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45-49 WARD ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts t\ �. Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One or Two-Family Dwelling �AV\ ,r €. "w°=, r.,• :.(This Section For Official Use Only) a= ' "N, Building Permit Number Date Applied: Building Official ++ 11I SECTION!:TOCATIOO`N(Please indicate Block#and Lot#for locations for which a street address is not available) YS-.Qc U�� . �t No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If If New Construction check here❑ or check all that apply in the two rows below qu Existing Building❑ Repair Alteration ❑ Addition❑ 1 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 J Is an Independent Structural Engineering Peer Review required? Yes ❑ No, 4a Brief Description of Proposed Work: =r u -'>SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR �3.:CHANGE IN USE OR-OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): 77roposed Use Group(s): - ,:,r.- 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 5:USE GROUP(Check as applicable);, A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 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-111 R-2❑ R-3❑ R-4❑ S: Storage SSl ❑ 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 ❑ IV ❑ 1 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 0 Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: .or on site system❑ required 4 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 ❑ .gg?a' SECTION S: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: i ;SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner "e(Print) No.and SbreA City/Town Zip Property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address -If applicable,the property owner hereby authorizes - 2n� c3glo !:' au `,,ao\`,_) inx WE_ 0�\\n9 e - Street Address City/ToLj State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. - "2' SECTION 10:CONSTRUCTION CONTROL(Please fill out:Appendix 2)' If buildingis less than 35,000 cu fr of enclosed space and/or not"under Construction Control then check here❑and skipSection 10.1 10.1 Registered Professional Responsiblep for Construction Control - ,+ y`�a�CbnyCLIodva= n \latoUl� Name(Regis t) Telephone No. e-mail address -Registration Number raLkim5 V'txu L;Ae_ \ nu, �) O�\1CA LA a111- Street Address City/Tom State Zip Discipline Expiration Date 1`0.2`General Contractor �\lcan�aoa\\�o9.aY1Pr�nCtG�v', Company Nam — C ,&,-, (YlaQ_ \o CS \ q�Fs Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip (10 -,m- p \1�00A\6nInFa0� Telephone No.(business) Telephone No. cell e-mail a0lress 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 is ante of the building permit. Is a signed Affidavit submitted with this application? YesZ' No ❑ 4;- - 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 - $ appropriate municipal factor)=$ 4 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 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 contained in this application is-true and accurate to the best o my knowledge and understanding. ` - -1 �'L Plea rinband sign n e Title ` elep one No. Date dL 6a\\owl Street Address _ City/ wn to .Zip Municipal Inspectoxto fill out this section upon application approval: 4 '`• to € `. "N Date CITY OF S.U.&M9 ANSSACHUSETTS BunDwGDEPART.N NT \ 120 WASHo4aroN STREET,3'FLOOR TEL. (979) 745-9595 FAX(978) 740-9846 IC11fBFut 1=Y URISCOLL MAYOR THohw ST.PIERRE DIRECTOR Of PUBLIC PROPER-rY/auiLDING CONMUSSIONER 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 e 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work sball 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 tore of p it applicant date JchrisafrT.dcx - r. 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 I Site Name: n Or4�, V C�e 1n `/0A4 LP Street,City/Town,Zip: b S e S MA Contact Name&Phone at Site: �G C O '�`r' - D Signature: 11\ 1� �� P`-A�!�_ Printed Name: Title: ii Organization: 000- 1 slyi bfe Mc- Date: Acknowledged by ABCD's representative: 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 parknhnstonabcd.ore Two Adams Place ®ADVANTAGE Suite 100 ®®INf,0R� 001"`A 1 U") Quincy, MA 02169 } .R.Date: '7/28/2011 _ AGENCY: Action for Boston Community Development, Inc. ABCD 178 Tremont St. Boston, MA 02111 HOMEOWNER: TOTAL Salem Street Properties WORK ORDER $6,731 45-49 Ward St Salem Date of walk-thoughs 4/20/11 _ Job Cost # .14037 DESCRIPTION QTY, UNIT UNIT PRICE TOTAL PRICE DOORS Weatherstrip w/Q-Ion or equal 12 ea 1 $43.00 1 $516 Automatic Sweep 12 ea 1 $22.00 1 $264 MISC. MEASURES Basement air sealing 14 man/hr I $75.00 $1,050 Building Permit 1 LS $131 $131 BASEMENT INSULATION Basement overhead insulation (Dense pack-9.5" - R32) 1,227 sq.ft. $3.75 $4,601 Strapping/ Sheet Rock, taped &coat-for holes in ceiling 32 32 $5.28 $169 Page 1 of 1 ' The Commonwealth of Massachusetts UlfDepartment of ludustrial Accidents Office oflavestigations 600 Washington Street Boston,MA 02111 w"mmass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individ V\' Address: I City/State/Zip: c. rnA. C \rA Phone.#: Are you an employer? Check the appropriate box: !Type of project(required):, 1. I am a Y em F to er with 10 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* nave hired the sub-contractors 2.❑ I am a'sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees - These sub-contractors have S, ❑Demolition workingfor me in an capacity, .. employees and have workers'._._ Y P ti'� 9:'-❑Building addition [No workers'comp,insurance comp,insurance.t required.] 5. ❑ We are-a 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 self. [No workers co - . m ' right df exemption per MGL Y 4 12.❑Roof repairs insurance required.] e. 152,t §1O,and we have no I, employees, [No workers' 13.❑ Other comp.insurance required:] i "Any applicant that checks box Hl must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lCuntracton that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp•policy number. I am an employer that is providinrg workers'compensation insurance for my employees. Below is the policy and job site information. /� Insurance Company Name: \ Y� N r c>\ Policy#or Self-ins. Lie,#: Expiration Date: l4. ZOpiC�}-3, Job Site Address: 1�'U� , �_1 • City/State/Zip: P M 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 G. 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 ORDBR 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 MA for insurance coverage verification. Ida hereby cer[lfy under the pains-and penalties of erj that the lnforntation provided above is true and correct. Si ature: . - Date• PAP.WPhone a2 Official use only. Do not write in thr a ea, tb be completed by city or town:official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A ® , DATE(NAWODM'YY) CERTIFICATE OF LIABILITY INSURANCE 06120/2011 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 Fred C.Chumh,Inc. NAME: 41 Wellman Street PHONE 9783227272 FAX (9T8)454-1865 Lowell,MA 01851 AIC E (AID,No (800)225-1865 q ORIESS: dshaw®fmdcchumh.com INSURER(S)AFFORDING COVERAGE NAICM INSURER A: Citation Insurance Company 40274 INSURED INSURER B: National Union Fire Insurance Company of Pittsburgh,PA 19445 Advantage Weathenzation,Inc. Navigators Insurance Company 42307 INSURER C: Two Adams Place,Suite 100 Gemini Insurance Company 10833 Quincy,MA 02169 INSURER 0: INSURER E: Stan Indemnity S Liability Company 38318 INSURER F: COVERAGES CERTIFICATE NUMBER: 18541 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 ADDITYPE OF INSURANCE INSR MIDSUBR POLICY NUMBER MMIDI�Y� MMIDDfYYYYY LIMITS TR GENERAL LIABILITY EACH OCCURRENCE $ 1,000.000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY -PREMISES Ea occurrence) $ 100,000 CLAIMS-MADE IX I OCCUR MED EXP(Any one person) $ 5,000 D VUMA0000890 4021311 402012 PERSONAL B AOV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY X PRO- LOD $ AUTOMOBILE LIABILITY COMBINED$INGLEUMIT 1.000,000 Ea accitlent $ ANY AUTO � BODILY INJURY(Per person) $ A ALL OWNED nSCHEDULED BBNT98 4I2)2011 402012 BODILY INJURY(Per accident) $ UTOS X HIRED AUTOS X AUTOS1 NON- ED Pe accFNUFEKdentDAMAGE $ X UMBRELLA LIAB IX] OCCUR EACH OCCURRENCEFJ $ S,000p00 E EXCESS LIAB CLAIMS-MADE BINDER 6I20I2011 fi1202012 AGGREGATE $ 5,000,000 OED X RETENTION$0 S WORKERS COMPENSATION X WC STATU- OTH- ANDEMPLOYERS'LIABILITY TORY LIMIT$ ER B ANY PROPRIETORIPARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? N/A 006430048 6I202011 6I20I2012 (Myandate,in NH) E.L.DISEASE-EA EMPLOYEE $ 1.000,000 DIf Ees describe under SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 $10,000,000 X of$5.000,000 C Umbrella NY11EXC7111931V 6/2012011 6I2012012 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 am included as Additional Insureds with respectto general(lability only. Weathenzation 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 REP/R{/EESSEENTTAATIVE Chant# 31461 Metp 1 bb4lCert Holder# ©19BB-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �- �1-r.K,iibu'.etit-Urp 1tY:41cni t�1 1Ti trhi ti ;� � � - Rfmid.of Boddimi R ulr swi:_ aad tit n3afu,.- C�Srrz.rLutIC25�p.r 4.r La._�ss Lmense[ CS 102976- Restricted to:-.00 $$.. 3 BRIAN MACHADO 97 MALSONE ROAD " ASSONET,IMA 02702 r- --�•- Erpiratiom 5/26/2013 - x5•n,mi.'.r•nrr .Tr=• 102978 is - j �e�msvrncou�ea��i c�'✓j�imor,�aeelYd ' OOffice of Consumer Affairs&Business Regulation License or registration valid for individul use only W I��"�910ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: rd Office of Consumer Affairs and Business Regulation ?' Registratlon b66'O75 Type: g Ex iration ]O Park Plaza-Suite 5170 P �ft2112O-12 Supplement Card Boston,MA 02116 ADVANTAGE WE:ATf•1EE21L1T10N{'INC. - - SRIAN MACHADO - TWO ADAMS PLACE SllITE100 a7—•6��__--- . QUINCY, MA 02169 _. Undersecretary _ Not valid without signature