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52 WARD ST - BUILDING INSPECTION (3) 1� * 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 Only) Building Permit Number Date Applied:._. _ .Building Official's SECTION IrLOCATION(Please indicate Block#and Lot#for locations for which a street address is not available),; s No.and Street City/Town Zip Code Name of Building(if applicable) SECTION.2:PROPOSED WORK -p' - Edition of MA State Code used If New Construction check here❑ or check allthat apply in the two rows below J Existing Building❑ Repair qu Alteration ❑ 1 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 Brief Description of Proposed Work: / ,SECTION 3.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) ❑ �I 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 5: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❑ I H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1 ❑ 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 Cl and please describe below: Special Use: SECTION 6 CONSTRUCTION TYPE (Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ _ SECTION 7:SITE INFORMATION.(ref er 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❑ Private❑- or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazazds to Air Navigation: MA Historic Commission Review Process: Not Applicable El Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed;01 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: R ' .SECTION 9; PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner - tl Y- nVv- `L'a � 0.�d1.lAv tlQ JS 1CC1rl a e(Print) No.and S et City/Town Zip Property Owner Contact Information: - Afir c-lx -1s w Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes - t'10\A1f��t3r���..�j0.� .� l C3n�O.mS 1�bu `iaCl\YJ it v � P!� 0?�Nucj l4�e Street Address City/To State Zip to act on the property owner's behalf,in all matters relative to work authol permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Append2): If buildin rs less-than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1 10.1 Re 'stered.Professional Reslionsiblefor Construction Control 4 .i, Name(Regis t) Telephone No, . e-mail address Registration Number a Q)atc5 3lnu v'c� .rno OA\12g LAall V - Street Address City/jqjvn State Zip Discipline Expiration Date 10��..\2 General Contractor Company— Name c �r mn r\ "At c� Name of Person Responsible for Construction License No. and Type if Applicable V 1 �a\�� w �d• SSO� 3t fy-\A Street Address City/Town State Zip - �� yU_�AAi N2a Telephone No.(business) Telephone No. cell e-mail address - SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT .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' Me of the building permit Is a signed Affidavit submitted with this application? - Yesd�' No ❑ SECTION I2:.CONSTRUCTION COSTS AND PERMIT FEE. Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1.Building $ \\uuu Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ 9Dappropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ 40 Enclose check payable to 6.Total Cost $ \\1_v'kv (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 infI d n this application is-true and accurate to the best o my knowledge and (uundersta`nding., Plea rint and sign n e Title lDate - Street Address City/ wn State p n Municipal Inspector to fr1 il out this section upon application approval: , Name `Date i CITY OF &U.EN1, . LNSSACHUSE`TTS BLu.DNG DEPARTMENT \ 120 WASHhNGTON STREET,3" FLOOR TEL 978 745-9595 FAX(978) 740-9846 KINfBERLEY DRISCOLL MAYOR THONLiS STYIERRE DIRECTOR OF PUBLIC PROPERTY/BE ILDNG CO\L,IISSIONER Construction Debris Disposal Affidavit (required for 0 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) J sig ature of p it applicant < 1A date - Jcbrivitt:dx - 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 nn Site Name: OTAk 4 G (e ��e 4Vi 61 Street,City/Town, Zip: b S Yet S Contact Name&Phone atSite: -CGCO� ���i6t 1 — -3L(s Signature: 1__Printed Name: Name: Title: Organization: OOCA} t Date: BI' Acknowledeed by ABCD's representative: �'4Yr G 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 _ Two Adams Place ®ADVANTAGE Suite 100 ®®�"r�T'R` < ` ;" Quincy, MA 02169 Date: - -1/28/2011 = AGENCY: Action for Boston Community Development, Inc. ABCD 178 Tremont St. Boston, MA 02111 HOMEOWNER: TOTAL Salem Street Properties WORK ORDER 52 Ward St Salem $11,666 Date of walk-throughs 4/20/11 f� k - v Job'cOSt#�14037 . x x Ili .. DESCRIPTION QTY. UNIT UNIT PRICE TOTAL PRICE DOORS Weatherstrip w/Q-Ion or equal 14 ea $43.00 $602 Automatic Sweep 14 ea $22.00 $308 Build plywood panel door/ hinged with slide bolts 1 ea 1 $111.00 $111 MISC. MEASURES Basement air sealing 16 man/hr $75.00 $1,200 Building Permit 1 LS $220 $220 BASEMENT INSULATION Basement overhead insulation (Dense pack-9.5" - R32) 2,415 sq.ft. $3.75 1 $9,056 Strapping/ Sheet Rock, taped & coat-for holes in ceiling 32 32 $5.28 F $169 Page 1 of 1 The Commonwealth of Massachusetts Department oflndustrial Accidents Office ofluvestigations d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual): Address: T Y, �c\o �c cK City/State/Zip: Phone.#: 0. o3) Are you an employer?Check the appropriate box: !Type of project(required): 1.M I am a employer with �O 4• I am a general contractor and I employees(fall 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 ship and have no employees These sub-contractors have g• Q Demolition working for me in my capacity. employees and have workers'_._. 9: Building addition [No workers'comp.insurance comp, insurance.t required.] S. Q We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l LEJ Plumbing repairs or additions myself. . m ' right df exemption per MGL , (No workers comp. 12.❑Roofrepai s insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.El Other comp,insurance required:] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating(bey are doing all work and then hire outside contractors must submit a new affidavit indicating such. lCoubactors that check this box must attached an additional sheet showing the name of the sub-cohtraotors and state whether or not those entities have employers. If the subcontractors have employees,they must provide their workers'comp,policy number. I am an entployer'that Is providing workers'compensation insurance for my employees. Below Is the polley and fob site i4ormadon. ,r\ Insurance.Company Name: \ I��-�utx'�\ ��Y�so'� �\t'a.�'(lyticU-nla C'u C_�,. Policy#or Self-ins,Lic.#: 0Qk04 `�C�l� ,' Expiration Date: lo. ZO p�013. _ Job Site Address: A,\n —• City/State/Zip: 2)�k\kffl 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 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$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 pains and penalties otf erf that the information provided above.Is true and correct Signature: Date \\ Phone/i: 12 - 1 i Official use only. Do not write In tht a ea, to be completed by dry or town offlelaf City or Town: Permit/Licease# 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#: - I ACORD® DATE(MM/DD/YYYI') CERTIFICATE OF LIABILITY INSURANCE 1 06/20/2011 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.Church,Inc. NAME: 41 Wellman Street PHONE 9783227272 - FAX (9]8)454-1865 Lowell,MA 01851 AIC No Ext: AIC No E-MAIL dshawQfredcchumh.com (800)225-1865 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC If INSURER A: Citation Insurance Company 40274 INSURED INSURER B: National Union Fire Insurance Company of Pittsburgh,PA - 19445 Advantage Weather¢ation,Inc. INSURER C: Navigators Insurance Company 4230T Two Adams Place,Suite 100 Gemini Insurance Company 10833 Quincy,MA 02169 INSURER D: INSURER E: Stan Indemnity 8 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 ADDLSUBRTYPE OF INSURANCE INSR MID - POLICY NUMBER POLICY EFF MM/DOYIYYXYI' LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED 100,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea gccunence $ CLAIMS-MADE 1XI OCCUR MEO EXP(Any one person) $ 5,000 D VUMA0000890 4RI2011 412/2012 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY M PEO LOD $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1.000,000 Ea accident $ ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED X SCHEDULED BBNT98 4122011 4122012 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPER YDAMAGE $ AUTOSX UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5.000.000 E EXCESS LIAB CLAIMS-MADE BINDER 612012011 6I20G012 AGGREGATE $ 5,000,000 DED X I RETENTION$0 $ WORKERS COMPENSATION X WC STATU- CET TH- AND EMPLOYERS'LIABILITY TORV LIMITS ER a ANY PROPRIETORIPARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBER EXCLUDED? NIA 006430048 6/2012011 62012012 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under 1,000,000 i DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ $10,000,000 X of$5,000,000 C Umbrella NY11EXC711193IV 62012011 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.Keyapan Energy Deliveries and It's subsidiaries,National Grid USA and its subsidiaries and NSTAR are included as Additional Insureds with respect to general liability only. Weatherizabon 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 clienttt 374biM,# I db4l Cart Holder# ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD '13..*+*.ti btlittP-19ep i,unoal€+Y IP1 hlt, .?. z B��art}.f I t3uddin:;iu ul�1fl•rt� axi �1anF13ru.1 Cn.1s.r,aatt4n S.te�. stir :, cs''-s 1,tceAse: 1'.6 102978 " '. Re4[r�cted Scl,::.0➢ .P, '.BRIAN MACHADQ :^ 47 MALB.CNE ROAD; xASSONET;,MA02702 ' Ste'- - --="` Expiration 5126r2013 LerFgn3XH+Aff Tmz 102978 f I i I. ✓hC l.�P'bN3K'MUlC6�fR f.¢✓�'�iZCJ6C3116C�Yd - _ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only vl� tp'MOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registmtwn 166075 Type:,�:,i Ex lratiau 10 Park Plaza-Suite 5170 P. $t212012 Supplement Card Boston,MA 02116 " ADVANTAGE WEATHERIZATIQN.'INC. - - TWO ADAMS PLACE SU4TE100 �— — QUINCY, MA 02169 Undersecretary Not valid without signature