51 WASHINGTON SQ NORTH - BUILDING INSPECTION (2) The- ---o-�n4e'altl�'otf"N-Iass"a-'�"husett's'
Department of Public Safety
'Massachusetts Stjte Builclirlg•,Code(780 CIOR)
, . I
Q UP Building Permit Application for any fluii-diin'g other.,tit, a an I ,0 0 He-or Two-Family Pivelling
(This Section For Official Use Oni
Building Permit Number: Date Applied: I
Building official:
SECTION 1: LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
51 IV M 4 , 59 N,AA%
No.and Street City/'roivn Zip Code Name of Building(if applicable)
SECTION Z.,PROPOSED WORK
Edition of i%,1A State Code used If New Construction check here Cl or cbeckall that apply in the hy'?rows below
Existing Building 13' 17 RT-,,,R-I Alli4atio-ii,;.
11 Demolition d (Please fall uut;tiulsubmit`Appcnit �'1)
Change Of Use , 0 1 Changeofoccupancy v�E]l Other 0 Specif�:, � �. . ,*,,', -41.:� 1 l Y, ...
Are building plans and/or construction documents being supplied as part of this permit application? Yes a No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No 0
Brief Description of Proposed Work: "Q I M`r
4 AACAE 0
SECTION :S:(?NIPLETETfIIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION, -ADDI ION,OR
CHANGE IN IjSt-OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CIAR-3.4) E3
EXisfing UgeGr6"p(5)? 4
Proposed Use Group(g):
SECTION 4:BUILDING HEIGHT AND AREA
IExisting Proposed
No of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.) as applicable)
SECTION 5:USE GROUP(Cluck
A: Assembly A-1 0 A-213 Nightclub 0 A-3 0 A4 C3 A-5 07B: Business 03;;JE: Educational 0
FF..: F-I 0 F2 0 1 H: Ifigh Flazard H-1 Cl H-2 13 H-3 [I H-4 0 H-5 Cl
Institutional I-ICI 1-20 1313 1-413IM: Mercantile O JR::: Residential R-111 R-213 R-311 1140
�S.' Storage S-1 0 S-20 U: utility 0 Special Use 13 and please describe below:
Special
SECTION 6:CONSTRUCTION TYPE(Check asapplicable)
IA 13 IB 0 IIA 0 3 VA C1 VB 0
SECTION
Flood Z, Disposal:
Cl".Lk if cut "Ill"Llp",0
or o�ltfy e"'Itell,Cl
I,V 0
SECTION 7.,SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Selvage Disposal: Trench Permit: Debris Removal:
Public 0 Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0
Private 0 indclitify Zone: required 0 or trench or specify:
or or on site system Cl
permit is enclosed 0
f
Railroad right-of-way: Hazards to Air Navigation: (F, rksion R"VwW
Not Applicable 0, �,Js Structu re wi Ill i n a irport 11 pproiyh a rea'17 7 Is their review,conipleted 7
or Consent to Build enclosed o Yes 0 or No 0 Yes 0"
SECTION 8:CONTENT OF CERTIFICATE OCCUPANCY
I'diti011 of C0110 Type of Construction: Occupant Load per Floor:
Lilho,of
coll, Use
the building contaillanSprinkler System?: Special`-;tipulatiolls:
Dues tile 111,11 , ..
Oct-& 17/c2r—S--4e /sue
r
SECFION 9: PROPERTY OLVNER AUTIIORIZAT1ON
Nante and Address Property Owner •/, -A .
21QN..¢J> wof >'L-IW 5 ' Sbtt f�u� W/ I[
Name(Print) No.and Street City/Town L'V
property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) a-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State , Zip
to act on the property owner's behalf,in all matters relative to work auHwtizeil.b this biiildinpermit a Iic:ifiq$:
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 nu.R.of enclosed.c ace and or not under Construction Control then check here 0 and skip Section 10.1
'lo.l Registered Professional Responsible for Construction Control
i
a c
u I c d�s; cro Rcbt
isvtraati-o�n Numb
Num (Rc.istrutt) icicphonc No.
er
Z
Street Address City/Town State -Lip Discipline Expiration Date
10.2 General Contractor ,_, •' '.
Company Name
Name of Person Responsible for Construction License Nu, and Type if able
3 c phi 9. Oil 4
Street Address City/Tow State Zip y,
I/H ��/ S
Telephone No. business Telephone No.(cell) a-mail address
SECTION 11: V,i RKVRL 'Ct N111F.MA I10N INSIJK: N:0;Al 'W AVI'f M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be cunhpleted 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 lication? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item 'i
and Materials) utal Construction Cost((rum Item 'S 6)=
1. Building S Building Permit Fee-Total Construction Cost s_(Insert here
2. Electrical $ appropriate municipal factor) =S
3. Plumbing S Contact nuuhici -ilia
Note: Minimum fee=S ( V� Y)
-1. Mechanical (HVAC) $
3. Mechanical Other - S Enclose check payable to
6.Total Cost 5 Z.� r S7O � � (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 of my knowledge and understanding.
A4 gal •eel +fit gl - ro 0"4 rC18- s3z egg 1�' I} 13
Please 4print and sign nonle Title f7 Telephone No. Date
Strrrt r\ddmss City/Town State Zip
Municipal Inspector to fill nut this section upon application approval:
Name Date
CITY OF SALE . XLxss kcHUSETTS
• BUIMIING DEPARTMENT
A 120 WASHINGTON STREET, P FLOOR
TF-L (978) 745-9595
FAX(978) 740-9846
lIN{gFRT EY F.Y DRISCOLL
D T Ho.%w ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COMMISSIONER
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:
, y
(name of hauler)
The debris will be disposed of in :
(name of facility)--
(address of facility) -
signature c, permit appl ant
date
a
CITY OF S:UX,1%f, '2 LNSSACHUSE-1TS
BLILDIING DEPbMIM'siT
3 }I_-Y.•'4i.,i) 5 120 WASHLYGTON STREET, 3i°F`LOO&
"ILL (978) 745-9595.
FA_X(978) 7404845
KIJIBERL.EY DRISCOLL ITiOR41S ST.PIERRH
vL'tYOR DIRECTOR OF PUBLIC PROPERLY/BCILDCNG CO.MUSSIO.iER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
lunlicant information Please Print Legibly
Name(Busiiiess,Organizatioru Individual): LTI'� (_.W57 - ev• ZNe
Address: 773 (_-!tt gat) QJk City/State/Zip: ®I��onell: q-2g - S3;L - d'l gq
5AUe you an employer?Check the appropriate box:_ 'rype of project(required):
i 1 am a employer with_ 4. ❑ I am a general contractor and 1 6.
employees(1LII.and/or part-time).• have hind the sub-contractors [:]Now construction
2.❑ 1 am a sole proprietor or partner- listed on the attached.sheeE 1 7•);�Remodeling
ship and have no employees These sub-contractors have a. [3 Demolition.
working.for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers'comp.insurance 5.0 We are a corporation,and its
rcquirctL) officers have exercised their Io.O Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL_ 11.0 Plumbing repairs or additions
myself.[No workers'comp, c. 152,g 1(4j and we have no 12.❑ Roof repairs
insurance required.)t employees.[No workers': 13.0 Other
comp,insurance rcquircd.).
;Any applicant that chuck&box et meet also fill out the soclion below showing their workers'compemsedon policy infurmolion.
I bvnoownars who submit this affidavit indicating they are doing all work and then hire oulridecimmactars most submit a new alridavil indicting such
40,mmssots that chick this box meet atmchadan adibilorml sheet showing the name ofthosub m1ractme and their workers'comp,policy infumation.
I um an employer that Is providing workers'compensation brsurance for my employees- Below is char policy and fob site
injonnation.
.Insurance Company?lame:
Policy 4 or Self-fits.Lic. 0: Expiration Date:
Job Site Address: S ( U-9A50. SQ Pdrifl& City/Stat&Zip: ✓A-%_jF A MA .
Attach a copy of the+workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required undar Section 25A of VIOL e. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a line
of up to$230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invcstigutimts ul'the D1A far insurmsc coverage veritieatiun.
/du/rerrby •e Ij mr puhr i penalties ojperjury that tha faformatiar provided ubuve is irate and correct.
Data•
Phoned
8
LEOilicr
only. Do not ivtire in this areas to be completed by city at town a/j/dal.
vn: Pcrmit/i.lcense
hority(circle one):
liealth 2. Building Department 3.Cityfrown Clerk 4. Electrical inspector 5. Plumbing Inspector
son: . Phonelt:
I
Aug 13 13 10:55a D& H Con�4ructiola Co.gj 978-532-7477 P.1
DATE(MM/DDRYYY)
ACORO'
CERTIFICATE OF LIABILITY INSURANCE
THIS CER7IFIC ATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CEIDEDRTI B CAT HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OA NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLlC1ES BELOW.
THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURE (S),AUTHORIZED REPRESENTATIVE
OR PRODUCER,AND THE CERTIFICATE HOLDER.
Ies muse be endorsed.If SUBROGATION IS WAIVED,older in the perms and lsenneans
IMPORTANT:If the certificate naider Is an ADDITIONAL INSURED,the policYC I
of the policy,certain polices may require an endorsement A statement on this cO1NTaA0 tlaes not tooter rights fo the certificate holder in lieu of such endorsemerrt(s).
PRODUCER NAME: FAX
PHONE (p/C.No): —
wC.W.Ertl' gZ71 23-4=4-4
ppylied R1Bk Tneur=OB SerYiCeBr IOC• E-MAIL
1DS25 Old Full Rd ADDRESS:
Omaha, NE 68154 PRODUCER
CUSTOMER ID A NAIC
{B77)234-4420 INSURFA(S)AFFORDING COVERAGE
-- INSURER A: Dn I t d .'tgS
INSURED INSURER B:
D&H C—Stlwt1On Co— ZaIC. INSURER C:
dba D&H ConatructiOn Co., Inc.
33 Central St INSURER D:
Peabody. IGL 01960-4339 INSURER E
CTL 1273 766372 INSURER F:
REVISION NUMBER:
COVERAGES CERTIFICATE NUMBER:
TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECTTO
THIS IS TO CERTIFY THAT THE PCLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,
wH4CH THIS CERTI F4CATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT A
LL
THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOW I—EFF MAY B BEEN REDUCED
XP BY PAID CLAIMS LIMITS
IN$R ADOL SUER
LTR TYPEOFINSURANCE INSR WVD POLICY NUMBER MkImO/ YVY MM�O/YYYY EACH OCCURRENCE $
GENERAL LIABILITY `� DAMAGE TG RENTED
S
f��J�CO._MMERC,ALGENER.ALLWBIUTV I � Fj PREMISES I'_a omu,m,cel
' CC
CLAIMS I MED EXP M one coon S
�J MADE CUR
— I I PERSONALB ADV INJURY IS
IGEGENERALAGGREGATE $
'LAGGREGATE LIVITAPPUES PER PRODUCTS COMP�OP AGG 5
_77 $
�I POLICY PROJECTI ILOO I IGOMBINEC SINGLE LIMIT IS
AUTOMOBILE LIABILITY 'I E °µ I
5 ANY AUTO I`II — II I 0ODILYIN URY( 1 IS
I BO ooaem
INJURY Pma
ALLOWNED AUTOS R
S
�JSGHEDULED.AbTGS POPEPE RTY DAMAGE $ —
Per aai]ernl
HIRED AUTOS
_�NON-OWNED AUTOS
3
EACH OCCURRENCE S
UMBRELLA LIAR OCCUR AGGR-GATE 5
EXCESS LIAR CLAIMSddALE u
CEDUCTIBLE I $
RETENTION - $. -- WC STATU- O_TF
TOR- T
WORKERS COMPENSATION V/N I E.L.EACH ACCIDENT $ SGOiDd4--
AND EMPLOYERS'LIAMUTY 1�
ANY PROPRIETORRARTNa Rr �T IN/AI ��66-829387-01-04 /06/201D t 1(06/2014
EXECJTIVEOFFICERMIENDEa J E.L.DISEASE-EnEMPLovEe $ 500 000
'EXCLUDED?
(Mandatary in NH) $
If yes,ticccrdle�n0er E.L.DISEASE FDucY urnrr
SPECIAL PROVISIONS telow
DESCRIPTION OF OPERATIOtLS/LOCATIONS/VEHILLES(ARach AcoM 1 Dl,Adtlitlonal Remarks SCNetlule,If more epece Is requUed)
CANCELLATION
CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
D&H COnSTTOGtYQl Co., rye, EXPIRATION DATE THEREOF,NOTICE WILLBE DELIVERED IN ACCORDANCE WRH
THE POLICY PROVISIONS.
33 Central St
Peabod17, FA 01960-4339 AUTHORIZED REPRESENTATIVE
1783118
AtCn7 Floject binarmr
ACORV 2S(20091091 The ACORD name and logo are registered marks Of ACORD
Bt BB40D9 AGORD COflPORATION. All rgnU resew