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80 WHARF ST - BUILDING INSPECTION (3) L13 RUFNEZZo ep The Commonwealth of Maw' MYAMsL S Department of Public Safety �f �f 4yU, Massachusetts State Bu ild ing Code(?whl TEC 18 P Ir S` Building Permit Application for any Building other than a ne-or Two-Family Dwelling .(This Section For Official Use Onl ) 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) *—( JH7`(YLf7 0MRIL) No.and Street City/Town Zip Code Name of Building(if applicable) I 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 V`\$ Existing Building❑ Repair❑ 1 Alteration ❑ 1 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 El— Is an Independent Structural Engineering Peer Review required? Yes ❑ No .0� Brief Description of Proposed Work: 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.) Total Area(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A -1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-t ❑ F2❑ FL• High Hazard H-1 ❑ H-2❑ H-3 ❑ 1-1-4❑ H-5❑ I: Institutional I-1❑ 1-2❑ 1-3❑ 14❑ 1 NI: Mercantile❑ R: Residential R-I❑ R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) IA IB ❑ IIA ❑ IIB ❑ 111A0 IIIB ❑ 1 IV ❑ VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CNIR 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❑ required ❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Ilazards to Air Navigation: Not Applicable O Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No❑ 1 Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition(it Code: Use Group(s):_ Type of Cunstntclion: . Occupant Load per Moor:. Does the build ine contain en Sprinkler System?: __ Special Sliprtlations. __._ Y% Kilt UED l z l 1 SECTION 9: PROPERTY OWNER AUTHORIZATION Name anti Address of Property Owner `l : Name(Print) No.and Street City/Town Zip -^ Property Owner CmtactInformation:.,. Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes Name Street Address 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 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 Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No, business Telephone No. cell e-mail address SECTION 11:1V0RFEhS'CORII'EN5A I ION INSURA;NQ:.AI+1DAVCI' M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed a nd 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 13 No 13 SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Budding S Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ d. ivlechanicd (HVAC) $ Note: Minimum fee=$ (contact municipality) 5. Mechanical Other - $ Enclose check payable to 6.Total Cost $ (contact nmicipality)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.cod accurate to the best of my knowledge and understanding. CPlease print and sign name Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Dale SECTION 9 PROPERTY OWNER AUTHORIZATION Name and Address of Properly Owner - 23 jar/ 6e lu) Ck. iS08 Consolvo Dn VI rut n I a Frkr h�lf: 7 Name(Print No.and Street City/T can Zip Property Owner Contact Inform ttion: zllwnd-n-- _- - lv17 S%6 Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the propertyow�ttej,"by aru•�thoriwns 6 /L/ a� 79-- Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this buikiftw permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) bt&ding is Im than 35MO cn.ft of m Mwd spare and/or rot under CD traction Control thmd rk here O and ' Section 10.1 101 ReWdered Professional Responsible for Construction Control Ira vl & a 2- WK-7/2:-32-sr zip 6V 6 Name((RR�ep�reetrtraa4Qt) Telephone No. e-mail address Registration Ntmber 8' Wh.GR,f/4/f� s}- • ,5�/�,n-r ac,5 DIV70• Z? 6w"exo� /eo Street Address City/Town State Zip Discipline Expiration Date 102 General Contractor j VAv14�6zE2 !YL-t Company Name •��77 " Name of Pe"Respo ble for Construction License No, and Type if Applicable R !d tiCC/7n �/��Pa 1 x QS1• d/ Street Address City/Town State Zip *7 Telephone,No.(business) Tel hone No. e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT G.L c.In§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 El No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(tabor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ • O O• Budding Permit Fee=Total Construction Cost x_(Insert here 2 Electrical $ appropriate municipal factor)=$ . 3.Plumbing $ 4 Mechanical WAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical $ Enclose check payable to 6.Total Cost $ (contact munidpali )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my rome below,I hereby attest under the pains and penalties of perjury that all of the information contained m this application st true,aAndd�accu/r/ate to the best of my knowledge and understanding. Please print and sign name Title Telephone No. Date Sheet Address City/Town State Zip ll Municipal Inspector to fill out this section upon application approval- -�'Vs^"e OL /9 Name I baft Rightfax C3-2 9/22/2014 6:12:22 AM PAGE 2/002 Fax Server "f CERTIFICATE OF LIABILITY INSURANCE DATE(M VDW WYI T CATE 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. HIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRO AND THE LDE MPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy0es)must be endorsed- If SUBROGATION IS WAIVED,subject to the arms and conditions of the policy,certain policies may require and endorsement. A statement On this certificate does not confer rlghtsto the certificate;holder In 11w of such endorsements. ' PRODUCER CONTACT NAME: METRO BOSTON INS AGENCY PHONE FAX 96 CENTRAL AVENUE CHEISEA (A/C,No,H3r0: (A1C,No): E-MAIL CHELSEA.MA 02150 ADDRESS: 76xxM INSURERS)AFFORDING COVERAGE NAICa INSURED _ INSURER A! HAR7PGRO llNDPAWRTI'liRS INSDRANCE COMPANY BAEZ.RAUL DBA DANTFS CONSTRUCTION INSURER B: INSURER Cr INSURER D: 8 WHEATLAND ST INSURER E: SALEM,MA 01971) INSURER N. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 8 BID T. OF INSURANCE LISTED HE WSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NDTWOHSTANDNG. ANYflEOUDQAENf.TE1TM OR CONOITIDN OF ANY CONTRACT OR OTH61 DOCUMENT WRN RESPECT TO WHICH TH6 CERTFCATElMY BETS SHOWN HO MAY PERTAIN.THE Cella CE AFFOflDED BY Iia:POLCIFB DESCRIBED MEflMN L48DelECr iO FILL THETFANB,FJICLI.daDN9 AND CONDrrI0N9 OF SUCH POLICIES,LMRB 6HOWNMAVHAVE BEEN NEWC®6Y PAD LIMNS. Wan ADD BUB PMCYff DATE POLICYEXPOATE - LTR TYPE or INSURANCE L R POLIOY'NUMBER (LW.1eD1YYW) (LW$DDIWYY) LIMITS GENERAL LIABILITY CH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY AMAGE TO RENTED $ CLAIMSMADE EJOCCUR. REMISES(Eaoccwenco) ED EXP.(Anyone person) $ ERSONAL A ADV INJURY IS GEN'L AGGREGATE LPAIT APPLIES PER: 3ENERAL AGGREGATE $ POLICY PROJECT LOG PRODUCTS-.COMP/OP AGG- $ AUTOMOBILE UABILITY COMBINED SINGLE - S ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY S SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNEOAUTOS PROPERTY DAMAGE $ - (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLANSWADE AGGREGATE $ DEDUCTIBLE S RETENTION $ S A WORKER'S COMPENSATION AND `Y WCSTATUrOY OTHER R EMPLOYER'S LIABILITY YINUB 5B601448-.14, QSMR2014 0911=015 UNITS ANYPRDPERITOWARTNEWEXEOUTNE ©NA E.L.EACH ACCIDENT $ 1,000,000 OFFICE"EMBER EXCLUDEOT (IAandndryb NMI E.L.DISEASE-FA EMPLOYEE g 1,000,000 Nyos.d�.nder E.L.DISEASE-POLICY LIMIT $ 1,000,(100 DESCRIPTION OF OPERATIONS MOW DESCRIPTION OF OPERATONWLOCATIONSIVEMCLES)RESTRICTIONS/SPECIAL ITEMS TMS REPLACES ANYPRIOR CERTIFICATE ISSUED To THE CERTSFICATH HOLDER AFFECTING WORKERS COMP COVERAGE. TT[B WORKERS'COMPENSATION POLICY DORY NOT PROVIDE COVERAGE FOR BAEZ,RAUL. CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 93 WASHINGTON ST IN ACCORDANCE WITH THE POLICY PROVISION AUTHORIZED REPRESENTATIVE SALEM,MA 01970 ACORD 25(2010)05) The ACORD name and logo are registered marks of ACORD 1988.2010 ACORD CORP 1 *bts reserved. 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) A 1 CC 1 r6 LQ�0rf �tvP, Un; C fijleg., , Mai 0!470 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) a. Unrestricted,,-Buildings of an} use group which contain less than 35,000 cubic feet(991m3)of enclosed space. Failure to possess a current edition of the Massachusetts` {1 State Building Code is cause for revocation of this hce�se=5 �nr..pRSlicer�++giefsia,ationvist�-www:�ss. ov DES 6 .S Massachusetts -Department of Public Safety_ Board of Building Regulations and Standards_ I construction Supervisor , License CS iOW4 � RA[JL BAC'Z - 8WHEATLANDS'fR =_ SsleiWhlA 01979 n` Expirati", 0 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 picable No. Item Submitted incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm etarepeaters) 6 HVAC 7 Electrical 8 Plumb' include local connections 9 Gas(Natural,Pmpam Medical or other 10 Surveyed Site Plan(utilities,Wetland,etc 11 S tions 12 Structural Peer Review 13 Structural Tests&inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Enerxv Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentauun 20 Other n otter 22 Other *Aires of Design or Construction for which plans are not complete at the time of application submittal most be identified hereon.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 7jp Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address Cr /Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address Town State Discipline Expiration Date