70 WEATHERLY DR - BUILDING INSPECTION (007) 6�
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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No.and Street City/Town Zip Code Name of Building(if applicable)
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 K I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Or—
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ea
nef Description of Pro osed Work:
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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):
SECTION 4:BUILDING HEIGHT AND AREA -
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 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❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-111 R-2M 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 ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 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 -Check if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required�r trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable( Is Structure within airport approach area? Is their review completed? ulfi
or Consent to Build enclosed ❑ Yes❑ or Now Yes El 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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
5���4 Wtskicvt 1 -y0�- 4LtSl _- - �Ina Ctlmr�t� n
Title Telephone No.(business) Telephone No. (cell) address
If applicable,the property owner hereby authorizes
0roavtn cuy4rt.A. 9G S vf,o%e-b4 12,E 3elew. ylp 4 �1�]a o
Name Street ddress City/Town 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 13 and skip Section 10.7
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 1
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Company Name
1 ttM Ot{nv C ` ) 0S
Name of Person Responsible for onstructi n rr � (( License No. and Type if Applicable
T ` $wOrvm�Cc c;-h '9-& r,G\etM /3zlA Ole'r
Street Address City/Town State Zip
fsc_ 2 3c3 6a-7-m- 45-1( -Fdous \«�y C� CErotmlco. CWtn
Telephone No. business Telephone No. cell 1 e-mail address
SECTION.11:WORKERS'CONMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Ye No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMITFEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)_$ SRO
1.Building $ ubD i
Building Permit Fee=Total Construction Cost x It-(Insert here
2.Electrical $ s' cw-o appropriate municipal factor)_$ .�.-
3.Plumbing $ 6 CpU ^
Note:Minimum fee=$ (contact municipality)
4.Mechanical (HVAC) $
5.Mechanical Other $ Enclose check payable to C R F SG'CVtn
6.Total Cost $ �'�p "- (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 hereby attest under the pai and penalties of perjury that all of the information contained in this
application is true and accurate to th\bes of my knowl ge Q uaderstanding.
4Uf2eryrCorrTelepbue
Please print and sign nam Title Date
4/ Sk)LIttns��� S c Street Address City/Town Z'
Municipal Inspector to fill out this section upon application approval: l� J
Name Date
Massachusetts- Department of Public Safetc
9 Board of Buildim-, Regulations and Standards
Construction Supervisor License
License: CS 77841 =---5
4
F
TIMOTHY C -DOUGHERTY "£
21 COTTAGE ST
PEABODY, MA 01960
mod- —sue-� Expiration: 8/25/2012
t O mmisshmer Tr#: 2416
9�
Office of Consumer Affairs and usiness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Con Registration
Registration
Registration: 104999 -
(T.1 _ Type: Private Corporation
Expiration: 7/16/2012 Tr# 298430
GROOM CONSTRUCTION, INC 1
Thomas Groom M/ =}
96 SWAMPSCOTT RD #6
SALEM, MA 01970 T
,_�
Update Address and return card.Mark reason for change.
Address [_] Renewal Employment Lost Card
DPS-CA1 0 50M-04/04GG110001_2166
Office`6l+eotr's23VA'ff�'YYryih ��4 ° License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: ,104999 Type: Office of Consumer Affairs and Business Regulation
ic
Expiration: 7/16/2012 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116 ONSTRUCTION,INC.-:
r \
Thomas Groom "
'nr
96 SWAMPSCOTT RD W6 o o
SALEM,MA 01970
Undersecretary Not valid without signature
t I
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information I Please Print Legibly
Name(Business/Organization/Individual):
Groom Construction Co. , Inc.
Address: 96 Swampscott Road
Salem, MA 781 -592-3135
City/State/Zip: Phone.#:
Are you an employer?Check the appropriate box: - Type of project(required):
L® I am a employer with 75 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.P11Mmodeling
ship and have no employees These sub-contractors have S, ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp. insurance.[ 9. ❑Building addition
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 I L❑Plumbing repairs or additions
myself, o workers'co right of exemption per MGL
� � comp. 12.❑Roof repairs
insurance required]t c. 152, §1(4),and we have no
employees.[No workers' 13.❑Other
comp.insurance required.]
!My applicant that checks box#1[mist also fill out the section below showing their workers'compensation policy infortration.
t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such.
tConitactors that check this box most attached an additional sheet slowing the name of the sub<ont actom and state whether or not those entities have -
employm. tithe sub-contractors have ettploym,they must provide their workers'comp.policy number.
r am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab she
-- information.
Mutualj
Insurance Company Nome: Liberty �
i
Policy#or Self-ins.Lic.#: WC 7 Z 11259713011 Expiration Date: 3-1 0- 12
Job Site Address: �W!x b, # ZUI City/State/Zip: SC f ec W.4 Ot 4 p I
Attach 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$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 j
Investigations of the DIA for insurance coverage verification. i
I do hereby ce ijy under r t pan and penaties of perjury that the information provided above is true and correct. j
i
Sion lure, Date: /0 — z Y -t(
i
Phone#: 9S71 !
i
Official use only. Do not write in this area,to be completed by city or town official
L6. 0ther
Permit/License#
ty(circle one):
lth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
: Phone#:
VumI wrrav UKUUMI:UNb-I
ACORD, CERTIFICATE OF LIABILITY INSURANCE D3110/2011 )
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
NAME: Certificate Desk
HUB International New England uc°Ne EXt 978 657.5100 ac,Nq: 9789880038
299 Ballardvale St - IL
Wilmington, MA 01887 ADDRESS:
978 657-5100 CUSTOMER ID#:
INSURER(S)AFFORDING COVERAGE NAIL#
INSURED INSuRERA.Liberty Mutual Insurance Co
Groom Construction Co.,lnc.and Groom Realty LLC INSURER B:Starr Indemnity& Liability Corn38318
96 Swampscott Road,Suite 6 INSURER C:
Salem, MA 01970-7004 INSURERD:
INSURER E:
[INSURER :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY 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 OF INSURANCE LSUBR POLICY EFF POLICY EXP
LM NS D POLICY NUMBER MM/Daripff' MM/DD LIMITS
A GENERAL LIABILITY YV2Z11259713031 3/10/2011 03/10/2012 EACHOCCURRENCE $1,000000
X COMMERCIAL GENERAL LIABILITY DA GE O
PREMISES JEa occurrence 11300,000
71 CLAIMS-MADE 7 OCCUR MED EXP(Any one person) $5,000
PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $2,000,000
X POLICY PIFCTRO LOC g
A AUTOMOBILE LIABILITY AS6Z11259713021 3/10/2011 03110/2012 COMBINED SINGLE LIMIT
X ANY AUTO (Ea accident) $1,000,000
ALL OWNED AUTOS BODILY INJURY(Per person) $
SCHEDULED AUTOS BODILY INJURY(Per accident) IS
PROPERTY DAMAGE
X HIRED AUTOS (Per accident) $
X NON-OWNED AUTOS $
B h UMBRELLA LIAB X OCCUR SISCCCL00011111 3/10/2011 03/10/201 EACH OCCURRENCE $1 O 000 000
EXCESS LIAB CLAIMS-MADE EACH
$1 O OOO,OOO
DEDUCTIBLE
RETENTION
A WORKERS COMPENSATION WC7Z11259713011 3/10/2011 03/10/201 we sTATu- oTH-
AND EMPLOYERS'LIABILITY YIN
ANY PROPRIETOR/pARTNER/EXECUTIVE❑N E.L.EACH ACCIDENT $1,000,000
OFFICERIMEMBER EXCLUDED? NIA EA EMPLOYEE $1,000,000
(Mandatory In NH) E.L.DISEASE-
Ify Ees,descnbeunder
D S C E.L.DISEASE-POLICY LIMIT $1,000,000
RIPTION OF OP ERATIONS helow
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
Blanket Additional Insured and Waiver of Subrogation in favor of; Lessor of Premise, Lessor of Leased
Equipment,and Blanket Additional Insured and Waiver of Subrogation -Person or Organization where required
(See Attached Descriptions)
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS.
96 Swampscott Road
Salem, MA 01970 AUTHORIZED REPRESENTATIVE
.exec
01988-2009 ACORD CORPORATION.All rights reserved.
ACORD 25(2009109) 1 of 2 The ACORD name and logo are registered marks of ACORD
#S506636/M506610 WR001
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