella NY11EXC➢111931V 6/20/2011 6/20/2012 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 and NSTAR are included as Additional Insureds with respect to general liability only. Weatherization 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 P Client# Mel# 113541 Cert Holder# 268f2 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 3.. 11*.a,+ibn�itts Ur;i e+tnicut �cf Pcilrizt ,= + - <. ^ t -� Bou rtEid Rutldut8 au vlr xinrlttct�+tnaLt r3;�-' _ Lu:ense- CS 102978'. . BRIAN MA€HADO' 47 MALBONE ROAD' ASSONET,MA 02702 Expualbrr, 5/282013 i maioi4Bnrtr 1m� 102978 I . .. ✓24 e�"I&c�./�noJ¢c�zaoelCa - Office of Consumer Affairs&Business Regulation License or registration valid for individul use only �fOME IMPROVEMENT CONTRACTOR - before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation v�, � Registration 166075 Type: 10 Park Plaza-Suite 5170 �W61 Expiratiah 4t2U-2Q12 Supplement Card Boston,MA 02116 ADVANTAGE Wt;6HER2ATION;INC. - BRIAN MACHADO c TWO ADAMS PLACE BUt, 100 QUINCY, MA 02169 Undersecretary Not valid without signature