77 WEBB ST - BUILDING INSPECTION (5) 'S RECEIVED
The Commonwealth of Massachusetts
tr Dfl .o•rntrl tSn CA
V➢� Massachusetts State u iing C e CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
/ ^ (This Section For Official Use Only)
N Building Permit Number: Date Applied: Building Official:
t SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
77 wtb6 9-wAP S'alL..1 DNA 77 Qe-U 31ftaf
No.and Street City/Town Zip Code Name of Building(if applicable)
( "I 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)
LChange of Use ❑ Change of Occupancy ❑ I Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering IA'e Iet.�c C
er Review required? Yes ❑ No ❑
557P70 Brief Description of Proposed Work: 3r R., ga�.re,wt - tntvX.L4r ww11 t ins�ll -JUL
Ga' c�
J rAJQIJK .cplaec 40f. .FI r.
2 S4N-o - Z 1=1.er� .nsJ�s�e. Lrtltrtsr Wel( e�unll CG1 i.y LJ414 iti IA,`I L&4 rL /-LIAL11 �ctlr.6,r.. C-L i"S
531'&01 I s+Fl r snsJloft. eul..r` well t wu t1 rL` &q n A wa11.1 aAA cr ewr s.`.,o1ew o�J
CaNJp-'l• in�e h�t.ri.r �Ar e.xs.e rc" a�t1 fit:N.nK Lw!'.:.e�4 r r[�14 e.[��
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): 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.) q 8pp FOO
Total Area(sq.ft.)and Total Height(ft.) 3 o 7-`(o o 3 o 2y d b
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ _
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H ❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2 R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA Cl IB ❑ IIA ❑ IIB ❑ 1 IIIA 17 IIIB ❑ 1 IV ❑ VA ❑ VB
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppjy: Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal:
Public Ef Check if outside Flood Zone Indicate municipal Mr A trench will not be Licensed Disposal Site
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ fp.A �-
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable M" Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No L7 Yes❑ No ❑
SECTION 8: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:
� N��-
SECTION 9i PROPERTY OWNER AUTHORIZATION --_
Name and Address of Property Owner
77 cyt,44 ArAfCe os 77 Ucbb S+,wl- Sajeo.l
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
"rqo - QKaaV,,.} 417 .474 -70S3 (,17-676-705 c _va IAoo.tewt
Title Telephone No.(business) Telephone No. (cell) e-mA address
if applicable,three property owner hereby authorizes /
QnaQrcw Ka.Qar 11 �an6w.r Court
Lu.t�Qo �/lT o3os?
Name Street Address City/Town I State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under 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_
/Qp/�otti, 3..4 Re ticNam
. p, p q
Co pert e
I l�dldts�r' CJ�f (p 1 )6 )
Name
/hoff Person Responsible fonrr�Construction " License No. and Type if Ap licable
r o�L r &yt• Lo..oCe.t.Perr W Qsas3
Street Address City/Town State Zip
At _yqo_ 3S►S - 90 -3515 a.roJarI@ rocLcbut`�.At1�
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.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 signed Affidavit submitted with this application? Yes Sr No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 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 I $ 30, U O p 1 (contact municipality)and write check number here
SECTION 13:SIGNATURE 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.Ytotcrr t./ )?.J r A&� 4, ,�(c.«ls 43 _49D -3SIS -31 1 14
Please rint and sign name Title Telephone No. Date
i\ �g�4,N sign,
L e.uQowd i(/� 03OS3
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name I D
(92. a, o�Vvta60t�leude{(b-
_ x Once of Consumer Affairs&Business Regulation
i
IW
OM�IMPROVE11
MENT CONTRACTORUExpiration:
egitration 157553 Type:
- 101412016. DBA
r
i, ROCK BUILT RESTORATI64�4
RADAR ANDREW 1
11 DANBURY COURT' g
F
LONDONDERY, NH03053
i Undersecretary
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supcnisor. - -
License: CS-091849
Andrew S Radar --- �,
11 Danbury Court _ 4
Londonderry NH%030
y
Expiration
Commissioner 03/12/2017
CITY OF S. .E.til, XWSACHUSEM
BUMDIING DEPARTSTNT
• 120 WASHNGTON STREET, Yo FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
(QxIBERIEY DRISCOLL
MAYOR THo&w ST.Pmam
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMN(ISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will1 be transported by:
/dtI1�K W4JlIL I�G OU`J'IiC SCtV�ts
(name ofhauler)
The debris will be disposed of in
T,�sboro Eta
(name of facility)
(address of facility)
si azure of permit applicant
date
JcbriufT.Jck
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location(Please indicate Block # and Lot# for locations for which a street address is not
available)
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
Construction 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 information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural -
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 FNAC
7 Electrical
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip
Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address CS /Town State Zi
Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address
Registration Number
Discipline Expiration Date
Street Address City/Town State Zi
i CITY OF S. .&M, NWSACHUSETTS
• BUELDLNG DEPAMEEI iT
• i20 WASHINGTON STREET, P FLOOR
n ' T EL (978) 745-9595
FAX(978) 740-9846
KIJIBERLEY DRLSCOLL
MAYOR TrIOMAS ST.PiERRfi
DIRECTOR OF PUBLIC PROPERTY/BUI DLNG CM511ISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Legibiv
cc�rbn _Name(BusittessOrganizatioNlndividtral): one�C -Kill
Address: (� dv 1 ou rl '
City/State/Zip: Phone#:��63) VIL -3SlS
Are you an employer?Check the appropriate box: Type of project(required):
1.L�J 1 am a employer with 3 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7. Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. q, ❑Building addition
[No workers comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME]Electrical repairs or additions
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 no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.❑Other
comp. insurance required.]
•Any applic.ua that checks box#1 must also fill out the section Itclow showing their workers'mmpensadon policy inrurmation.
I lnmeawrsas who submit this anidsvb indicating they are doing all work and then hire outside contractors most submit a new amdavit indicating such.
-Contractors that cheek this box must attached an additional sheet showing the name of the auD-mntmctore and their workers'comp.policy information.
I am an employer that is providing workers'compensation hrsarotrce for my employees. Below is the policy and job site
information. A
insurance Company Name: z r�-I of :: snA r.M..t
Policy#or Self-ins.Lio.#: q/Z 182 i ]1.5 Expiration Date: 11111,116
Job Sire Address: 7 (4 J'f City/State/Zip; K
'7 t.� rtcd'�
Attacb 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 well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ol'thc DIA for insurance coverage verification.
do hereby cent fy trder t pains and penah/es o er u that the information provided above is true and orrecL
IP j ry l p c
&Lrlatore: / Date* 311!t C
Phone#• 403 qq0-7.T15
Official use only. Do not write in this area,to be completed by city or town ajjtciai
City or Town: Permitll.icense#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.Cityifown Clerk 4.Electrical Inspector 5. Plumbing inspector
6.Other
Contact Person: Phone#:
AUTHORIZATION TO PERFORM SERVICES
ROCK BUILT RESTORATION LLC.
11 Danbury Court
Londonderry,NH 03053
(603)490-3515
Fax(978)364-7264
O l tJAW VA* ro , Herein referred to as"Customer,"
authorizes Rock Built Restoration LLC., herein referred to as"ROCK BUILT" to perform any and
all necessary restoration services on Customer's property at:
-3-1 V.I li l'l 41'�s EET " u W rr ap• SAI.EM AkA. o ldkno
Customer authorizes Insurance Company, herein referred to as
"Insurance Company", to pay ROCK BUILT solely and directly.
If for any reason the check should come to or be made payable to Customer, Customer agrees to
pay ROCK BUILT immediately upon receipt of the check from the Insurance Company. In order
to expedite payment to ROCK BUILT, Customer hereby appoints ROCK BUILT as attomey-in-
fact, authorizing ROCK BUILT to endorse Customer's name, and to deposit Insurance Company
checks or drafts for ROCK BUILT services. Customer agrees to pay Customer's deductible in the
amount of$ %�DOD,°'that applies to this claim and also if the loss is not covered by insurance,
Customer agrees to pay the total amount to ROCK BUILT immediately upon receipt of the invoice
amount.
It is fully understood that Customer and it agents, successors, assigns and heirs are personally
responsible for any and all deductibles, depreciation, or any costs not covered by insurance. Any
and all costs for services not reimbursed by the Insurance Company are the responsibility of the
Customer and are to be paid upon completion of work.
The liability of ROCK BUILT is expressly limited to the total amount of the services authorized
herein.
If ROCK BUILT submits this account for collection, Customer agrees to pay interest at 1.5% per
month or at the highest rate allowed by law, court costs, reasonable attorney fees and all costs of
collection.
Customer agrees that ROCK BUILT is working for the Customer and not the Insurance Company
or agenttadjuster.
Remarks:
*Snzgture Date �—
lt 4
Printed Name