191-211 WASHINGTON ST - BUILDING INSPECTION (2) The C&II11onwealth of Massachusetts
1\. Department of Public Sf I
I�
;. ..\lassarlutsetls"I'll(.Build ing Cudar(7811C\Ili)
Building Permit Application for any Building other than a One- wtrFa ' y ling,.
(this Section For Of 'ci.d Use Only)
Building Permit.Number: _ ' Dale ApRited: " > Building Official:" _
SECTION 1: LOC AFION(Pleaseindicate Block Nand Lut*fur locations for which a S cet ad ess is nut ailable) '
No. ,unl Street City /fuwn Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK -
Edition of\L\State Code usvd" If New Construction check here❑or check all thet apply in the two rotes below --
Fxisling Building❑ Repai,,�g I :\Iteration ❑ 1 Addition❑ Demolition O (Please till out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:--- _ --__--
Are building plans and/or construction dta'unmnls being supplied as part of this permit application? Yes ❑ No W
Is an Independent Structural Engineering Peer Review rcyuired? Yes ❑ Nu ❑
Brief Description t Proposed Wor 1
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,AUDITION,ORI'
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclused(See 780 CAIR 1l) ❑
Existing Use Group(s): Proposed Use Gruup(s): -_
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total:\rca(ay, ft.)end Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-'_'❑ Nightclub ❑ A-\ ❑ A-I❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Factory F-I ❑ F2❑ H: Eli h Flaz.vd H-I ❑ H-2❑ 1 f-1 ❑ 11-4❑ 1.1-5❑
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14 ❑ AI: Mercantile❑ R: Residential R-113 R-2❑ R-\❑ R-f❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ PIA ❑ IIB ❑ MA ❑ IIIB ❑ I IV ❑ 1 VA ❑ VU ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: French Per mit•. Debris Removal:
:\ trench will nut be I.icenscd Uiaposal Site❑
Puhlii❑ Check if outside Ilnnd /_unc❑ Ind icalc numiiipal❑ .
rryuin•d ❑nr trench ar sprrifv: _-
Privale❑ or indontify lone. -- _-- or on site aystem❑
permit is enclosed❑
Railroad right-of-way: Ilatards to Air Navigation: -k 1 ... ,
Not Applicablq❑ Is Sim,ture tc ilhin airport approac It area? IS their roe new iamldeled'
or lou.enl to Budd enc lo..vl ❑ 1 cs❑ or.No❑ I 11.5❑ No Cl
SECTION 8:CON I ENT OF(TR I lF[CA'I'F OF OCCUPANCY
l.rl;rnup(s): - I\poollotwruttion: (ttt upanl lead per l-lonr:
Ito". Ihr builtint;conl.tin.nt sprinkler;%.tent': Spec ial SliPulalians. "
e <
SECTION 4: 11ROI'P:R'IY OWNER AU IORIZA'I ION
ut c,unl Address of Pnoporly Uwncr -.
Nome(Print) / No.and5net SHmI/a/Ph1,p dlr ,'13 Zip
CQnf' C 7 rf/4lIA1 Aft N/G /rf/7"
Properly Opvner Contact Information:
Title 's �„• rolephone No.(business) Telephone No. (cull) a-oral]address
If I ical Ie, the property owner hereby authorizes s A�r �-
_ as i y
Name Street Address City/Town State Zip
lu eel o I the pro url owner's behalf, in all matters relative to work authorize) by this building permit a ,plicatiun.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if building is less than 35,IIW cu.0,of enclosed s pace and or not under Construction Control then check here O mid ski Suulinn Ill.]
10.1 Registered Professional Responsible for Construction Control
Nano(Registrawt) rclephone No. c-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
kfffl% bLAH Cn�Sf«�fi�
Company Name �
-ennp5 � naaT) 5 9y6i unrrsfne�+-'�
Name of Person Responsible o Construction License No. and Type if Applicable
o)�i
Street Address City/Town q State Zip
M-2 31700 957 L/SA9 c/E/rt�a,rT Is er61 //rn1D .coca _
Tole phone No. business Telephone No. cell a-mail address
SECTION 11:of t l_[_y_t-��.\ t.���.,�rh pN I� I n•.tNn;f.v_I,JI,"w1 M.G.L.c.152. 25C 6
A Workers'Compensation Insurance Affidavit from the NfA 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 signed Affidavit submitted with this a lication? Yes❑ No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Rent and Materials) Total Construction Cost(front Item 6)=S_
1. Building 5 Building Permit Fee=Total Construction tit
(Insert here
'_. Electrical $ appropriate municipal factor)3. Plumbing 5
I. Mechwnical (HVAC) $ Note: Minimum fee=S__(counicipality)
3. ,Mechanical Other 5
Enclose check payable to _ _.—
Total Cost 's (contact municipality)and write chock number here
SECTION 13:SIGNAI'URE OF BUILDING PERMIT APPLICANT
By uttering my none below, I hereby attest wider the pains and penalties of perjury that all of the information contained in this
application is true aa}nd,Iccur.11V to the hest a env ledge and understanding.
Please print and <itpn name I itle - I,h phone No. Il,lie
�tf'd Address c1t.% r„tco SI'Ite /1f p
\tunic ipal Inspector to fill out this section upon application approval:
Name male
gL The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1 Please Print Leeibly
{� l J
Name (Business/OrganizationthWividual): Ir)2 I I er�I,]I I
Address: ' LJo..le<
CiWState/Zip: a Phone#: -7$/ - 'aye- "J 900
Are you an employer?Check the appropriate box: Type of project(required):
1.® I am a employer with�_ 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).' have 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 g. ❑Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp.insurance comp•insurance?
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL 12.❑Roof repairs .
insurance iced: t c. 152,§1(4),and we have no
1 employees.[No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 mast also fill out die section below showing their workers'compensation policy information.
t Honxowners who submit this affidavit indicating they are doing all work and Wen hire outside contractors mist submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the nape of the subtomttractorsand state whether or not those entities have
enlaloyees. If the sub-contractors have employees,they trust provide their workers'comp.policy nurnber.
I am an employer that is providing workers'compensation insurance for my employees. Below is the pohcyand job site
information.
Insurance Company Name: CCQ ,aSfKr2 (1CP t135nc,, t'Sa� —
Policy#or Self-ins.Lic.#: q?q G P rl j 1 Expiration Date:
Job Site Address:)C!:� (b ag n� n rt'Pf City/State/Zip: So /PirlI mA Qj9��'
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required tinder Section 25A of MGL c. 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 ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify and e pins and n o erjury that the information provided above is true and correct.
Si aturre: Date:
Phone# f �3 9CL
Official use only. Do not write in this area,to 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#:
Information and Instructions
Massachusetts General haws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are,required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemrit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of industrial Accidents
office of Investigations
600 Washington Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia
CITY OF S.11 Nfj Alss.ICHusETTS
OLMDLNG DEPAjtTNtLNr
120 W'kiNLYGTON STXW, JOIZOOA
rM (978) 745.9595
KMOERUY DROLL FAX(978) 740-9946
MAYOR
Tko.+w sT.ptaA"
DIRECTOR OP PI:BLIC P40P8RTY/8CQ.OLVG CONNISSIOVEIt
Construction Debris Dis
osal
p At'ttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111,1
Debris, and the provisions of MGL o 40, S 34;
Building permit# is issued with the condition that the debris resulting from
Ibis work shall be disposed of in a properly licemed
I 11. S I JOA. waste disposal facility as defined by,yGL c
The debris will be transported by:
04me of hauler)
The debris will be disposed of in
Un,
. (name of �Clllly) P
t�ddn,a�r•r,,a �y---
iyn�mreofpermi Jpplio.
4-6113-0
!ate
✓Re "fOtr9xaRaruaeR�L o�,/�la�uJBad -
mm Office of Consumer Affairs&Business Regulation License or registration valid for individul use Only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration,`a 0616 Office of Consumer Affairs and Business Regulation
Type: 10 Park Plaza-Suite 5170
Expiration: Su Boston,MA 02116
.t a Supplement Card
BETTER BUILT ENT
DENNIS i
DENNIS DROGGITISC.¢yam,r j
27 WATER STREET\� �,/
WAKEFIELD,MA 01860'�y_,''r
Undersecretary Not valid without signature
Massachusetts- Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 94612
Restricted to: 00 f
DENNIS J DROGGITIS
26 BRISTOL ROAD
PEABODY, MA 01960
t
��-- Expiration: 41262012
i
Conan kMmier Tr#: 2260
CERTIFICATE OF LIABILITY INSURANCE °""� 2'
THIS CERTIFICATE M ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CEFITIFICATE 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 ONSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certlf sate holder is an ADDITIONAL INSURED,the poLicy(ies)must he endorsed. M SUBROGATION WANED,subject to
the terms and conditions of the poft certain policies may reWhe an emlomemerd A dabmem onthds eerBReate does not carter rights to the
certllcate holder In lieu of such end
PRODUCER Carmen COO=
Cocoa Insurance Associates Ina 7811 2$5-0888 wa-4781) 24r-3926
dba Water Street Insurance Age ZArcatmen@aetinsurancehare.cout
27 Water Street S058
- Wakefield, MA 01880. --- INSURE AFFORDRUCOVERAGE .RAMP _
RZURED .—. INMMtA-.$,SSeX
Betterbuilt Enterprises IS.0 IMURaR8:TraVQler8
27 Water St - Ste 115 r C:
Wakefield, MA 01880 IMMERGED;
INSURER E-
iNSU F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAM®ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY RMUIREMENT,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 CONDTIONS OF SUGi POLICIES_.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS.
LTR POI( LINTS
GBIeRALLIA�fIY FACHODCUSiFNCE S_S_ DDD 060
A X coAaVERcwuraEPAutAsAJn T.3687741 1/11/12 1/11/13 ORWOETO $
5 000
CLAM-MADE ®0WAR MED9EP vo S -- 5,000
P12IMML8ADVINAARY IS 1,000,000
GENFRALAGGRBOATE Is 2 000 000
GMLAGGREGATE LIMIT APPLIES PER I PRODUCTS-mMPIDPAGG s 2,000,000
X POLICY LOC Is
AUTOMO®LELUUMM COMEINEDSINGYELIMIT S
(Fe ewmn)
ANYAUTO OODS.Y MARY(Pa Pars) I$ —_—
ALLOWAEDAVfOS 8ODLYINAHtY(Par8Zk%nQ S
SCHEDULEDAUTOB
PRDPERIY OANACE S
HIREDAUYOS P�aaitlenQ
NON-0WMI)ALROS S _
$
UISIMIALIAB OCCUR EACHOCCUIIRENM S
E 99SUAB CLAIMSMAOE AGGFEGATE s
DEDUCTIBLE
ReFEW10N S S
B WORKERS COMPEMATWN 4895P09511 12/4/11 12/4/ilI vvc BrnnA mH-
MID BAPWYERV LIABAJTY
ANY"OPREM@���m)lEQrnvE Y j NSA ( E.L.EACH AC IENr $ 500,000
OFFIMMNAamlabry In NN) J i FL.fRSEASIZ-EABMPLOY $ 500,000
reyyas dWawaevndar
DESGIRIPRON oPERATIoase�w EL.OSEASE-PoucYLNert s 500 000
IIESCWgMOFOPERA7WNSr LIDOAYOMMBBMAS{JVYtl11�1Di.Ai®mN ReaeAr BMedmla,eeKaeerue&rBgWeA)
CERTIFICATE HOLDER CANCELLATION
SHOULDANY OF THE ABOVE DES POLICES BE CANCELLED BEFORE
THE FXPIRATWN ®ATE TWAEOP, NOTICE WILL BE DELIVERED IN
ACCOROANCE Wr8)THE POLICY PRDV191ON3.
AUDXN1®rEAE!®iD17NE
Carom CQCxM
__.. . 0 19"09 ACORD CORPORATION. AD rights.reserved.
ACORD 26(2009109) The ACORD name and logo am regWored marksofACORID