250 WASHINGTON ST - BUILDING INSPECTION ���°yam
Tlie Commonwealth of 1�lassachu • S
a,
+ Y Department of Public Safety J
L� ! '•,•� .\hi.�erhu.rll5�t.dc lfuildinl;Cu,lr(TVII C.\I )
I ` Building Permit Application forany Building Other than a One or v roily Dwelling
(Phis;eklioo For Officiel L'se olliv)
Ifuildiug Permit Number -_ Date Applied: 80. - _ Ifuilding Official:
SECTION 1: LOC',\T[ON(Please indicate Iilock 4 and Lut s for locations for which a street address is not available)
Nu. ,rod titne't Cily/town Zip Code Name ut Ruildln)1(it applii.dge)
SECTION 2: PROPOSED WORK
I iditinn„Ir
\IA Sync C,.de u,rd _ ._ It:New Cunctrur tiun cheek here❑or nccrk,dl than.tpplt in the taro ruwv lyluw
ilding lirpair� :\Itentliun ❑ Addition ❑ Demolition ❑ (Please lill uut,u1,1 sol slit \ppendi.xl)
Use ❑ Changeo(Oiiuut ❑ Other ❑g pLms an ❑ \'t)ndent Structural 6lgincering Peer Review required? Yes ❑ Nu
ptiun ut Pntp+!scd Work:7:COMPLE'rE TIIIS SECE(ON If EXISTING BUILDING UNDERGOING RENOVATION, ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check hero it,in Existing Building Investigation and Evaluation is enclosed (See 780 C\IR.N) ❑
E\isling Use Gnntp(s): —____-- _ Proposed Use
SECTION J: BUILDING IIEIGIIT AND AREA
Existing Prn,posed
,N'u.ut Flours/Stories(include bascntent levels)h Ama Per Flour(sy. ft.)
Total :\rn,a(sq. 1't.).unl rutal Height(ft.)
SECTION 5: USE GROUP(Check as applicable)
.k Assembly:\-1 ❑ A-?❑ Nightdub ❑ A-3 ❑ A-a ❑ A-i❑ B: Business ❑ F: EJuca tional ❑
- -- F: Facto P-I ❑ 1:2❑ 11: fli h fiaz.vd II-I ❑ H-?❑ I I-i ❑ I I-a❑ I i-i❑
1: Institutional 1.1 ClI.2❑ I-t❑ 1-a❑ \I: Jlercantile❑' K: Residential li-to R-2❑ R-1❑ R-a ❑
S: Storage SI ❑ S-?❑ I U: Utility❑ Special Use❑and plv.lse describe below:
tiprrial Use
SECTION 6:CONS FRUClION IYPF:(Check as a+ lira ble)
IAA Ill ❑ IIA ❑ fill MA ❑ 111110 WC3 VA VII0
-__-- — sa ri )N 7: SI'rF INFORMA110N(refer to 791)C\IIt I I Lo fur details on each itcut)
Water Supply: Flood Lune Information: Sewage Disposal: 1'rench Permit. Debris Removal: —
I+ublir❑ CL•eck It,mbidv Ilnnd Gme❑ Ind irate unulicip,ll ❑ .\ trench +,ill nut be I.irensed Ilisp„sal�itr❑
I'm.oe❑ „r wdenlit7 /env „ram stir sr avm ❑ rrquin•d ❑or boor It urspec11%
R.Iiln,.tJ right-u t.,v.ly: I laiards to .I., .Vsig.ttion: , i; ; •A (
\..I \pi,hr.tid,' I la Inn tiro 1, thin.urpnrt,Ippmd,h.two" Is Ihe,r f, r,,„ n,IdrlrJ' I .-
I.rC,nn,wt„ Iluild,mlu.r,l❑ lc�❑ , r\'„l� 1 ❑ \ i7 - n
tillI ION 9. lO?.I L.VI (IFllItIII I( .\1I: OF ( ( L1•.\.\'( Y
I Jinrn ,.l 1,,dc L ,r l,rr ;p(') I,) ryl„n.lru,
r „up.wl I )d I„ r I L ,a
I l,v • the Duil,lin) „•n i,tw.m �l�rmklrr Ks.it W `•l,r,i,d ';lil•u l.lhnns
M
( r
- _� , 2sF( 1ION 1 I1401'If It IY OWNLRAU'I'IIORILA I ION __--
roc and \d tress nl l ol, rty Ocnmr r
No. .III,[Streit Ctly/ town
lip
N.unr (Print) .
I'rol+crty Owner Cunlect Iofunnat it'll: ( �\ u2-3�77b7
L "-V--------------
___-_._ _._____.__ __._._ relephune No. (business) rvlephone No. (Cell) c-mail address
b�14t C-
It eppliceble, the property owner hereby authorizes
----_-..---_---...—_-_— _---_..------'-_-- slate Zip Name Street Addreess City/rown - F
Iu,t,t on the property owner's behalf, in all matters reLuivv to work authorized by (his holding ,vrnlit e ,,lication.
SECTION 10:CONS'I RUCTION CONTROL(Please fill out Appendix 2)
If boildin g isIcas than bt,M)cu.ft,oI enclosed a+ace and or nut under Comoruction Control then check here❑and skip Section 111.1
to.I Registered Professional Responsible for Construction Control
telephone Naa-mailaddress _ Regislr.ltio
Nome(Registrant) P _
<urct AJd ress Cily/Town Slate Zip Discipline Expi Rion Date
10.2 General Contractor -
Company Name
k Q, GpLeC (_�1 Zf Cl?if ApptA-plp illicable�i01 C . 1n.(!1
Nanw of Person Re11sp__onsi//ble lfo�r Cunstnld;uo License No. �nul type
Street Address City Town State Zip
rclr ,bona Nu, business Tele ,hone No. Cell a-mail addmss
SECTION li:t\, rr). r.:, , tIMrtv .Nlo'\ t>r•tn:.\\yt ..\I u'.'.\'II M.G.L.c. 152. ZC6
A Wmkvm'CunlpenSation II SUMoCe Affidavit from the k1A Department of Industrial \cctden is must be cum pleted and
subnlittecl with this application. Failure It,provide this affidavit will result in the denial of the issuance of the building permit.
1.4a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 11 CONSTRUCTION COSTS AND PERMIT FEE
Estimated Curls: (Labory�•
Item and �\laterials) rota)Construction Cost(from Item h) -S--
I. Building S Building Permit Fcr-Total Construction Cost x —(Insert here
'. Electrical 5 appropriate municipel factor) -5
1. Plumbing y Note: \linimton fee"S-.___(Cunt,lct nnutiripality)
1. \WwIlicol (I IvAC) 5
i. \IccltanitoI (Other) 5 Enclose check +ayable to
I,. Laal Cast S �` (Contact municipality)and ,%rite Chuck nwnbrr here ..._ .. _..__
S LCTI(^ 11 SIG NA TU It OF BUILDING I,LIt,\IIT A1'1'L IcANT
Ity rn h•rin l; nw name below. I hercbv attest under the poinS end Pc111116CS of pvrjory that all A the inform.niun iaol.igird in this
.il+ld iC.itian is Iruc and anurate to the best of my know ledge aml undersLutding. �rr�Q v ('
lI'I •r.e pruu .uul atn name title Irlchhone\u ll,ttr
'•I reel W,I rc.a Clly, rnut 'Mate /tp
I
\Iunicipal Inspector to fill out this scdioo upon .Ippli,:ation approval: ._..._ _ .. -
N.une I�alr
CITY OF S.1L.EM2 INL\SS,1CHUSETTS
UUILOING DEP.%armE.NT
120 WASHLYGTON STREET )`a FLOOR
1'IFL (979) 745.9595
F.CC(979) 710-99.16
tI\10ERL.EY DRISCOLL
IILAYO:I 7�iOtL\3 ST.PtaaxB
DIRELTUR OF FLOCK PROPEaTY/0L•ILOr\O co%L%a5SIONER
Workers' Compensation Insurance AtTldavit: l3uilders/Contracture/Ele4:tricians/Plumbers
%oolleant Informatinis M931e Print Le!zlhiv
Na Inc ll III nilw,vtlrgJln13611MIndlvlllll.In: _vc^nlaV�1� GtOvct�,n Cjn(, p„��f
CilyrStatc/ZiP: 01`7 ( PhoneNr
Are you an employer!Check the appropriate boss 'type of project(required):
1.(] I am a employer with 4, �I am a general ounlractor and t 6. 0 Now eonsWction
unlpinyca(full and/or part-time).• have hand the subeanlractors
2.0 I am a sole proprietor or partner. listed on the mtached.rheet.: 7• ❑Remodeling
,hip and have no employees These subcontractors have 8. 0 Demolition
working tier me in any capacity. workers'camp,insurance, y, 0 Building addition
(No workers',comp, insurance 5. 0 We are a corporation and its
required.) officers have exercised th-it 10.0 Electrical repairs or additions
3.0 1 am a homcownur doing all work right of exemption per MOL 1 I.0 Plumbing repairs or additions ,
myself.[so worlicn'sump. c. 152,§1(4),and wehaveno I2.QRoorrvpaira
insurance required.) t employees.LING workers' 1 j, OtherlMfl G-�1QIr7
comp. insursncercyuired,J Y4 T�
V1 Ipplll u nW Omke Iwo rl mu11 atwr fill um Ihv wcliw beluw.howine_Ihvir"k0'ogmMnudun policy waunludoa
'I hvnauwnery who wlunil Ihie ulldavir indlen7ne they an Jainy ali.writ and lherl hire"ll'"contracw0 mlt/l mhmlt s new anlJavil Indiaine weh
$'„mncwn that chvik this ba mwt arlachud an aJdutunul.heel.huwine IIW nwnu a/the rokr'unlHctere and Chair wnrkvn'eum0.pulley In/ermaggq.
/urn en rurpluyrr spur/r provfJ/nX rvorkrq'cumpwrtaden lnaarunee/or my etnp/uyrr>< Below/a du policy andJub s!!e
in/arrnurlan,
Rnuranca Company .Name:
Policy 4 ur Sclr ius. Lic.n: Expirulian Dale: - - -
lab Sile Address: CilyiState/2ip:
.mach a copy of the workers' compensasloa policy declaraUan page(showing the polity number and�diplraflon data).
F.tiluru to wcuru cuvdmge as required under.Section 2J.\ot•�tOL c. 152 can lead to the imposition ofcrilfllnal penalties of a
fire up ro S 1,500.00 und/ur one-year impri.sonmcnq as well as civil Penalties in this term of a STOP WORK ORDER and a tine
of.;p to 5 oJ:0 a Jay )-willst lilt violamr. Ile advised Ihat a copy of this 11tvmunt may be iurwardcd to rite 011icu ur
I,ncdigeliuns,a the nIA Isar insunnec Coverage verilic.ltiun.
140 hereby certi/y rmder r/u puLl/t a, prnulrlr.r �/perjury that r/rr infunnu!/car pruviJrJ ubuvr it our nJ conrcc
surly. /l,r noI tvrirt in dni,�rnr. td.Sr cutup/�ItJ by riry rn rumen njJlcr�L
City nr fawn: .___. .. _.. i'crmiULiceme i
I. !:uurJ III' Ilcoilh !. Iluihlln OCII.11 bncel i. ( ,IyI'folvn.C lark
h i•:leetritll (n.pcchlr i, l'hnnbi n;� Lupeehlr
G. Ihhar
l'naLLl I'.nnn:
1'hooe h
ACORD,m CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIVY"
08/07/2012
PRODUCER (978) 922-4600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
ARCHER INSURANCE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
271 CABOT ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
BEVERLY MA 01915- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A NAUTILUS INS CO.
Arben Hoxhaj Ben the Mason INSURER B.TRAVELERS INS CO
11 Central St Apt 2 Left INSURER C:
INSURER D:
IBeverly MA 01915- INSURER E:
COVERAGES
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.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION
LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE(MWDD/YY) DATE(MMIDDlW) LIMITS
A GENERAL LIABILITY NN245529 06/14/2012 06/14/2013 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PRA M SES OEa occu'INTEeence $
50,000
CLAIMS MADE Fx] OCCUR / / / / MEO EXP(Any one person) $ 5,000
PERSONALBADVINJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 1,000,000
POLICY PRO-
JECT LOG / / / / NOWND
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS / / / / BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS / / / / BODILYINJURY
NON-OWNED AUTOS (Per accident) $
PROPERTY DAMAGE
(Per accident) $
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO / / / / OTHERTHAN EA ACC $
AUTO ONLY: AGO $
EXCESSIUMBRELLA LIABILITY / / / / EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
Is
DEDUCTIBLE / / / / $
RETENTION $ $
$ WORKERS COMPENSATION AND 7P.Ti1B-5829509-6-12 03/27/2012 03/27/2013 X TORVLIMITS OT
EMPLOYERS'LIABILITY
R.
ANY PROPRIETOR/PARTNER/ ECUTIVE EL EACH ACCIDENT S 100,000
OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE$ 500,000
If yes,describe under
SPECIAL PROVISIONS belay E.L.DISEASE-POLICY LIMIT $ 100,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSN HICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
RICHARD GOLDBERG FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
250 WASHINGTON ST INSURER,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPR VE
SALEM MA 01970- .,F�
CITY OF SM-E.Ni, Akss.,Cf-iL'SETTS
f3ClLOLVC DEi.1RTtE�i1
I .O W-UNLVGTON STXW, J`FtOOR
U1®t RLFiY �RLSCOLL Fkx(973) 74O.9844
MAYOR MQ-%W ST.PMUS
D1mcrO;air PLBL(cPROPQtl7Y/3t.'MDLN000wassro it
Construction Debris Disposal Affidavit
(required for aU demolition and renovation work)
In accordance with the sixth edition of the State Building Code. 730 CMR section 11 I.J
Debris, and the provisions of MGL a 40, 3 34;
Building Permit 4 is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licemed waste disposal facility as defined by MGL c
i 11, S I JOA.
Thee debris will be transported by:
(n.one ut'hauler)no debris will be disposed of in :
(name of r uihry)
ynuure u(permit rpphcanf
L/7Z°/'i
;SF1 "b 1 BOARD OF BU LDIN( •GJooaac/ ff[
-` 'LiCense: CONSTRUCTIONSUGULATIO�NS 3.
Number SUPERVISOR
I CSti 035269
< I Y B�rthdate 0194g
r 3/03/. i!
Expues 03/03/2006 Tr.no: 20029
Restricted 00` "� p
RICHARD B GOLDBERG " !t
7 RANTOUL ST
SEVERLY, Iv1A 079�5
IL
I Actlng C mie oner