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71 WEATHERLY DR - BUILDING INSPECTION 1,9 RECEIVED The Commonwealth of MassaAAWsl Department of Public Safety V h1assachuselts State Building Code(780 CMF615 MAY 15 A fT 10 Building Permit Application for any Building other than a One-or Two-Family Dwelling (rhis Section For Official Use Only) Budding Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block H and Lot t for locations for which a street address is not available) 71 0tct R S4IG•n 044 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2.PROPOSED WORK Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair4l'I Alteration ❑ 1 Addition O I Demolition ❑ (Please fill out and submit Appendix t) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ NWV— Is an Independent Structural Engineering Peer Review requir Yes? t / ❑B f Description of Proposed Work: (6me k1 A . CLJS i' 441f �11-e baNp oor� reMovC QO in 11 ho. W000' oaiT V&4"4 nii 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) ❑ Existing Use Group(s): I Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor.(sq. ft.) 21doo Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) MFactoryF- A-t❑. A-2❑ Nightclub ❑ A-3 Cl A-I❑ A-5 I B: Business ❑ E: Educational ❑ F-1❑ F2❑ H: Hi h Huud H=l❑. H-2❑ H-3 ❑ H-1❑ H-5❑l 1-1❑ 1-2❑ f-3❑ 14❑ M: Mercantile❑ R: Residential R= R-2❑ R-3❑ R4❑1 ❑ S-2❑ U. Utility❑ Special Use❑and please describe below: SECTION 6:CONSTRUCTION TYPE(Check as a licable)10 ❑ IIA ❑ 1160 IIIA ❑ HID ❑ 1 IV 13 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public k Check if outside Flood Zone k IndicatemunicipallirA trench will not be Licensed Disposal Site er required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: \I\I li_hg,i l"tngui,yio IL_n _riio,_I'r.xr.p: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Cod¢: Use Group(s): Type of Construction:. Occupant Load per Floor: Does the buildiny contain an Sprinkler System?: Special Stipulations: _ W e-o. 5 zc, c-C�- L.t;o 1� p L) SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner II � I rc ha�I'S oJl fk 0 l ryta ermfe /V�t✓ n Mf�- OJY6 Name(Print) No.ant Street City/Town Zip Property Owner Contact Information: � 1- 6 Gs—�L mg —sume & , a ma4l,604w Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the pr perry owner hereby authorize/s D r'o da e /yt�.L Nun' S reet Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this budding permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If budding is less thin 35,0M cu.ft.of enclosed SPOMandlOf not tinder Construction Control then check here O 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 10,M Ond SulI " Comp.Tny Name n `' rr// // Name o�ersospnpQn�ib)e for Cgnstruc�tt�on Cam„-�License No. and Type icable02Q dJ /S�trre1�eetggA,,ddodress7 99LLCCUU11 KK TIIHIIF--LLY�I � City/Town I �//j State / /Z1'p ��(A�D. WM Telephone No. business Telephone No. cell e-mail address SECTION 11:41'ORFEKS'C0MI'ENSAI'I0N INSURANCE APFIDAVff M.G.L.c.152.9 25C6 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 t e' uance of the building permit. Is a signed Affidavit submitted with this application? - Yes No O SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE' Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)=$ I. Building $ 00 0 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ -' 41,000 appropriate municipal factor)_$ 3. Plumbing $ d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ o21,000 (contact munici ality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, i hereby at st um er the pains and penalties of perjury that all of the information contairiLd in this applicatiot is tru and accurate 61 e b st o t y I owledge and undderstanding. J 1 cl� o6DSd6 .3VD Siv/ Please print arld sign name /( r Title Telephone No. Date A ]i'rChUQ ( C�Obl Street Address City/Town / Slf ue Zip Municipal Inspector to fill out this section upon application approval: '� U Name Dale The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organization/Individual): ltt-rt1 CN Address: S City/State/Zip: M �aS1a Phone#: 6 0 84 `B/,� Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $. 4Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]1 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. twill 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑ROOF repairs These sub-contractors have employees and have workers'comp.insurance.t 6.t We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other tttttt'''"' 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: D 1f p n O N arJn q Policy#or Self-ins.Lic.#: N 1 Y 10��`�� `454 Expiration Date: I� - Pr, n^ Job Site Address: �( �Cri TW 14 V o� Mt s Co City/State/Zip: SG,6✓1 Attach a copy of the workers'compensatioi policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cern der th pains a n Lties ofperjury that the information provide abo a is true and correct. Silenati r Date: Phone#: 10(1"gt� 2✓ )o 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 Laws 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 shalt 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 permit/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 bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia AC ao& CERTIFICATE OF LIABILITY INSURANCE DA 09/19/2013�) 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 policy(ies)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 endorsement(s). PRODUCER CONTACT Dnlitry DuW1on ALD Insurance Agency Inc. PHONE FA% 60A Brighton Avenue c No , (617)787-7877 F C,No):(617)787-7876 Allston,MA 02134 ADDRESS: dmitry@Galdinsurame.com INSURERS)AFFORDING COVERAGE NAIC# INSURERA: WESTERN WORLD INS CO INC 13196 INSURED Diamond Builders Inc INSURER B: TRAVELERS INDEMNITY COMPANY 25658 5 Springdale Ave INSURERc: HARTFORD UNDERWRITERS INS CO 30104 Canton,MA 02021 INSURER D INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CEFTIFY 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. INSR TYPE OFINSURANCE ADOL SUERPOLICY VPAQPDDCY NUMBER MMIDDIYYYY MDNYYY LIMDS II A GENERN-UABIDTY NPP8103956 05/28/2014 05/28/2015 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LABILITY DAMAGE TO RENTED 100000 PREMISES Ea ELATED occurrence) $ CLNMS.MADE OCCUR MED UP i My one person) $ 1,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1,000,000 \/ POLICYPRO LOC $ B AUTOMOBILEUABIDTY BA-2d214660 05/14/2014 05/14/2015 COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Far person) $ 100,000 ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ 300,000 AUTOS \� AUTOS NON-OWNED PROPERTY DAMAGE $ 1�000 HRED AUTOS AUTOS (Peraccident) $ UMBRELLAum OCCUR EACH OCCURRENCE $ EXCESS LMB CLAIMSMADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION 6B200454 08127/2014 =2712115 \� WC STATLL 1 01 AND EM PLOYERT DABIUW YIN ER ANY PROPWETOILPARTNEILEREOT E E.L.EACHACCIDENT $ 1,ODO,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EAEMPLOYEE $ 1,000,000 M yes,describe under 1 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 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. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �ite�d/rN)YO/att/va�o�C��a�cu,{eaeel� 'Office of Coosunur Affairs&Susmess Regulation OME IMPROVEMENT CONTRACTOR WE egistration 76304 Type: xpiration�8 �(d15 Corporation - - DIAMOND BDILDEFF -CS ORPffE'��l, - ri �3 DMITRY DEYCH 5 SPRING DALE AVEv r' �o. CANTON, MA02021 3Mpa -__,- Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor . License: CS-107988 DMITRY DEYCH= ; 42 LAURELWOOb ; Stoughton MA 027172 //r A �¢- Expiration -Commissioner 04/29/2018