0018 WASHINGTON SQUARE WEST - BPA-12-782 6glA
3 The Commonwealth of Massachu tts
Department of Public Safety o
,NL155ai 1Itis,-(is State llu ilding Qulc(7s
Building Permit Application for any Building other than n r erFamily Dwelling
(I'his Section For Official Use Only)
Building Permit Number: _ _ Date Applied: Building Ofl vial:
SECTION 1: LOG. 1 (Please indicate Block If and Lot N for locations for which a street address L not available)
�8_W_►_rh.' �-NO and S11111 — City /Town Zip Code Name of Midding(if applicably)
SICI'ION 2:PROPOSED WORK
lidition of NIA State Code used "_" If New Construction check here❑or check all that apply in the two rows below
Esistinf; Building❑ Repair,k Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:---- _
Are building plans and/or construction ill x'W110m18 being supplied as part of this permit application? Yes ❑ No kF-----
Is an Independent Structural Engineering Peer Rev' pw reyuired7 I Yes ❑ No kf
Brief cvcription of Proposed Work: �lt?P� dvl. 9i Wlrsr 19J(. & tt0AW 'tl d ley•1rr r CI_p'U py-4--
--�' --fit � ---
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here it an Existing Building Investigation and Evaluation is enclosed(See 780 CMR.11) ❑
Existing Use Group(s): _ Proposed Use Gruup(s):
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Slories(include basement levels)&Area Per Floor(sq. ft.)
Told Area(sy, ft.)and Total Height(ft.)
SECTION 5: USE GROUP(Check as a licable)
,\: Assembly A-1 ❑ A-2❑ Nightclub ❑ A•3 ❑ A4❑ A-i❑ B: Business ❑ E: Educational ❑
17: Facto F-1 ❑ F2❑ H: Ili h Flantrd H-1 ❑ H-2❑ H-t ❑ 11-a❑ 11-i❑
I: Institutional I-I ❑ I-2❑ 1 .10 I-a❑ \I: Mercantile❑ R: Residential R-I❑ R•'_'❑ 12-3❑ 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 ❑ 1 ILIA ❑ IIIB ❑ IV ❑ VA ❑ N'II ❑
SECTION 7:SITE INFORMATION(refer to 7sB C MR 111.8 far details on each item)
--Water Supply: Flood Zone Information: Sewage Disposal: 'I-rench I'ennit: Uebris Removal:
Public❑ Check if outside Flood Zone❑ Indicate mum,ipal Cl A trrndt will not be Licensed Disposal Site❑
v,itv❑ r in odcntik Zonv: _._ or on site sy stem El ❑or trench or aprril}
Pri `.__.._
permit is enclosed ❑
Railroad right-of-way: Ilaiards to Air Nae igatiun: ti i,,.i, ,,.,. .
Not :\pplicul+IU❑ Is Structure evithin airport appmaclr Arco.' Is their rvv ivty rany+lUlUd.'
or C om"rnt to Build Unclosed ❑ )vs❑ or.No❑ ),,.❑ No ❑
SE( IION 8:CON I EN OF CF:RI'MICA IT OP OCCUPANCY
I:Jitwo nl 1,"do, .. . ._ L'w Group(.)' .. _ I\pc of Conetnn two _ l)cc upant I„od per Floor:
I)oos the build ing con L1111,m<1um],1Ur S\mcin l: ';pac1,11 Slil+ulalions:
SRA ION 9: PROPIi R'IN OWNFR AUI'IIORIZA1 ION
:Nente and Address of Pnrporly Owner - —_-
Name(Print) —�- — ._— No. and Street City/Town ziF'___
Property Owner Contact Information:
I itle telephone No. (business) Telephone No. (cell) c-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 authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if building is less than 35:0W cu.ft.of enclosed s pace and ur not under Construction Control then check here O and skip Section 10.1
111.1 Ite istered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town Stale Zip Discipline Expiration Date
10.2 General Contractor
SAC-
Company Name
m;" �s ere,/ 4 h'
Name of Person Responsible for Construction License No. and Type if Applicable
31 PkfroMp 6Pr Irryamareo A..
Street Address - Ci /Town State Zip
Tole ,hone No. business Telephone No. cell a-mall address
SECTION 11:1%', wKik:, t-t 0,111 IVAINA.M r.u.1aalyn M.G.L.c. 152.1 25C6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this appl icatiun. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor `,�
and Materials) Total Construction Cost(from Item b)-S d��}
I. Building S Building Permit Fee-Total Constniction Costs_(Insert here
2. Electrical S appropriate municipal factor)-5 _
3. Plumbing 5
J. Mcchanical (FIVAC) $ Note: Minimum fee'5--(contact municipality)
5. Mechanical Other 5 F.nclnse check payable hp
u,.Total Cast 5 (contact runic ip,nlity)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 inhvmalion contained in this
application is Iruc and accurate to the best of tn) kuow ledge and understanding.
�ShtYi"P�
I I ne print old sigu�,u e I' [life frlophone No. Date
alb . - Iw11 -1-Cr. - ara er_. — N/h.. Ddza 1
titrevt Address Cih'i Town Stale Z=p
Municipal Inspector to fill out this section upon application approval: b " ._ V-_42t
L_ - --- - —\ante -- - Il,dc---
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UASSACHUSETTSy *
rr- DRIVERiS,LICENSE- _ " - � i
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MGSHEFFREY
MICHAEL B ' 'l,"'
21SHEALEY TER
BROCKTON
02301 1742 1 t C,,7•; i�rt,+r}'gS4q �� G+�l.;r
Massachusetts- Department of Public Safet)
f
y Board ni'Buildim, Rc}:ulations and Standards
.f
C anstructlon Supervisor License
License: CS 68159
:try«
Restricted to: 00
MICHAEL B MCSHEFFREY y
218 HEALEY TtR ..
BROCKTON, MA 02301 1,
Ecpiration: 1/=0111
1'u...... 6mrr T:.+: 14361
A
CITY OF S.t[ &Nr, NL1SS.ICF-iL:SETCS
f31.'t DOD DEPM MONr
I _'0 WASHNGTON STXW, 1iO FtOCIt
RVt(978) 740-984
KIMSE CLAY ORMOILL
.titAYO X i komks ST.Putts
O fIECTOlt Cr Pt SLlC PROPER7'Y/3j;QALNG CO\LpltSSION ER
Con9tructloo Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,,730 CMR section I 11.5
Debris, and the provisions of MGL o 40, S 54;
Building Permit At is issued with the condition that the debris resulting from
1 11 work shall be
i 1, S I JOA. disposed of in a properly licemed waste disposal facility as defined by NIGL c
The debris will be transported by:
42,10 Cony A" Q/n f/c
(n+ma ol'haular)
The debris will be disposed of in
(name or r4m141Y)
(1'lartls orri.iLly)
0
❑gn�mreofpermrtrpp6crnf —
r .
ACC)M ® CERTIFICATE OF LIABILITY INSURANCE ��9123e/1)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CFRrIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CEKnFICATE 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() must be endorsed. 1f SU&20GATION 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 endorsemen
CONTACT
PRODUCER NAME:
Tobman, Molignano 6 Weiner Ins PHONE 617 471-1123 RAJC N : (617) 773-2474
21 McGrath Highway, Suite 303 ADDRESS:
Quincy, MA 02169 PRO°UDR 4455
ER
INSURE SAFFORDING COVERAGE NAICA
INSURED INSURERA:Asr en Specialty Insurance Co I
Pivotal Builders, Inc INSURERB:SafetV Insurance Co
Dino Stati INSURERC:Scottsdale Insurance Company
31 Parsons Dr INSURER D:Associated Employers Insurance
Swampscott, MA 01907 INsuRER E:
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 15 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
CERTFICATE 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.
L POLICY EFF POLICY EXP
iYPEOFINSURANCE AmLSUER PODCYNUIIEER &CMY eMADYYYY LIMTS
GENERAL LUe&LITY EACH OCCURRENCE S 1 00O 000
pAMAGE TO RENTED
A X CONMERCIALGENERALDABRJTY BCS0025660 8/20/11 8/20/12 $ 50,000
CtAPASMADE OCCUR MEO EXP(AMare pears) S 5,000
PHRSON\LIIADVINJURY $ 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'LAGGREGATE LNNTAPPLESPER PRODUCTS-CONPMOP AGG $ 1,000,000
$
POLICY X PR0. LOG
COM18eRE0 SINGLELMR
AUTOSIORILE LIM311nY $ 1,000,000
(Ea RIMED
ANYAUIO BODILYINJURY(Per Pagan) $
B ALLOWNEDAUTOS 5003423 8/20/il 8/20/12
BODILY INJURY(Per acideM) $
SCHEDULEDAUTOS PROPERTY DAMAGE S
IPeravbeM)
X HIRED AUTOS
S
X NOWOWNED AUTOS S
X UA®RELIA DAB X OCCUR EACH OCCURRENCE $ 5,000,000
C MMSLUU" CLAIMSAIADE XBS0016791 8/20/11 8/20/12 AGGREGATE 5,
000,000
s
DEDUCTIa1E
$
RETENTION S X WC STATU- OTH-
MARKERS COMPENSATION
AND FNIPLOYERF LIABILITY YIN 8/20/11 8/20/12 ELEACHACCTDENT S 500,000
D ANY PROPRIE3[) I ARTNERIEXECIJTNE —I NIA WCC5009429012011
OFFIlF RMENIDER EXCLUDED'! J EL DISEASE-EA EMPLOYEE $ 500 000
Blab pea ro in NH
Nyas,Eesenbeuntler EL.DISEASE-POLICY LIMN $ 500,000
DESCRIPTION OF OPERATIONS belew
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHIP c5 IAUach ACORN Tdl,Adeealal Remlrks$LNeB1Ae,Bmwe space c rcAJretl)
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.
AUTHORRED REPRESENTATIVE
GARY D HEBSCH
IJ 1988.2009 ACORD CORPORATION. All rights reserved.
ACORD 26(2009109) The ACORD dame and logo are registered marks of ACORD _
i-t
CrrY OF SiuEm, NWSACHUSETTS
13L'IMING DEPART>tENT
120 WASHLNGTON STREET 3aa FLOOR
TEL (978) 115-9595
FALV(978) 110-9846
U:•t3ERIEY DRISCOLL
INLAY0a Tutonts ST.PiERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSOIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlclans/Plumbers
klipileant Infnrmatlnn Please Print Legible
N;iinC lnuritx,.vUrgomntionlndividuall:
Address:
City,Statc/Zip: Phune Nr
,%re you an employtr!Check the appropriate box: IR
project(required):
I.[] I am a employer with 4. I oral a general contractor and INow construction
enlpinyea(ILII and/or part-time).• have hind the sub-contractors
2.0 lain a sole proprietor or partner- listed on the attached ahccL tmodeling
ship and have no employees These sub•.contrsetors have molitionworking f;ar me in any copaciry, workers'comp.insurance. iWing addition(No workcro:comp, insurance S. 0 We are a corporation and itsrequired.) officers have exercised thelr ctrical repgits or additions3.❑ I am a homeowner doing all work right of exemption per MGL mbing repairs or additionsmyself.(No workers'Bump. c. 152, §1(A),and we have no of ntpairsinsurance required.) f vmpluyees.[No workers'
sump.insurance required.jer
-.vny epPfk,wV1 dW cinch,We At moat alvu nil uu1 rhs raetiva butow aAowint thBir"fign'campnudun putiay tril,"mton.
'If, nQuwnas whu.uhntlt this rmdavil indicaing they an doing all work and then his uutride can mitt"mtul adtmll a new affidavit indlaine wch,
$'mm�rwn that chalk this bus mwt nfult"d ae adddturvd.hvd.huwing the nwne of the mb+-orimtute and chair workers'Bump.pulley intemunas.
1 urn an rurpluyer that/s pruvlJiax workers'cumprnsaden besuruneefar my employers Bdaw/s rde polky and job ylse
infnrarradom
Innumnce Company .Name: _._ --'--
Policy 4 ur Self•ins. Lic. H: Eapiratian Date:.
lob Site Address: City/Stuter2'ip:
Attach a copy of the workers' campansatlao pulley deelarotlon page(showing the policy number and axpiratioe data).
Klilura to wvuru coverage as required under Section 25A ot'NiGL c. 152 can lead to the imposition of criminal penalties of a
rire up to 11,500.00 und/ur one-year iinprisnnmenL as well as civil penalties in the farts of STOP WORK ORDER and a line
of up to S230.(10 a Jay Jgainst the violator. He advised that a copy of this,talcment may bu furwurdcd to ilia Oftico of
lave,tigarinmol'lhe DIA fur insuronce coverage vcriiicatiun. -
, , t
/Flu hrrrby rrrnfy rmJrr du p v u1,J penulNe.r,uf per/ury that the Lr�unnuNml pruviJrJ about it sue,urJ cutrrK
1-2
96i7
011h iul ate-mly. Oar unf vritr in this area, ra he rmuplerdJ by airy ur ru wn AA/�Iriu[
I'crmiuLlevoye i
I„uinq \uthorily (circle una): --._. _....__ - ...
I. Nuord of Health L Iluilding Departwenl I. ('ilylfawn Clerk 1. F:reetric.tl fn,pcct,tr i. pill in;; Inlpxhu
0. 0111"
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