64-74 WHARF ST - BUILDING INSPECTION 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
('Phis Sechon For Official Use"In]y),.
Building Perm it Numbei ! '-- Date Applied "" ;Budding Ofhmal . ' -"
•SECTION 1:LOCATION(Please indicate Block#and Lot:#for locations for which a street address is not available)
Ca�1y1J�a.ES� . So\�m Cr^ GV41C1 P��2\\�
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 crows below
Existing Building❑ Repair V1 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Cihmge of Use ❑ Change of Occupancv ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an independent Structural Enginee ing Peer Review required? t� Yes ❑ No
Brief Description of Proposed Work: VNQ�' d 0. �-
C\40iC1Jc.-c G� t
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'HEIGIITAND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&AreaEPerE(sq. )
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 P-1❑ F2❑ j H: Hi h Hazard H-1 ❑ H-2 El ' H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage 5-1 ❑ S-2❑ _ I U: Utility❑_j Special Use ❑and please describe below-
Special Use:
SECTION 6:. STRUCTION'LYPE(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 Suppi Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Q Check if outside Flood Zone❑ Indicate municipal A trench w'}'i not be Licensed Disposal Site
Private[I or indentify Zone: f�.0`-t or on site system❑ required f3 or 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?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
-_- SECTION,Si 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:
.SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.an eet City/Town Zip
Property Owner Contact Information: _
�.�,ras 1.t�i1',crcoa�..c`i�.\F`11t'c�'1`\y- GS90 . -10\ Ce''j\ _'�-l0 mroCY�eact-t"JMr,coc\S�N.CaM
Title Telephone No.(business) Telephone No. (cell) a-nnad address
If applicable,the property owner hereby authorizes
CYV'\ o\q A j
Name Street Address City/Town State Zip
to act on the propertv 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,b6ildin .is lesthan 35,000 cu.Ift of endosed s ace and/or not under COnsCiLLction:Contr'ol then cbeck here El and ski Section 10.1 :
10.1 Registered Professional Res onsiblelfor Construction Control
Name( nstrant) Telephone No. e-mail address Registration Number
\G%Qi <,�-5� C`c�tb\�\mod _nNjN CY.41% o\R \o e \
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
P
Name of Person Responsible for Constniction License No. and Type if Applicable
--\\ bra' M MedF elZ rnR oaosa
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION II:WORKERS``COMPENSATION INSURANCE AFFIDAVIT M.G.L::c.152.9 25C 6
A Workers'Compensation hnsurance 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 iaSuance of the building permit.
Is a signed Affidavit submitted with this application? Yes No ❑
SECTION 13:CONSTRUCTION COSTS AND PERMIT FEE,
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$1'dC$tJ—
1.Building $ I Ac-c� 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 CI �F �sG\ -CY-)
6.Total Cost $ \`a,CxfJ — (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.
�. CY1: i�\
Please print and sign name Title ',.fie ep orie No. Date
\c1G e\ne-c�el o\gy�
Street Add City/Town / ate Zip
`Municipal Inspector ti fill out this;section upon applrcation-approval:
. . . .: '. Name .. Date .....
i
CITY OF SME141 MI ASSACHUSETTS
BI:n.DNc DErARTafEN'r
2 N STREET San FLOOR
e �SHINGTO ,
1_U W.
TEs. (978)745-9595
FAX(978)740-9846
KIN
IBERLEY DRISCOLL THOMAS ST.PIERR14
MAYOR DIRECTOR OF puBLIG PROPERTY/Bt:mnING COJLL%MIONER
Workers' Compensation Insurance Affidavit: Buiiders/Contractors/E1ecc'Please umber Legibly
4Ltplicant Information Q 2
game(BusirmwOrpriizeioNlndividmq: �C•M ` C•r�'la..r �X \��•�
Address: —11 \A \\
City/State/Zip: CYle-C\R:SASI C(\ASaC�SA Phone#:
Are y as employer?Check the appropriate box: Type or project(required):
I.at am a employer with 4. 1 am a general contractor and 1 6. ❑New construction
employees(frill and/or pact-timc).' have hired the sub-contractors
10 t am a sole proprietor ar partner-
listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors have. 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp. insurance 5. We are a corporation and its 10.�]Electrical repairs or additions
required.] officers have exercised their -
3.0 1 am a homeowner doing all work right of exemption per MGL I t.�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' 13.0'Othas=d'•na
comp.insurance required.]
Any applicant that checks box gl must also fill out the sectim below Jawing their watkea'compensation policy infomtado t.
*t Inmeawnm who submit this Affidavit indicating they ate doing all wok and thin hire amide commeam,most submit a new affidavit indicating such
=Contmctan that check this box most attached an additional abaci showing the name of that sub�comncta s and their workem'tamp.policy inib madm.
1 am an employer that Is providing workers'compensation Insurance for my employees. Below is the Polley and job site
information.
Insurance Company Name: C to P:n'n=�5• '"\�-f�C�'L'"�C'
Palicy#orSelf--ins.Lic.4: U�' SOCoO�i\S \ \� Expiration Date: sAnq t>
lob SiteAddress: (:ILL \��\��j F Sk City/State/Zip: SG\°m �f �,S,CS\c —
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 SI,Soo.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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DI r urance coverage verificaC - -
;dohoreby ce under t Palos a d penatt jeer thatthe njormaflon provided above Is true and cotrecL•
Date: 14\
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permillucense#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3,Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
04/17/2013 09:54 FAX 978 283 2401 cape ann insurance DO Z 0001/0001
Rightfax C2-1 4/17/Z013 6: 10: 53 AM PAGE 2/00,Z, Fax Server
CERTIFICATE OF LIABILITY INSURANCE DATE(MMrnor1
T FICATE IS ISSUEU AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICA
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:Ifthe certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. IT SUBROGATION IS WANED,subject to
the terms and conditions of the policy,certain policies may require and endorsement. Astatement on this certificate does not confer rights to
he certificate holder in lieu of such endorsement(s).
PRODUCER - CONTACT
NAME:
CAPE ANN INS AGCY INC PHONE FAX
23 DALE AVE (A/C,No,Exqu IA/C,No):
EMAIL
GLOUCESTER,MA 01930 ADDRESS:
25LPO INSURER(S)AFFORDING COVERAGE NAM
INSURED INSURERA: ACE AMERICAN ENSURANCE COMPANY
PARKER,PHILLIP S INSURER B:
INSURER C:
INSURER D:
70 LNDIAN HILL ROAD INSURER e
MEDFIRLD,MA 02052
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
C S T 0. MIMEO ABOVE THE POLICY PERIOD INDICATED.
NOTMTHSTANIONG ANY REOUIRFTnEHT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MY
PERTAIN. THEINSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICES. LIMTS SHOVM MAY
HAVE BEER REDUCED BY PAIO CLAa6.
DISK ADD SUB POLCYB IITE POLCYEXPDATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MA100%YYYY) (NMVJmYWY) UNITS
GENERAL LIABILITY zACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED $
CLAIMS MADE O OCCUR. EMISES(Ea occurrence)
MED EXP(Ary one parson) is
RSONALB ADV INJURY $
GENL AGGREGATE LIMIT APPLIES PER:
POLICY PROJECT 0LOG E PRODUCNERAL TS
AGGREGATE $
DUCTS-COMp/OP AGO $
AUTOMOBILE LIABILITY
COMBINED SINGLE $
ANY AUTO LIMIT(Ea accidert)
ALL OWNED AUTOS BODILY INJURY $
SCHEDULE AUTOS (Perpersan)
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per acrJtlerrt)
PROPERTY DAMAGE $
Per o.rIerd)
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESSLIAB CLAIMS-MADE AGGREGATE g
DEDUCTIBLE $
RETENTION $ $
A WORKERS COMPENSATION AND X WCSTATUTCRY OTHER
EMPLOYER'S LIABILITY YM UB-5BC09157-12 09119/2012 09/192013 LIMITS
AM'PRCPERITCRIPARTNENID(ECUTVE 0N/A E L EACHACCIDENT $ 100,000
OFFICERNEMBER EXCLUDED')
pAARAMA in NH) E.L.DISEASE-EAEMPLOYEE $ 100,000
Y res,aesalx unacr
DESCRIPTION OF OPERATIONS WIow EL DISEASE-POLICY LIMIT $ 500.000
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIRESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTINO WORKERS COMP CO VERAOE.
THE WORKBRS COMPENSATION POLICY DOES NOT PRO VIDE COVERAGE FOR PARKER,PHILLIP S. -
CERTIFICATE HOLDER CANCELLATION
M R ROCKET MANAGEMENT SHOULD ANY OF THE ABOVE DESCRIBED PO DCIES BE CANCELLED
C/O KATHY CHAPMAN BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL Br DELIV59M
IN ACCORDANCE WITH THE POLICY PR22R�g
23 CONGRESS S'T AUTHORIZED REPRESENTATIVE
SALEM,MA 01970
0/05) The ACORD name and logo are registered marks of-A A ORD 198&2010 ACORO CORPORATION: rights served.
CITY OF SMEM, 1+LAssAcHUSETTS
f
BL'II.DC`IG DEPARTMENT
1 t? 120 WASHINGTON STREET, r FLOOR
tiec ear TEt- (978) 745-9595
FAX(978) 740-9846
KI,ffiERL EY DRISCOLI THOD W ST.PMRSM
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUn DING CONC'aSSIONE.R
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 will be transported by:
��K ttIS/J1 f7 �C.-c�l(1G1-'CIC
(name of hauler)
The debris will be disposed of in
(name of facility)
es5 9�d,
(address of facility)
signature of permit applicant
date
dcbrWMAuC