94 WHARF ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
UlfDepartment 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) 77,
Building Permit Number: Date Applied: Building Official.•
SECTION 16 LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available),•,i:.,'?'
Ti J} n M v a4021 n7G 13�l X
No.and Street City/Town Zip Code Name of Building(if applicable)
"�lx. :• SECTION 2:PROPOSED WORK
t 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 ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Other ❑ Sec
Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
��. Is an Independent Structural EngineermR Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: tea, c1 N' t� to
S lr cf
D : s Tut L
Irvy^610 Q,6 CD O
•r,w SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING NT)ERGOING RENOVATION,ADDITION OR N
CHANGE IN USE OR OCCUPANCY .s.: " ,}'_•
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
'< '*••'< s SECTION 4:BUILDING HEIGHT AND AREA :Er
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Z, fSO
Total Area(sq.ft.)and Total Height(ft.) Z4 t
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❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ 1-2❑• 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
'' , "t';'%J, 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)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public Check if outside Flood Zone❑ Indicate municipal A trench will not c P
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ 1.pt�14;S►1xl/' kt
Railroad right-of-w y: Hazards to Air Navigation: MA Historic Conmrission Review Process:
Not Applicable Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No Yes❑ No
- ,SECTIONS: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:
r
' SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner C -
Ja�PVr
f Name(Pr' No.and Street City/Town Z1p
Property Owner Contact Information:
�o�lc�npel �ocke7 _ L --
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the perry owner hereby authorizes
51 Wy NarF 5t- S1eAE r.•
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 a2pljution.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
buildingis less than 35;000 cui ft.of enclosed space and/or not under Construction Control then check here and ski 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
16..2�-General Contractor
Company Name
CS Cq 77-3 U
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
ow
Tele hone No. business Tele hone No. cell a-m ' ddress
SECTION 11:WORKERS'COMPENSATION 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' ance of the building permit.
Is a signed Affidavit submitted with this application? Yes No ❑
- SECTION 12.CONSTRUCTION COSTS AND PERMIT fEE
Estimated Costs:(Labor
Item 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 $
Note:Minimum fee=$ (contact municipality)
4.Mechanical (HVAC) $
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ Q (contact municipality)and write check number here
' • SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT •n
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.
Please print and sign name ` Title Telephone No. Date
Street Address City/Town State Zip
r
Municipal Inspector to fill out this section upon'application approval
' Date
Nanie .
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'Y'where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters) "
6 HVAC
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 Pro ram
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 S ec'
22 Other S ec'
"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
\7CAW ;� �� 839-335 lrn rcldcs r Cs-�f7��
Name(Registrant) Telephone No. e-mail address i� " VA
Registration Number
_ fir ' lD I
Street Address City/Town State Zip Discipline Expiration ate
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
Discipline Expiration Date
Street Address City/Town State Zip
T° CITY OF &U-EM, NLUSACHUSETTS
i
BL'ILDtNG DEPART MINT
120 \\'/.1SHLNGTON STREET, 3rO FLOOR
T EL (978) 745-9595
FLY(978) 740-9846
K!\IBERL.EY DR]SCC LL THOW&W ST.PIEM
,NLAYOR
DIRECTOR OF PUBLIC PROPERTY/BI:II.DI1G CO\L\fISSlONER
Workers' Cofnpensation Insurance Amdavit: Builders/Contractors/Electricians/Plumbers
Anolleant Information ` , 1 Please Print Leeibly
V;II11C Iflusin¢ss Orgmsinli°m'Individual): Clr 1•V�.. C.�caJdt�
Address: I ooj3 k)Hz;iv(� 5}-
City/State/zip: Sr, leiu , l Phone N:
Arc you an employer?Check the appropriate boa: Type of project(required):
I. I 1 am a er with employer 3 4, 0 1 am a general contractor and I
p y 6. []New construction
employees(full and/or pan-time).• have hired the subcontractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. C]Demolition
working liar me in any capacity. workers'romp.insurance. 9. 0 Building addition
lNo workers comp. insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions
myself(No workers'comp. c. 152,§1(4),and we have no 12.0 Roorrepairs
insurance required.) t employees.(No workers' 13.0 Other
cutup.insurance rcquin d.j
-Any applicam thus checks boa rl most also rill out the mi un below showing their wotken'compensation policy information.
'I l,unaowm"who whmit this aQktnvis indicating they art doing all work and then him outside eontneton mml suhmil a rww alfidavit indicating ,ch.
:Cwometoo Out chwlt Ibis box mtnt amchal an addiliuml steel showing the name of the sub.anincton and(heir worked'camp.policy infwmalion.
l run un rntpluyer ifimf lr providing Ivorkers'conipeitsation iururdncejor my employees. Below lx fbe pollcy and job Nile
in/urination.
Insurance Company Name: ' e 6z Awe .._Jns VY'QN eL ,� �,
Policy it or Sclf-ins. Lic.�J0: ' 1NAJ Q1 54`Q Expiration Date:__?1`-a- _
Job Site Address: 9 T to Cx I��Jh City/State/Zip: S j,i 0[ ram_
Astach a copy of the worlten'compensation policy declaration page(showing she policy number and esplrmlon date).
Failure-to seeurc coverage as required under Section 25A of NfGL c. 152 an lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprismmvens,as well as civil penalties in the farm of a STOP WORK ORDER and a fine
of up to S230.00 a day against the violator. Ile advised that a copy of this statement may be rurwarded to the Office or
Investigations orthe DIA for insurance coverage vcrificatiun.
/du hereby cent(j and dse pubs erjury lbuf the btfunuudon provided ubuvve�is Prue an t d correct.
S ,•nt Uatd 1'L171ZJZ1)I`f
P i A: _ r t
!7J/trial uae onl),. Ou not Ivriu in this urru,to be completed by ally ur folvn njjiriat
City nr Town:
Issuing Aulburily(circle uric): -- -_- --- --
1. Board of Ilealth 1. Building Departntrut .1.Cilyrfnwn Clerk 4. F.IectrieNl Inspector 5. Phnnbing luspect°r
6. Other
Contact Perron: Phone 1J:_
f
DATE(MMIDDIYYYY)
ACORD CERTIFICATE OF LIABILITY INSURANCE rl/21/2014
! PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS:A MATTER;OF INFORMATION:
Rose Insurance ONLY AND CONFERS NO RIGHTS. UPON THE. CERTIFICATE
HOLDER.. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR-
66 Loring-'Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 958,
Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC4: ._._
INSURED INSURERA:MI'.RCHANTS INSURANCE GROUP _
daddi:s, James'.� INSURER R.Guard
lOOB Wharf Street INsuaERc.
INSURER D'
Salem MA 01970-
(COVERAGES .. __. .
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 MAYBE ISSUED OR MAYPERTAIN,.
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN'IS SUBJECT TO ALL THE TERMS, EXCLUSIONS:AND CONDITIONS OF SUCH,POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIDCLAIMS.
INSR DDL POLICY EFFECTIVE POLICY EXPIRATION
LTR INSR TYPE OF INSURANCE :POLICY:NUMBER OATE(MMIDOIYY( DATE MMIODIYY). UMITS
A GENERAL LIABILITY BOPIO80314 07/07/2014 07/07/2015' EACH OCCURRENCE : $ 1000006
X} COMMERCIALGENERALUABILITY DAMAGETORENTED 50000
PREMISES Ea o=rrerwe
CLAIMS MADE ❑OCCUR / ./ / / MED EXP(Mn one Parson) 5 5000
PERSONAL&ADV INJURY '$ 1000000
'GENERAL AGGREGATE 'S' .2000000,
GENT AGGREGATE LIMIT'APPLIES PER- PRODUCTS-COMPIOPAGG. 6 2000066
Poucr �Ea LOc
AUTOMOSILELIABILITY / / / / -'
COMBINED SINGLE LIMIT
ANY AUTO' (Ea acc,dem). $
.ALL OWNED.AUTOS BODILY INJURV
SCHEOUIED AUTOS' IPer person); - 0
HIRED AUTOS / / I ! BODILY INJURY
NON-OWNED.AUTOS (Pera c on '8.
PROPERTY DAMAGE
(Per ecviderd) .5
GARAGE EDIBILITY T
AUTO ONLY-EA ACCIDEM-. s
ANY AUTO / / /
OTHEREA ACC`AU'rOONLY: .5'.
AGG; S
' _..
.EXCESSIUMBRELLA LIABILITY /' / / / $
'
OCCUR �CLAIMS MADE AG�H OCCURRENCE 3
DEDUCTIBLE'
B WORKERS COMPENSATXNTAND JAWC556040 03/05/2014 03/05/2015 $ M5TATU- OIH
ERA
EMPLOYERS'-LIABWTY
ANY PROPRIETORRARTNERIEXECUTIVE E.L.EACH ACCIDENT S :100000
OFFICERAMEMBFR EXCLUDED? E.L.DISEASE EA EMPLOYE 5 100000
If m.de5Ql1'2 MDQr
SPEOIALPRON51ONSbeb E:L.DISEASE POLICY LIMIT 1 -500000.
OTHER
DESCRIPTION OF OPERATIONSLOCATIONSrVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS '
:CERTIFICATE'HOLDER :CANCELLATION _
'SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE:
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER°NAMED TO THE.LEFT,BUT
Insured'S records FAILURE TO DO SO SHALL IMPOSE NO OSUTATION OR LIABILITY OF ANY KIND UPON THE
E
INSURER,ITS AGENTS OR REPRESENTATIVES.
AUTHOR REPRESENTATIVE
ACORD 26(2001108) O ACORD CORPORATION:1988'