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260 WASHINGTON ST - BUILDING INSPECTION (2) '" ' �z g �`�' � 3�s� � The Commonwealth.,o�d�¢D'a�dAt1��N4f�s � Department af Public SafeEy Massachnsetts State Bvi1��7�D� � 2"� Building Pemtit ApplicaHon for any Building a a ne-or wo-FamIIy Dwelling �-- � (This Section For Official Use Only) - � �� Building Permit Number: Date Apptied: Building OfficiaC � � - v I , . �SECTION 1:LOCATION(Please indicate.Block A and Lot#.for locations for which a street addresa ia not available) - 260 Washington St., Unit #31, Salem � No.and Street Gty/Town Zip Code Name of Building(if applicable) , � �� I , SECTION 2:PROPOSED WORK ��. �� . � � � � Edition of MA State Code used�_h If New Construction check here O or check all that apply in the rivo rows below 1 Existing Building� Repair❑ Alterarion � Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) � Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: _ Are building plans and/or wnstrucNon documents being supplied as part of this permit applicarion? Yes ❑ No I] Is an Independent Shvctural Engineering Peer Review reqUired7 Yes ❑ No� Brief Description of I'ropased Work: e room rom exis ing neig oring uni , e oca e a room, ns a new cabinets, remodel unit_ SECTION 3:COMPLE'TE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Exisring Building Investigarion and Evaluarion is enclosed(See 7S0 CMR 34) 0 � Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA � Fxisting I'roposed �� ^` No.of Floors/Stories(include basement levels)&Area Per F1oor(sq.h.) 4 4, ��"'�'"' Total Area(sq.4t.)and Total Height(ft.) � SECTTON 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazazd H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Ins4tutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3 ❑ R-4❑ S: Stmage S-1 ❑ S-2❑ U: Ufility❑ Special Use 0 and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable)� � I.A � IB ❑ IIAO IIB ❑ IIIA ❑ IIIBI� N ❑ VA ❑ VB ❑ SECT'ION 7:SITE INFORMAT'ION(refer to 780 CMR 111.0 for details on each item) � Water Supply: Flood Zane InformaHon: Sewage Disposal: Trench Permit: Debris Removal: Public� Check if outside Flood Zone� [ndicate municipa!■ A trench wID not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on sire system❑ required O or trench or specify: permit is enclosed❑ Railroad right-of-way: Aazards to Air Navigation: MA Historic Commission Review Process: Not Applicable� Is Structure within airport approach azea? Is their review completed? or Consent to Build enclosed❑ Yes� or No� Yes❑ No � � SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Conslruction: Occupant Load per Floor: Does the building contain an Sprinkler 5ystem?: Special Stipulatioms: (v� A��,� Z'�� SECTION 9t PROPERTY OWNER AUTHORIZATION Name and Address of Properiy Owner RCG 17 Ivaloo St Somerville 02143 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Jim Gagnon �Z_625$315 R17 519 ��R� J9agnon�a rcg-Ilc.com Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the proper[y owner hereby authorizes - Scott Allison 58 Glad Vallev Dr Billerica MA 01821 Name Street Address City/Town State Zip to act on the ro ownei's behalf,in all matters relative to work authorized b this buildin ermit a lication. � SEC'I'ION 10:WNSTAUCI'ION CONTROL(Please fill out Appendix 2) . � � buildin is less tlian 35,000 cu.k.of enclosed s ace and/or not under Construchion Conhnl then check here O and ski Sertion 10.1 101 Re 'stered Professional Res onsible for Construction Control . � � � � � � � � � James Gilmore 508 380.3105 Name(Re straM) T le }�one No. e-mail address Regish�ation Number 200 �nter St I�o�liston MA 01746 Street Address City/Town SYate Zip Discipline Expiration Date 10.2 General Contractor � � � � � � Supreme Builders Company Name Scott Allison CS 069628 Unrestricted i.f. _ z2 — t � Name of Person Responsible for Construcfion License No. and Type ff Applicable 58 Glad Valley Dr Billerica 01821 Street Address City/Town State Zip -= 781_9538036 scott@supremebuilder.net Tele hone No. usiness Tele hone No. cell rmail address SECITON 11:WORKERS'COMPENSATION]NSLTRANCE AFFIDAVIT .G.L.c.152 25C 6 � � � � A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidenis must be completed and . submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a si ed Affidavit submitted with this a lication? Yes■ No � � � SECTION 12 CONSTRUCC[ON COSTS AND PERMIT FEE . � Item Estimated Costs: (I.abor � and Materials) Total Consirucfion Cost(from Item 6)_$ �.Building $ 15 000.00 ' Building Pemut Fee=Total Construction Cost x_(Insert here 2.Electrical $ $,QOQ.QQ appropriate municipal factor) _$ 3.Plumbing $ 6 Q�0.00 4.Mechanica] (HVAG� $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ � Enclose check payable to �6.Total Cost $ 26,��.0� (contact municipality)and write check number here � SECTION 13:SIGNATUAE OF BUILDING PERMIT APPLICANT � � By entering my name below,I hereby attest under the pairis and penalties of perjury that all of the informarion contained in this application is true and accurate to the best of my lmowledge and understanding. Scott Allison Contractor 781_953_6036 02/10/16 � Please print and si�name Tifle Telephone No. Date 58 Glad Valley Dr Billerica pi g21 Street Address Ciry/Town � SYate Zip Municipal Inspector to fill out this section upon applicaHon approval: � � � i � I( Name Date � SECTION 9: PROPERTY OWNER AUTHORIZATION � Name and Address of Properry Owner RCG 17 Ivaloo St Somerville 02143 Name(Print) No.and Street City/Town Zip Property Owner Cuntact InformaHon: - Jim Gagnon 617_625g315 F,_17 519 22A� jgagnon@rcg-Ilc.com Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Scott Allison 58 Glad Valley Dr Billerica MA 01821 � Natne Sheet Address City/Town State Zip to act on the ro e ocvne�'s behalf,in all matters relarive to work authorized b this buildin ermit a lication. . SECTION 10:CONSTRUCTION CON'PROL(Please fill out Appendix 2) � buildin is less than 35,OW cu.ft.of enclosed s ace and/or not under ConstrucRon Control then eheck here 0 and ski Section 101 �10.1 Re 'stered Professional Res onsible for ConshrucNon Conirol � James Gilmore 508 380.3105 Name(Re �strant) T�OR.IStOtI o. e-mailadMA �1,�46 RegistrationNumber 200 V�inter St i� Street Address City/Town State Zip Discipline Expira8on Date 10.2 General Contractor Supreme Builders Company Name CS 069628 Unrestricted SCOYI AIIISOfI Name of Person Responsible for Construction License No. and Type if Applicable 58 Glad Valley Dr Billerica 01821 STreet Address . City/Tocvn State Zip 781_953Fi036 scott@supremebuilder.net Tele hone No. usiness Tele hone No. ceIl e-mail address � SECI"ION 11:WORK&RS'COMPENSATION 1NSU2ANCE AFFIDAVII'(M.G.L.c.152.$ 25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Ind�vstrial Accidents must be completed and submitted with this application. Failure to provide this af.fidavit will result in the denial of the issuance oE the building permit. Is a si ed Affidavit submitted with tlus a lication? Yes■ No � SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (I.abor and Materials) Total Construction Cost(&om Item 6)_$ 1.Building $ 1 rJ,000.0� guilding Permit Fee=Total Consiruction Cost x_(Insert here 2.Electrical $ $,Q��.00 appropriate municipal factor)_$ 3.Plumbing $ 6 QQQ.QQ 4.Mechanical (HVAC� $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ � 26 ��.�� Enclose check payable to 6.Total Cost $ e (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PEAMTT 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 Imowledge and understanding. Scott Allison ,�� a�_ Contractor 781_953_6036 02/10/16 �. Please print and si na e TiNe Telephone No. Date , 58 Glad Val�ey Dr Billerica 01821 � Street Address City/Town State Zip Municipal Inspector to fill out this section upon applicaHon appzaval: Name Date ,..,�.;. �! Massachusetts Department of Publlc Safety = C Board of Buitding Regulations and Standards License: CS-069628 Co�struction Superv�sor SCOTT B A4lISON 58 GI.Ap VALLEY DR BILLERICA MA 01821 . - �.,;/'.�+�',,� �t�� ExpiraUon: �.�eli�m�sa�.aR�^ y 3 04/22120�7 i�pa:�P 1 • - • ry�F Appendix 2 ConstrucHon Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact informaHon of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mazk"a"whem a licable No. Item Submitted Incom lete Not Re uired 1 Architechual 2 Foundation 3 Structural 4 Fire Su ression 5 Fire Alarm(ma re uire re eaters) 6 HVAC 7 Electrical 8 Plumbin (include local connections) 9 Gas Natural,Pro ane,Medical or other) - 10 Surve ed Site Plan Utilities,Wetland,etc.) ll S ecifications 12 Structural Peer Review 13 Struchual Tests&Ins ctions Pro am . 14 Fire Protection NarraHve Re ort 15 Existin Buildin Surve�/Investi tion 16 Ener Conservation Re ort � 17 Architectural Access Review(521 CMR) x 18 Workers Com ensation Insurance 19 Hazardous Material Miti ation Documentation 20 Other(S ec' ) 21 Other S ec' 22 Other(S ec� ) , *Areas of Design or Construction for which plans are not complete at the time of application submittal must identified herein.Work so identi(ied must not be commenced until this application has been amended and the proposed construcdon document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original qermit fee. Registered Professional Contact Information ��s �i'i �r�u�e �-3�- 3�65 � Name(Registrant) Telephone No. e-mail address Registration Number � 260 (�Uon.�er S'�- /�/Irsbn � 0/7 b Street Address Ciry/Town State Zip Discipline Expirallon Date I Registration Number �I, Name(Registrant) Telephone No. e-maIl address �. Street Address Ci Town State Zi Discipline Expiration Date I Name(Registrant) Telephone No. e-mail address Registration Number I'�I Street Address Ci /Town State Zl Discipline ExpiratlonDate II PROJEGT TITLE: I L�C��N I� : APARTMENT RENOVATIONS VI� 4 ��PJ�u� THIRD FLOOR - UNIT # 31 260 WA5HIN6TON STREET �—= NEW WALL/PARTITION -; SALEM, MA 01970 - -- i �XISTIN6 WODD STUDS 3 I/2" WOOD STU1D5 EXISTING EXISTING ! AT I'-4" ON GENTER TO EXISTIN6 WALL/PARTITION TD REMAW STUDS STUDS UNDERSIDE O� D1EGK - - - - - --- EXISTING WALL/PARTITION BE REMOYED I ` FRIGTI ON P ITT OWNER: EXISTING PLASTER EXISTING PLASTER J BATT INSULATIOi�� - - - w�,�D w,a�� OR GYP BOARD � OR GYP BO�RD �G� — LLG I-f IVALOO STREET PAINT / PATGH PAINT / PATGH TWO LftYERS 5/8" TYi�� X ONE LAY�R 5/8° sot--ter�vi��, r�,�, AS R�QUIRED AS REQUIR�D GYPSUM WALLBOARD TO GYPSUM WALLBO,ARD TO lT) bi�-62s-e3is x-roo UND�R5IDE OP D�GK UNDERSIDE OP D`�GK ! � TYi�IGAL BOTH SIDES TYPIGAL BOTH SIIDES ; ' ; � ��i�T i T I ON �Y�� I ��T I T I ON TY�� T I �T I ON TY�� I T I ON �Y�� i- GO��.GTOR: S�GAL�: NOT TO SGAL� SGAL�: NOT TO SGAL� SGALE: NOT TO SGALE SGAL�: NOT TO SGALE SU�iZEME BUILDERS ING. 58 GLAD VALLEY DRIVE �XISTIN6 REATED W,4LL siLLe�zic�,, r��. (T) -/81-�f53-6036 • I i � ' � ( I 2'-0° ARGHiTEGT i , II � -_. . . . r�y�.xi,r; Y t ,-� : —_.._ � . . . . � .. . � � . . . . � . . � . � . . _'_ _' I.�. '_"'_—'__...__..._ . � .. . . .. � ,. . . —.__ _ . . . -' . . . '' '. . . . . . . .. . .� . � - m�t _.. __ _ _ ---- -- I � EXISTING � � �;: _ _ _ RA�'ED WALL _ _ _-- -- _ :_ - �, ' . x. — -- i i FIEI_D VERIFY _. . -. —.- a . � _ . ._ �,:_ . _ ; ; �, .- �� '�II �-�� ' I % - - - - - � JAMES GILMOUR � �� 2 j ;� ?�RGHITEGNR� s�:, 1�-- I i �� -- ' 200 WINTER STREET ( I I I �I � ((� HOLLISTON, MA OI'146 � ' ''- Y' `1 �U ' � I 1 (T)So8.380.3105 \ N I T # 3� ' UN I T # 3� i � sTAr.,P: , , ; ''.j ss4 s� � I -roo F � , `� ,c, I ,i" . �� #� DOOR TYPE f� L' �� I I �� O,'� EXISTIN6 SIX PANEL SOLID GORE WOQD '�"� UNIT # �8 /^` WOOD �LOOR JENWELD CR EQUAL � ' PAINT FINISH � � � � � � � � I ';[ ' ll �� ,. � � � � � � � � � � � � � � 8"14 SF " ( I � . � . � � � . � . . � . � . . / � . . � � . . . ; I � . HARDWARE �. � . . . , J/ ' � I I/2 PAIR HINGES i �� i'\ UNI �� I 1 I 2 PRIVAGY SET - BATHROOM iAND BEDROOM I 468 5F PASSA6E SET - GLOSETS ' I i I � FINISH TO MATGH EXISTING / I � � � ` � � � � I --- _ �,�-� , , � � � � � � � I SSUES � ; , i . , � � . �_ � �� , , x, : ' � ', 5,_6�� ,_ , � i I I�' . �.1 EXISTING .. ,� 10'-3 I/4" I . � � . � � � . ,: . � - - � � . ��i � , . � . . . � ,. . . � . . . . . . i . � '.. . ,. . � �� SMOKE . , . . �, ` PATGH EXISTING NEW SMOKE DETEGTOR ' I � ;� 12-IS-2015 - � I WOOD FLOOR EQ EQ DETEGTOR i � �OR PERMITS - -- ._ _ - i AS REQUIRED - I -- _-- --. � �,i ; , _ — � i i ' > EXISTING � so•xeo• F+ % � ; ; \ ' RATED WALL 2 � Sr;' 2 Ii i � I FIELD VERIFY I � � � L� Q ! � i ' m NEW WOOD FLOOR `t ( INFILL PATGH EXISTING � I� EXISTING PLASTER GEILIN6 TO MATGH EXISTING _ I WALL AS REGiUIRED p . p , i; � �L � � GL ry �� . � � � � � � � � I � I / � . . ._ _ — _ _ � � <Y I L I \ i'F I . 24"XBO" �i I �i . 24'Xb0' m � � � . __ . __ _. _ ' I' � , I ry 3 REFINISH � _ �T��'�°v EXI�TIN6 j � _ - -- — ---�--� -- — � \ / \\- . � � ��I � . , i I EXISTING � SMOKE _ RE Y I S I ONS � '4 � '4' DE'EGTOR y� '\ � � ro �� WOOD FLOOR I � +` ' r � . .. �, ,�,I . I .. . . . . . . . �. � �� ry � . . � . . . —,—i . `j) . � . � . . �' . . � . � INK I 30'XHO" . . � � . \� NIT 32 J � � � � ; I. ' - ; I � ' � I % f 392 5� ', \ — ff ��G�J , e/J � \ �+\y � , . _ • --.. -- -...._ —� ' � . � � �i � . � � �. . . . . � . � - -- — - � -- - TIILE . ' ' �i . . , � . . . . . � .. �s :>� � # � �" . , �. . . � . . � . . i . . . . . . . . . � - ---- .. ----- ,._ ---- --- I . . . . . --� T 34 I --, � I U1�14oa sF ' � ' , i � i REMO�lE EXISTING � ' I � WP�LLS, DOORS AND � . . . i .. . . — — _ _ . . � .: . . _ 51NK . . . . . . 'i �� i � pRAMES AS SHOWN a��"� ii • � � . '-� � ?�REA OF WORK � o „ �� #2 � �! j�i t, UN�T #3�J ' I � . � a REMOVE EXISTIN6 ry —� � I UNIT # �JI � '�_., SHOWER, 1NG, SINK AND REF EXISTIN6 = , �� ,` i� . 511 SF I I I � 814 SF \R£LOGATE EXISTIN6 WOOD FLOOR I � � � �- I j P_LUMBING AND ELEGTRIG �� I . I -� � . � � � � TO 1VEle1�GATION AS SHOWN �I�'.�. ' ` _ ] � �` - ` , �_- - _ �\ � I ``,, KITGHEN � ; i \ - n + � PLASTER GEILING � �IOOD FLOO� 5rovel �:_ _,.. _ <. : � � ' �� . � _, c : ' � I ; . AS REQUIRED _ �� r � ---- ------ -- - - �� ; . i; _ -- --- ; �`- ' , � PATGH EXISTING .. --- - DRAWN BY: . . . . . . , � . . � . . - . � ,] .�.� �. i . . . . � � � � . WOOD FLOOR � � . -- ------.. — � -- � . . JMG � �\, �� ,I AS RPQUIRED GHEGKED BY: \`��_\¢ � J : : JMG _ JI 2�� DATE: 12-15-2015 1�� , 13�_�� 1O'-�" 10'-5" SHEET TITLE: . k LOGATION PLAN 13,_,,, 20�_„• , ,,�.�,A�py! I ,,. . EXI5TIN6 GONDITIONS ' 34,_0„ �� . �`�`� �� PROP05�D �LOOR PLAN �. � � I /�, /� � I I� � ISHEET NUMBER �X �� I I `4l� �� I �� I� I V GALL�D �� l� l `l GALLED n ��_ �_ �� NORTH � �� NORTH l'� - ( O O SGALE: I/8 - I O SGAL�: I/4 = I -O _____ _ - -- _ __ _..__ . __ - -- ----- I� _ - -----_.___ ; .. : _ . _ PROJEGT TITLE: I J�� I `�l./ : APARTMENT RENOVATIONS �� 4 ��8uu , THIRD FLOOR - UNIT p 31 260 WASHIN6TON STREET � .;._ -_-'-�"�._:__� NEW WALL/PARTITION SALEM, MA OIG70 EXISTINC WOOD STUDS ; 3 I/2" WOOD S�TUDS �)C15TING �XISTING � AT I'-4" ON GENT�R TO ' EXISTIN6 WALL/PARTITION TO REMAIN S��DS STUDS � UND�RSID� O� D�GK � - - -- - -- - EXISTIN6 WALL/PARTITION BE REMOVED I ` PRIGTI ON �I TT OWNER: -- --- --- E;(ISTING PLAST�R EXISTING PLAST�R � BATT INSULATION R,e,reD wP,il O'� GYP BOARD � OR GYP BOARD � RG� - LLG - - ' — i I'7 I VALOO STREET ' P:41NT / PATGH PAINT / PATGH TWO LAYERS 5/8" TYPE X ONE LAY�R 5/8° e sor��rzvi��, r-r�. AS R�QUIRED ASREQUIR�D C-�YPSUM WALLBOARD TO GYPSUM WALLBOARD TO (r) 6rr-62s-asis x-roo I . UND�RSIDE O� DEGK I UNDERSIDE OP DEGK , . � TYPIGAI. BOTH SID�S i TYPIGAL BOTH SID�S I � � I ' � I �� I I I O I `� TY�� I T I O I `� TY�� GONTRAGTOR: �� I � I O I `1 ' �Y�� I ; �� I � I O I `l �Y�� SG?�LE: NOT TO SGAL� SGALE: NOT TO SGALE � SUPREME BUILDERS ING. SGAL�: NOT TO SGAI.� SGALE: NOT TO SGAL� , s8 e�A� vA��eY �Rive �XISTING R�AT�D WALL : �iLLerzi�A, r��. �T� -181-q5B-6036 � i � - ---II I 2�_�� ARGHITEGT _ ( ' _, .,, � -. � I -.- _ -- ------ -—--- � ___ - - t _._ ._ ,. _ -- - � r -- _ - _ -- � � � � r �; - _ _. . = :_ -_- --- � EXISTING -- _. - -._ - _ I I � RA'!�D WALL $ ` ' -� J r _ -- i i FIELD VERIFY _ � _.. �C - _ , --� ' � � - - - - - L. ,_ L I � ��. I ' % � J�MES GILMOUR I � �i II / 2 r � {�RGFfITEGT/R� i I " , I� o-- ' � I �� 3�� • i �� i 200 WINTER STREET I ; i I HOLLISTON, MA OI'f46 � � . , � , (� � � I / �, ; r � { I �r�soa.3ao.sios I —' UNIT # 35 / �.� � � � _�N I T # 3�I "!00 F a � V� 'T 3 STAMP: � � sa4 s� V ,�, � c o � � DOOR� TYPE � � �'J � 1 � �-9 � EXISTING �I� SIX PANEL SOLID GORE WOOD —� WOOD FLOOR JENWELD OR EQUAL iI J �c� UN�� JP /e,� ^ ; i PAINT FINISH I I', � / � -;'I I j ' HARDWARE I- � � � i I I/2 PAIR HINGES � l \ UN I � 3FJ �; '� 2 � PRIVAGY SET - BATHROQM AND BEDROOM 468 SF % � � PASSA6E SET - GLOSETS II i _�I / -- i ,, \\ \, FINISH TO MATGH EXISTIN�G � \ \ I�� ` -- � �SSUES ' , I IJ I � ' 10'-3 I/4" 5�_6" � EC EXISTIN6 I . . . � � : . , '., . �.. .. .. ..... . ... • . � � . . PATGH EXISTING � " . DETEGT IZ � � � _ .. �� i . . . � � � 12-15--�015 .. � � �� i,� . . WOOD FLOOR . '.EQ EQ � NEW SK10KE " O , . � . � � .. _... -- —. .... - -- -. _-- --. �� ! . . � AS REQUIRED DETEGTOR � j I . � . FOR PERMITS - - ......._...... _._.. .... . � . � . _.. .----- -— -- --- � I . � , „i . � � . � . . . � �. � . � � - . . �li � . . � � � � . — _ . � . � .. . � � . . . . � . . � . . � . . � . . . �, �� . i . . - . � . . . � ! � ` EXISTING � 30•�• F+ �I i j I �� RATED YJALL 2 N Sr� 2 - I D O - PIPLD VPRIFY � � � L , . � � � � . � � �, . . �� . I � I .- -I . . . � m NEW WOOD PLOOR. . . . `r . . , I . , I INFILL PATGk EXISTIN6 TO MATGH EXISTIN6 I r � EXISTING PLASTER GEILIN6 j 1^IALL AS REQUIRED I '� �L � �� GL ry ; i I ; _ � ! , i . . . . . . . . . :,.. . . . ; i , . . . . . : � y� a . �4•X80� - � I �. 2<•X80• _ . . . � . � � � . , : � - - - - - cv 3 L�IS� � � � � m t+Ewwoov ; , .-_._.. _. l._ ...._ _._ ' '. . �� I / E7(15TWOOD �, . . . . . . \ / },� . i� ��, II—� i WOOD FLOOR 4 I 4 DEISTING R� Y I S I O I`1S ', OKE ' I TEGTOR }�ya\�\ 7 � . ` . �� ^.`3I . � . � . .. . � � . , . . . . . . N . . . �. . � - � �1� � � � � . . . . I � � � INK: I �30 JCHO� � CJ) . . . � � ' ��I. % � . . '�, � � � , � . . � . ��i . . � . �I . . _ . j� , , ` NIT #32 ' I -- — — C� — E T�G� �s / , \\�\y� i � �� 392 SF �`� � � � � � , . TILE � � � � � � � �� UN I T #34 �' , ' : - -- ----. _.. . ._. _...__ � � I II i 409 SF ; � . ,' REMOVE EXISTING � � ; ; � - - - - WALLS, DOORS AND i � � i i ; FRAMES AS SHOWN �r� - siruc� �� i II : . �•\ . ' O � f, I i L� _ ' _ �I, I'I UN�T #�J3 . � � \� U N�T $k 3 1 f�tREPt �� WORK �`` S H O W E R, W G, S I N K A N D R E F � ry I� � E X I S T I N 6 � j O � ❑ REMOVE EXISTING O l_�_ . 511 SF . I I � 814 SF i i ��\, RELOGATE EX�STING '� WOOD FLOOR i i = �� _ � I _ I � � � j j ��.p�UMSING AND ELEGTRIG �� j _:; , ❑ �-i i I ��J -I i ,, TO NEIc�LOGATION AS SHOWN 2�_4�� IIVItLl1 � ' _ � .... � I ` �� 0 �'� ' <` srove , ,:; , \ L _ � -- -.- n I PATGH EXISTING EXISITING � 5 �%) -c_ :� . � `' PLASTEf2 GEILING � �pOD FLOO � �- _:. ' � � . . AS REQUIRED ,n ��`I , -— — ------- -_ _ __ —.. ` � � I PATGH EXISTING DRAWN BY: � � . WOOD FLOOR .—.---.. ,1MG — � , AS REQUIRED �� . ��..,.. _ J GHEGKED BY: _.,. ; JMG -¶ ' -➢ �� ' DATE: 12-IS-2015 • 13�_�� 10'-O" 10�_5„ SHEET TITLE: . . LOGATION PLAN � s 13�_�� _�� ,�,� �XI5TIN6 GONDITIONS 34,_0�. ~� M�� PROP05�D �LOOR PLAN _ � � �X �� I l �ll� �� I �� f� l �l GALL�D �� I �� I `4 GALLED , s+��er NUMaeR , ��_ �_ �� NORTH � �� NORTH � — I O O S G A L E: i/8 - I O SGP�L�: I/4 =1 -O > -- � ' I ' r . _ _ _ I—�-.- ,, _ _ n-- -- __ , ' � � _ _ � � � The Commonwealth ofMassachusetts DepaMment of Industrial Accidents O�ce oflnvestigations � 1 Congress Stree� Suite 100 Boston, MA O21I4-20I7 www mass.gov/dia Workers' Compensation InsuranceAftidavit: Builders/Contractors/Electricians/Plumbers Auplicant Information Piease Print Leeiblv Name �sus�nes5ro�g��Zano��a��au�q: Supreme Builders & Design,�nC Address: 58 Glad Valley Dr City/State/Zip: Biilerica, MA 01821 Phone #: 781-953-6036 Are you an employer? Check the appropriate box: Type of project(required): I.❑■ I am a employer with 3 4. � I am a general contractor and I employees (full and/or pazt-time).* have hired the sub-contractors 6. ❑ New construction 2.� I am a sole proprietor or paztneo- listed on the attached sheet. 7. ❑■ Remodeling ship and have no employees These sub-conhractors have g. � Demolition workin for me in an ca aci employees and have workers' B Y P �Y� $ 9. � Building addirion [No workers' comp. insurance comp. insurance. required.] 5. � We are a corporation and its 10.� Elechical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. � right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no �3.❑ Other � employees. [No workers' comp, insurance required.] *Any applicant that checks box#1 must ako fill out ffie section below showing[heir workers'compensation policy informa[ion. t Homeowners who submit this allidavi[indicaung they are doing all work antl then hire outside contractors must submit a new affidavit indicating such. =Conhzcmrs that check this hox must attached an additional shee[zhowing the name at[he sub-contractors and state whether or m[[hose entities have employees. ff the sub-contractors have anployees,fhey mus[pruvide their workers'comp.policy number. I am an employer that is providing workers'compensadon insurance for my employees. Below is the policy a�id job site information. � Insurance Company Name:Travelers Policy#or Self-ins. Lic. #:�PJUB-4768P16-5-13 Expiration Date:��6 , Job Site Address: 260 WBShIf19t0I1 St City/State/Zip:Salem Attach a copy af the workers' compensafion policy declaration page(showiug the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead[o the imposition of criminal penal[ies of a fine up to $1,500.00 and/or one-yeaz 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 viola[or. Be advised that a copy of this statement may be forwazded[o the O�ce of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties afperjury ihat the injormation pravided a6ave is true and correeG 2/10/16 Sienature: Date• Phone#: 781-9536036 Officia(use nnly. Do not write in this area, tn be conepleted by eity or town ajficia/. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CiTy/Town Clerk 4.Electrical Inspector 5.Plumbiug Inspector 6.Other Contact Person: Phone#: