120 WASHINGTON ST - BUILDING INSPECTION (8) - NO - $
The Commonwealth o 9811 usetts
Department of Public Safety P �• u
Massachusetts State Buildin C,,q�
Building Permit Application for any Building other a One-or Two-Family Dwelling
(� (This Section For Official Use Only)
Building Permit Number. Date Applied: Building Official:
SECTIONS:LOCATION(Please.indicate Block#and Lot#for locations for which a street:address is not available)
I I`Za M/wt1A�t'+94 en�A" S �Lu•�. rht� o19�'I3 e� 'n�.rjt C
No.and St�t+ce City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used ,'If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 13/
Is an Independent Structural Engineering Peer Review required? i Yes ❑ No �
• Brief Description of Proposed Work: ntw If;U5 on tra.��S awa Floor- of �•ld4'L. J aAyk/'aa,^7
Ck LA L Y f.AA S a• V i 2 "J A T i' 0 D C2 E?X 5*
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) O
Existing Use Group(s): 0 Z Proposed Use Group(s): 2.
SECTION 4:BUILDING HEIGHT AND AREA
Existing:. Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.fL)and Total Height(ft.)
'SECTIONS:USE GROUP(Checkas a' licable
A: Assembly A-1❑ A-2 Nightclub ❑ A3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ I H: High Hazard H-1❑ H-2❑ H3 ❑ H-4❑ H5❑
I: Institutional I-1❑ 1-2❑ 13❑ 1-4❑ M. Mercantile❑ R: Residential R-10 R-2❑ R3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION&CONSTRUCTION TYPE!:(Check as a licable)
IAO IB ❑ IIA ❑ IIB ❑ IIIA ❑ 111B0 IV ❑ VAO VB ❑
SECTION 7:SITE INFORMATION,(refer to 780 CMR 111.0 for details oneach 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: Hazards to Air Navigation MA Historic Cornmission Review Pr«ess:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
"SECTION&;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
RCCT Lac 1 LVa)oo sF -IjOD S.,e-ry;jle. Yo o219.3
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
wnef 6b-6zS-�31� - - �rwu.�CGILC , co
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
1011nAte Ps-, a,r, 443 Cr)dec- A!' E , t-��Lip.Lk MR o2032
Name 9 6),-7� 93 9 d q a ) Street Address CityCity/Tov6 State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
'n SECTION 10:CONSTRUCT[ON CONTROL(Please fill out Appendix 2) '
f building is less than 35 000 cu:It of enclosed spa6e and/or not under Construction Control then check here 13 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control>
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
l * cc, . ConlrCAr-T V1'a tic
Company Name
a 6-r.> trtc/atnrt ,t,
Name of Person Responsible for Construction License No. and Type if Applicable
RZ SC" e+rnrOat S,4-44 1 Ck•-► lmr,JaA Y" ozf -rl
Street Address City/Town State zip
-�- 3o2f jCa",DaNetGGT)PaCYrvs9 (w 6Md.�• rrn
Telephone No.(business) Telephone No.(cell) t7 a-mail ad
SECTION 11:WORIER5 COMPENSATION INSURANCE AFFIDAVIT -G.L.a 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 issuance of the building permit.
Is a si ed Affidavit submitted with this application? Yes D No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT PEE
Item - Estimated Costs:(Labor _.
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 15- O a o, Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $
Enclose check payable to
6.Total Cost $ j (contact municipality)and writs check number here
SECTION 13SIGNATURE 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,.
Q a.•^ Pis
Please print and sign name Title Telephone No. Date
5{2 S c+mtaAAm z19'
StreetStreet Add�i�ess City/To�' State Zip
Municipal Inspector to fill out thus section upon application approval:' "dt9vt d -"Wt 7
Name Date
CITY OF Sell.&&, 2ANSSACHUSETTS
BL'D.DLNIG DEPxR11tEr'T
' 120 WASHINGTON STREET,3eO FLOOR
T1 L (978)745-9595
PAX(978) 740-9846
KINIBERLF-Y DRISCOLL
MAYOR THOMAs ST.PtFRRE DIRECTOR OF PUBLIC PROPERTY/BUILDINIG COWNUSSIO,iER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print IL.eeibly
Name(ausicness organimtionandividual): rJ f G O pelt V a� I n n I n�. S i I C Lt d41 A(!
Address: aZ 5 C i a r^ A, 4- A!� 1
City/State/Zip: t—,AsMk7r'#%4 4 yh l* oz12 1 Phone#:
Are youan employer?Cheek the appropriate boa: Type of project(required):
I.CJ I am a employer with 1 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full anNor part-time).* have hired the sub�contracmrs
2.❑ I am a sole proprietor or partner-
listed on the attached sheet 2 7. [91(eemodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. []Building addition
(No workers'comp.insurance 5. ❑ We are a corporation and its )0.❑Electrical repairs or additions
required.] otTicem have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have an 12.❑Roof rcpairs
insurance required.)t employees.[No workers' 13.0Other
comp.insurance required.]
•Any applicant that checks box#1 must also rill rut the section below showing their vmd='",4"anion policy itduttrcatioo.
t I Inmeoemen,who submit this affidavit indicating they ate doing all wade and it=hire outside cam man; must aubmd a trew af1TdavV ittdieling such.
:Commeton that check this box mum attached an additional sheet showing the name of the sub.eomractpa and their workers'comp.policy information.
i tint an employer that is providing workers'compensatan Insurance for my ettplayeex Below is the policy andJob site
inforarration. _
Insurance Company Name: i'Q 8 V EL E n S
Policy#or Self-ins,Lie.#:4 HLO DG Z 92.403A1 S Expiration Dater
Job Site Address: 1 20 we-%h; t?eI S r City/StatetZip: Sot ton MYi D 1� ?6
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 S 1,500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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 theeppa)ins and penalties of perjury that the information provided above is true and correct
�in� /Signature•< Date'
Phone#: 49 1 JS' a 2 6
Ojfchd use only. Do not write in this area,to be completed by city or town ofciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. hoard of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Cnn%tructiun Supeniknr
License: CS-108681 7 r
`tit t .t t.En
JAMES MCKENNA
82 SCIARAPPA STREET APT4 c
Cambridge MA 6214tv;.
J„(.►„ �lj/.�G „ '� �"`.. Expiration
Commissioner 12/26/2018
1
'A Ro" CERTIFICATE OF LIABILITY INSURANCE DATE(MIIIDD/YYYI)
0324/2016
• 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 polley(les)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 endora rment s.
PRODUCER =r Steven Gear
METRO BOSTON INSURANCE AGENCY PNDNE 617)ssa saao f N,:
ESIAIL s sgear@metrobostominsurance.com
96 CENTRAL AVENUE INSURER AFFORDING COVERAGE NAIC0
CHELSEA MA 02150 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA HE 25666
INSURED INSURER B:
J &CO CONTRACTING LLC INSURERC:
INSURER D: -
82 SCIARAPPA ST APT 1 INSURER E .--
CAMBRIDGE MA 02141 1 INSURER F:
COVERAGES CERTIFICATE NUMBER: 39762 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.
NSA MIDIL LTA TYPEOFINSURANCE Man
POLICYNUMBER LILY EFF POLICY E%P UMnb
COMMERCIAL GENERA IULIUanY EACH OCCURRENCE E
CWMS-MADE OCCUR PR AMAGE TO O E
MEDEXP An oro E
N/A PERSONALSADVIWURY E
GEML AGGREGATE UMIT APPUES PER: GENERALAGGREGATE $
POLICY JE6 LOG PRODUCTS-COMPIOP AGG E
OTHER: E
AUTOMOBILEUAINITY COMBINED SINGLE UMIT S
Ea ac ea _
ANY AUTO eOOILYIWURY(Perperaan) $
ALL OYMED SCHEDULED N/A BODILY IWURY(Per dN ) S
AUTOS AUTOS
HIRED AUTOS NOIT OO wNED P OPERrYDAMAGE E
E
UMBRELLA MR OCCUR EACH OCCURRENCE $
EXCESS LIAO CLAIMS-MADE WA AGGREGATE E
DED RETENTION $
WORKERSCOMPENSATON X PER STATUME ETH-
AND EMPLOYERS IUABILDY
ANYPROPRIETORIPARTNER/EXECUTIVE Y/N E.L EACH ACCIDENT E 1,000,000
A OFIRCERMEMSEREXCLUDED? WA WA WA 6HUBOG28203A15 09/04201$ 09/042016
(Mandatoryin Nl) EL DISEASE-EA EMPLOYEE S 1,000,000
R yea deatr Under
DESCRIPTION OF OPERATIONS W. E.L DISEASE-POUCY UMIT $ 1,000,000
WA
DEWRIPTIONOFOPERATIONS/LOCATIONS/VEMCLES(ACOROtel,Adddb,ml RawduS ul%nmy EaattarJrd Nmomapaceiareq h )
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certifcate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this twverage Can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at w .mass.gov/Iwd/workem- mpensationlinvestigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Somerville building department ACCORDANCE WITH THE POLICY PROVISIONS.
1 Franey Rd AI IOMMED REPRESENTA7wE
Somerville MA 02145
Daniel M.Cro v ey,CPCU,Vice President—Residual Market—WCRIBMA
®1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
;aco CERTIFICATE OF LIABILITY INSURANCEF 3°iD 416
•THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CEFrrIRCATE 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: O the certificate holder is an ADDITIONAL INSURED,the pollcy#es) oust 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 certifi®te does not confer rights to the
certlOcate holder In Ileu of such endorsemen
MODUCaT OP Chris
Metro Boston Insurance Agency, PHDNE _ r'AX _ (617) 884-6487
96 Central Ave A'Dfi cmatarazzo729@ il.Com
Chelsea, MA 02150 INSURE AFFORDING COVERAGE NAIL#
INSURERA:Atlantic Casualty Insurance Cc
INSURED INSURER B:
James Stephen Mckenna INSURERC:
dba JBCo Contracting LLC INSURER D:
82 sciarappa at #1 INSUREII
Cambridge, MA 02142 IIrSURO E
R F::
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAM®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 TI-E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS.
ILTH TYPE OF INSURANCE ADD POUCYNUMBER IN1
P Y Dd�YI WATS
A GENERAL UASKITY L118001688 9/3/15 9/3/16 EACH OCCURRENCE $ 500,000
X COMMERCIALGENEPALLIABIUTY DAMAGE TO RENTED $ 50,000
CIAIWWADE ®OCCUR MEDEXP(A,Vore aem) $ 5 000
PERSONnLa ADVIN RY $ 500,000
GENERAL AGGREGATE $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS-OOMPH AGG $ S00,000
POLICY PRO LCC $
FIREDAMOS
091LEUADIJFrT
U Y COMBINED N Iaac d 1BODILY IWURY(Pw person) $
VAUTO LOWNEDSCHEDULED BODILY INJURY(Per a de„n $
TOSAUT0.5
NON-OWNED PROPERTY DMIAGE $AUTOS eraaitled
E
LMBIEUALUIB OCCUR EACHOCCUWENCE $
UCESSUAS CLAIMS-MADE AGGREGATE $
DM RETENTION
WORKERS COMPENSATION WC STATU- OTH-
MDEMPLOYERS'LMDIUTY Y/N
AdJY PROPRIETIXiIPARTNERE%E(x1TNE N/A EL.EACHAC GEM
OFHGERMMEMBER EXG-WED?
alantlab,y In NH) EL_DISEAS -EAEMPLOYE
tt yee tlesaibe antler
DESCRIPTION CF OPERATIONS WIow E.L.DISEASE-POLICY LIMB
DESORP MOFOPERATKMILOCATIONS/VENCLES (Mmd,ACORD1eI,AMMmW M.ift Sol ,ff o speae M,egdM)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCHES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Somerville Building department ACCORDANCE WITH THE POLICY PROVISIONS.
1 Franey Rd
Somerville, MA 02145 AUTHOIIMtED REPRESENTATIVE
Christo her Me arazzo
®1988.2010 ACORD CORPORATION. All rights reserved.
ACOR0 25(2010A5) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E-Mail: