153 WHALERS LN - BUILDING INSPECTION &
r. Ar Z6 1 ,
f he Commonwealth of'MAssichusetts
Department of Public Safety
iMassachusetts State BUilding Code(789 CMR)
"..' ' - , .- I
B u^I I d t n g' Permit Application for any-Builoijag other ,an a OnefprJ w %H466i n
, q
(This Section For Official Use Only)
Building Permit Number: Date -JI-f---3 Building Official'
'. I . 1. -.9
SECTION 1.10CATION'(Please indkite Bfilck#and Lot#for locationilor which a streetaddressis not ivSflabf@j
193 Wk0e(-, Ln gAlew% M& nk
No.and Street City ITown Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
EditionofMAStateCodeused— If New Construction check here 13 or check all that apply in the two rows below
Existing Building M Repair D/I Alteration 13 1 Addition�ODmolition 13 (Please fill out and submit Appendix 1)
Change of Use 0 Change of Occupancy 11 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No Ell
IS all Independent Structural Engineering Peer Review required? Yes 11 No
Brief Description of Proposed Work: rasM
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) 13
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.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 0 A-2 0 Nightclub 0 A-3 0 A4 13 A-513 I B: Business 0 E: Educational 0
F: Factory F-I 0 F20 H: High Hazard H-1 0 H-2 0 H-3 0 H-4 0 H-5 0
-1: Institutional [-10 1-2 0 [-3 C] [4 T 0 M: Mercantile 0 R Residential R-10 R-2 0 R-3 0 R4 0
S: Storage S-1 0 S-20 U: Utility 13 Special Use Oand please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IB 13 HA 0 IIB 13 1 IIIA P IIIB 0 1 IV E3 I VA 0 VB 0
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: "French Permit: Debris Removal:
Public El Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 13
required 0 or trench or specify:
Private 13 or indentify Zone:— or on site system 13 permit is enclosed El
Railroad right-of-way: Hazards to Air Navigation: %I!\I hsL" C"-'mnnmksi..IN'e,ww Pr'n„S:
Not Applicable C3 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of COLIC:—Use Group(s):— Type of Construction:— Occupant Load per Floor:
Does the building Contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name an 1 Address of Property Owner/ r � I_ _ f C 1
Y2cteric -r1 JucQ�``�. Ky2t� 1530+�t�l'11.4�F �tlCut di O
Name(Print) No,and Street City/Town Zip
Property Owner Contact Information:
kr�a�ca,��,f. fi
Title Telephone No.(business) Telephone No. (ceB) e-mail address
If a licable,the proper owner hereby authorizes
owtias -i 1'CMft 41 MIA,- -Al 03 o7 7
Name Street Address City/ own 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 Appendix2).. .
If building is less than 35,006 cu.ft.of enclosed space and/or not under Construction Control then check here 0 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 - - -
D ', $;
Company Name o ..rr
Name of Person Responsible for Construction License No. and Type if Applicable
q !hA L, A/ Re,.gm6r7d AE[ 03o77
Street Address City Town State Zip
• 136D 715.1 -�Ys - 1500 i i2i co Co m .A
Telephone No. business Telephone No. cell e-mail ac dress
SECTION 11: I'ION INSURANCE AFFIDAVCC M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Rem Estimated Costs:(Labor C q 6 O
and Materials) Total Construction Cost(from Item 6)_$ I.
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_
3.Plumbing $
d. Mechanical (HVAC) $ Note:Mininmm fee=$ (contact municipality)
5. klechanicril Other $ O� G q'. O C)
' Enclose check payable to
6.Total Cost $ p coo (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 b t of n k owledge end understanding.
Please print print and sign name Title Telephone No. D,t,
1 / 604 4 Al P.nyfnon L 63077
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application appro IV 4".
Name Date
12/02/2013 16:30 16038691722 THE BERGERON AGENCY PAGE 01/01
CERTIFICATE OF LIABILITY INSURANCE lzi2i2ai3" '
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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER.
IMPORTANT: If the aeAfloate holder Is an ADDITIONAL INSURED,the pollcy(lea)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 hoidor In lieu of such endursamerd(s).
CONTACT
PRODUCER NAME. JODI DAIGLE
The Bergeron. Agency PH NE (603) 861- 7708
361 Main St aC No„Ett} (aC.no):(603) 969-1722
ADDRESS:DA.T.GLEJIWNATIONWIDE.COM
Nashua, NkI 03060
INSIJRER(S) AnIOR LNG COVERAGE: NATION
INSURER A:NORTHFIELD INSURANCE
INSURED DIPIETRO FAMILY CONTRACTING LLC INSURER B:HARTk U. ....SURANCE
INSURER C.
4 IDA LANE INSURER D:
RAYMOND, NH 03077 INSURER E:
INSURER F
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.
LTR r
LrR TYPE OF INSURANCE I wvn POLICY NUMBER MM1O01YYYY MM bMIV LIMITS
GENERAL LIABILITY EACH OCCURRENCE E 1,000,000
r' COMMERCIAL CENGRAI.LIABILITY 50,000
PREMISES Es ocwnence E
CLAIMCMAOF O OCCUR MEDEXP Anyone person) $ 5,000
A W8118044 08/03/13 08/03/14 PERSONAL It AOV INJURY S 11000,000
_ GENERAL. AGGREGATE $ 2,000,000
GF-N'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPOP AGG F $•'DOD,OOC
POLICY FRO-
x LOC 1
AUTOMOBILE LIABILITY ER accident E_
ANYAUTO BODILY INJURY(Per person) S -
ALL OWNED AUTOS
AIIrOS UOS SDOILV INJURY(Per accident) S
HIRED AUTOS AUrOSWNEO PROPERTY OAMAGI,
Per accident) S
E
UMBRFI,I.A I,IAB OCCUR EACH OCCURRENCE S
EXCESS LIAR CIAIMB.MADE ACGREGATE S
OFD RETENTION$ $
WORKERS COMPENSATION ][ TATU. OTH-
AND EMPLOYERS'LIABILITY TORYUMR$ �.
36WECLN4561 06 15 E.L.GACH ACCIDENT E
P ANV PROPRIEIOWPgRTNERI[%@({Ufl'/E YIN
/ /13 06/15/14 rj OD,DDD
OFFICEWMEMSER E%GLODEm C NIA COVERS MA rn NH r
IMnndtlor,In Wo F,,I„DISEASE.FA EMPLOYE $ .p00,000
IIyes,aesorlbe under 500,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT F
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Auech ACORD 101,Additional Rem91`49 Schedule,It mms ence le required)
ATTN: Salem Building Dept,
F: 978-740-9846
CERTIFICATE HOLDER CANCELLATION
Krell
1.51 Whalers Lane SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DIGLIVERED IN
Salem, MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZE EPRESENTATIVE
I p i 1�,e,.,F, � a� __�
1988-201 D C CORPORATION. All rights reserved.
ACORD25(2010I05) The ACORD name and logo are registered marks of ACORD
cv2e 6OK?ItO"We"111'/n// -Jcrd(tie/6
�-\ Office of Consumer Affairs&Business Regulation
OMEIMPROVEMENT CONTRACTOR
egistration 140384 Type:
VU55xpiration 10/28/2015 Individual
r
;3t
THOMAS A DIPIETRO
THOMAS DIPIETRO SR ". _ ` '
3W
199 ATLANTIC AVENUE,_1
MARBLEHEAD, MA 01945' Undersecretary
t Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Super isor
License: CS-085053 j
THOMASADIPIFTRO
4IDALN
RAYMOND NH 03077t't=
S.
9,14., J" .\ Expiration
Commissioner 12/01/2014
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual): 7\A ^MA4 I�Ltnr?, .'P_».1a2 tfii I LLC
Address: L/ Shia I N—.fit- Ymemd �/jL/t 03e-77 i-
City/State/Zip: Phone#:
Are Ypu an employer?Check the appropriate box:
Type of project(required):
1.M I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).: have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working forme in any capacity. employees and have workers'
[No workers'-comp.insurance comp. insurance.t 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 LE]Plumbing repairs or additions
myself,[No workers' comp. right of exemption per MGL 12❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill 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.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: L�e..e
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State(Zip:
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
Investigations of the DIA for insurance coverage verification.
I do hereby certify, the pains an naldes- perjury that the information provided above is true and correct
Sipnature• Date_/2-Z-3 3
i
Phone#: ���- 2 Sc/ 7 3oo
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitiLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CityiTown 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 shall 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 permittlicense 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia