5 WOODSIDE ST - BUILDING INSPECTION (3) � cK i l � � 5�0 „�
� . RECEIVED �
��+ IONAL SERViL"ES
�� The Commonwealth of Massachusetts
� Department oE Public SaF��b J�H 'L 1 P �� ��
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This SecHon 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)
� 5 tJaad..s��de Sl�ree� .�ler� /�'l.� Oi�76
� No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
{ EdiHon of MA State Code used_ If New Construction check here O or check all that a 1 u�the two rows below
(1 PP Y
`�} Existing Building�I Repair� AlteraHon ❑ Addition❑ DemoliHon �' (Please fill out and submit Appendix 1)
� Change of Use ❑ Chan e of Occu anc ❑
1 8 P . Y Other ❑ Specify:
Are building plans and/or construction documents being supplied as art of this permit application? Yes � No ❑
� IsanIndependentStructuralEngineeringPeerReviewreqvired? ���^�• U�wWwsc+.4 nt.� Yes ❑ No ❑
Br'ef DescripHon of Proposed Work Lr�o a.i S�a,� �„�e� I�e+rovt j wa�l�, qnot ca. ' h . �V�.
—' �co�fii �.i C '��o�� S a/ w e l� -` o o�Co✓� r� d na e ht�� e roo.v. i n L,e �o F n�
C/'2a�1'e o� SQcO�..c�- �. ��.i r �`cr✓'� S��l��� w e�1 on l�c � ha- ✓�n; d.�f n.0 -F'1 hOr.+e
3`t � i� C(JQW0.�I�tO �e J� ��lo � e,c �¢ or o�e�l c-� r � ol� M >
��h- a oa� � va C�O,,.� Sai., r �,c 1 C✓ea'ce a NeU �� erio[ S
S�� , oor p��tie
IGoC v.�' a.\\ ��a Ir�1�C�n ;1-n �v.\I c�i lerS on raeF �� p�s. rnz �b,�,s
SECTION 3:COMPLETE THIS SECTION IF E � ING BUILDING UND RGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building InvesHgaHon and Evaluarion 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.) S6Qv S-G ,�6� S�—
Total Area(sq.ft.)and Total Height(ft.) �Z�Sy 31,3"N
SECTION 5:USE GROUP(Check as applicable)
A: Assembly q-1 ❑ A-2❑ Nightclub ❑ A3 ❑ A-4❑ A-5❑ B: Business ❑
F: Facto F-1❑ F2❑ E: Educational ❑
H: Hi Hazazd H-1 ❑ H-2❑ H-3 ❑ H4❑ 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 Sl O S-2❑ U: Urility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUC'TION T'YPE(Check as applicable)
IAO IBO IIA ❑ IIBO IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Informarion: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indenfify Zone: or on site system❑ Ce9uired O or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigarion: Mr�tti,taric Comm�ssion Re��iew P�nce:s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes O or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
EdiHon of Code: Use Group(s): Type of ConstrucHon: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special SfipulaHons: .
M ri 1 t.-� "i-'o Y�) • Ca�tZra�-1 � �Z�i �1 te
SECTION 9: PROPERTY OWNER AUTHORIZATION .
� � N�m�e and Addrp�s�of Property Owner
1-I�n��ne,a I V eti1�0.11 �vr c T�1,.,1✓1
_ Name(Print) No.and Street City/ own � Zip
Property Owner Contact Information:
d,..�n e r" ��I _.fa4 _ 71� b y81 _97�' _ 731`� r'�{I'he„✓_ne..il, I �z ,co,.�
Title Telephone No. (business) Telephone No. (cell) e-mail address
If a plicable,the pro erty owner hereby authorizes
�;H�� �ro�V _ 3�'jr�ludr�rell�ni�� .^I-�%1'�� �DrS_�_
Name St et Address City/Town State Zip
to act on the ro er owner's behalf,in all matters relative to work authorized b this buildin ermit a IicaHon.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendiac 2)
If buildin is less than 35,000 cu.ft.of enclosed s ace and/or not under Conshuction Contro]then check here O and ski Section 101
10.1 Re istered Professional Res onsible for ConstrucHon Confrol
'-7 ��/10�+� l�fw... 1/U _Z�� -�� I/Ni'��11��'fhwU'�1ayGwy '��166 � L L
� Na e(Regis�{ant) 1 T ephon No. � e-mail addres��} Registration Number�_ /G /y
� V c�\(Xl S1(C� LJ2 � �� �I�1� 1 I
Street Address City/To State Zip Discipline ExpiraHon Date
102 General Conlractor
C�i�� l �e��-o
Company Name
C.G r 1 Ir e n�Q C;S - U-1CaC�t3
Name of Person Responsible for Constmction License No. and Type if Applicable
� �3 �oSl'dv1 S� fee� .��eM Vhv� O1�1'0
Street AddressG City/Town State Zip
l-y�-�} - � 7p✓ _= CAr� . �en�-p � �G��loo,Gp.^'�
Tele hone No. business Tele hone No. cell e-mail address
SECTION 11:WORKERS'COMPEA�SA"1'lON INSURANCE AFFIUAVIT M.G.L.c.152.§ 25C 6))
A Workers'CompensaHon Insurance Affidavit from the MA Depaztment of Industrial Accidents must be completed and
submitted with this applicafion. Failvre to provide this affidavit will result in the denial of the issuance of the building permit.
Is a si ed Affidavit subauHed with this a lication? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item EsHmated Costs:(Labor p
and Materials) Tota]ConstrucHon Cost(from Item 6)_$ 0 d���U� Q�
. 1.Building $ gb 000,°O Building Permit Fee=Total Construcfion Cost x_(Insert here
. 2.Electrical $ a ro riate munici al factor =$
PP P P )
, 3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to ���ln 6�" `��n�P^
6.Total Cost $ (contact municipality)and write chec number here
SECTION 13:SIGNATURE OF BUILDING PERMTT APPLICANT
By entering my name below,I hereby attest under the pains and penalfies of pequry that all of the informafion contained in this
application is true and accurate to the best of my knowledge and understanding.
� - N�-�h�� G�a,� H�.G oWne� 9n _z�o _-��6 � � 6
PI�7s � tt��-,,ed name �7 Title Telephone No. Date
` � �ie��' / W�'�o�J ��Jef�h Y"1P 019�
Street Address City/Town State Zip
i"
Municipal Inspector to fill out this seckion upon applicaHon approval: v 'S � � /
Name Dat
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections aze 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) ,,�+-. �,
� �oc�si�e S�Ge�'r" ��e.r���c. -(Q*' a
No. and Street City/Town t� �x Name of Building(if applicable)
� � ..
a�� :
For the above described property the f llowing action was taken "
,
«�
s..
Water Shut Off? Yes�I No ❑ Provider notified and Release obtained?:"Yes ❑ No ❑
Gas Shut Off? Yes�J No ❑ Provider notified and Release pli'tained? Yes ❑ No ❑
Electricity Shut Off? Yes'� No ❑ Provider notified and R�se 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)
�,
r
�
Appendix 2
Construction Documents are required for siructures 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 a licable
No. Item SubmiHed Incom lete Not Re uired
1 Architectural X
2 Foundation 't �
3 Structural X
4 Fire Su ression
� 5 Fire Alarm ma re uire re eaters
, 6 HVAC �(
7 Electrical k
�8 Plumbin include local connecfions �C
' 9 Gas Natural,Pro ane,Medical or other �r .
10 Surve ed Site Plan UtIlities,Wefland,etc. �C
' 11 5 ecificaHons �!
� 12 Structural Peer Review k
� 13 Structural Tests&Ins ections Pro am
14 Fire Protection Narrative Re ort
15 Exisfln Buildin Surve /ImesH ation
16 Ener ConservaHon Re ort
17 Architectural Access Review 521 CMR
18 W orkers Com ensation Insurance
19 Hazardous Material MiH ation Documentation
20� Other S ecif
21 Other S ec'
22 Other S eci
. *Areas of Design or Construction for which plans are not complete at the Hme of application submittal must be identified herein.Work
so identified must not be commenced until this applicaHon has been amended and the proposed construction document amendment
, has been approved by the authority having jurisdiction.Work started prior to approva]may be subjected to triple the original yermit
fee.
, Registered Professional Contact InformaHon
NQ�LI NPJ� l:l �0.v -/ /0_��� - ���0 }��IIUCI �•W�' Mry �Z3 6G
IVame(Registrant) Tg�hone No. e-mail address � RegistraHon Number
�w��1o,� Sfi��e� JSever�U j 1�, Glq�_> G � ��
Street Address City/To . State Zip Discipline ExpiraHon Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci /Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address aegistration Number
Street Address Ci /Town State �Zi Discipline ExpiraHonDate
� Marssa�Chus+ett� - L�ep�art�r'�ent t�` i�e�biic Sartc�
B�aard r�f Buil�iin� Regulaticns and Star��iards
,y� r+^a`�
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t..icettse: �5-Q70�d3 �
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S�AL�M MA Q19'� .�
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'� � y COMMERCIAL LINES POLICY
, rl BUSINESSOWNERS POLICY DECLARATIONS
Policy Number: BOP 1078179
Namedlnsured: NATHAN M GRAY DBA PolicyPeriod: 03/14/14 to 03/14/15
BUSINESS LIABILITY
Limit of Insurance
Business Liability Limits
General Aggregate Limit
(Other than Products-Completed Operations) $ 2,000,000
Products-Completed Operations Aggregate $ 2,000,000
Personal and Advertising Injury Included
Business Liability/Occurrence $ 1 ,000,000
Fire Legal Liability Limit (Damage to Premises Rented to You) $ 500,000
Medical Expense (Any One Person) $ 15,000
Business Liability Class
Loc. No. 001 Bldg. No. 001
132016 Handyman
Full Time Employees 1
FORMS AND ENDORSEMENTS ATTACHED AT INCEPTION APPLYING TO THIS COVERAGE PART AND MADE
PART OF THIS POLICY AT TIME OF ISSUE:
BP0446(0106) ORDINANCE OR LAW COVERAGE
BP0456(0106) UTILITY SERVICES-DIRECT DAMAGE
BP0457(0106) UTILITY SERVICES-TIME ELEMENT
BP0523(0108) CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM
BP0542 0108) EXCL-PUNITIVE DAMAGES RELATED TO CERTIFIED ACTS OF TERRORISM
BP0702 0702) AMENDMENT-AGGREGATE LIMIT OF INSURANCE (PER PROJECT)
MU8237(0907) EMPLOYMENT PRACTICES LIABILITY
MU8271 (0907) EMPLOYMENT PRACTICES LIABILITY INSURANCE SUPP DECLARATIONS
MU8285(0907) FINE ARTS
MU8286(0907) COMMUNICATIONS EQUIPMENT
MU8369(0109) CONTRACTORS' INSTALLATION TOOLS AND EQUIPMENT
MU8540 0109) ROOFING EXCLUSION
MU8543 0109) EXCLUSION OF INJURY TO EMPLOYEES
MU8544(0109) INSURED CONTRACT REDEFINED
MU8545(0109) SPECIFIED ROOFING EXCLUSION
MU8684(0310) HANDYMAN PLUS ENDORSEMENT
MU8938(0114) POLICYHOLDER NOTICE-TERRORISM
BP0003(0106) BUSINESSOWNERS COVERAGE FORM
BP0108(0106) MASSACHUSSETTS CHANGES
BP0453(0106) WATER BACKUP AND SUMP PUMP
BP0454(0106) NEWLY ACQUIRED ORGANIZATIONS
BP0493(0106) TOTAL POLL EXCL W/BLDG HEAT E�UIP EXCEPT/HOSTILE FIRE EXCEPT
BPO501 (0702) CALCULATION OF PREMIUM
BP0517(0106) EXCLUSION-SILICA OR SILICA RELATED DUST
BP0564(0107) CONDITIONAL EXCL OF TERROR-RELATING TO DISPOSITION-FED ACT
BP0577(0106) FUNGI OR BACTERIA EXCLUSION (LIABILITY)
BPO606(0107) MASSACHUSETTS-EXCLUSION OF LOSS DUE TO VIRUS OR BACTERIA
BP0698(0906) MASSACHUSETTS-FUNGI ,WETJDRY ROT, BACTERIA EXCL & LIMITATIONS
MSIU05(1199) FRAUD TIP LINE
MU7912 0114) NOTICE-OFFER OF TERRORISM COVERAGE AND DISCLOSURE OF PREMIUM
MU8186 0107) IDENTITY RECOVERY COVERAGE
MU8239(0907) EQUIPMENT BREAKDOWN
MU8281 (0907) ASBESTOS EXCLUSION
MU8382 0907) MAP POLICY DECLARATIONS
MU8403�0907) MAP POLICY JACKET
MU 8382(09/07)
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