4 PARADISE RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
',��„,f \lassuchusetls Stair Budding Code(780 C,\IR)Seventh Edison
City of Salem
Building Permit Application for any Building other than a i-or 2-Famil
(This Section For Official Useonly)
Building Permit Number: Date Applied: Building Inspector:
SECTION l: LOCATION Alease indicate Block N and Lot N for locations for which a street address is not available)
C-a
,No.and Street Ciiv /Town Zip Code Name of Building(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration O2 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change u(Ocatpancy ❑ Other ❑ Specify:
Are building plansand/or construction documents being supplied as part of this permit application? Yes e No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No lik”
Brief Description of Proposed Work:
.Zw r.r rn;�ew.f<' tCk i.11 r<✓/a/en Ate,.., r'n 4.".,
Ffre.x f� Wfie k /
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing UseGroup(s): JR * reaH..r.,P - 0oq,ir..:a. Proposed UseGroup(s): 8 - 8s� k S
Existing Haavd Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
NA Existing- Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.) 2/✓u /-1 2rac Z o
SECTION 5:USE GROUP(Check as ap lieable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc Cl A-3 ❑ A4❑ A-5❑ B: Business le E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1❑ H-2 ClH-3 ❑ HA❑ H-5❑
1: Institutional 1-1 ❑ 1.2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ Ri Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:., .
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
i
JA IB ❑ IIA ❑ IIB ❑ IIIA ❑ 1116 ea" IV ❑ 1 VA [3 VB (3
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
-I Debris Removal:
Water Supply: I Flood Zone Information- Sewage Disposal: Trench Permit: _/
�r` 11 A trench will not be Licen,ed Dkpuwil Site
Public C heck it out>�dr Flu,�d Lum• Indiertr muniapal CJ
rvywnd N(Ir trench or�pecil'r:
I'nrak•❑ ,r uuirnu(c Zone;._._ ur,,n.dr•c.trm ❑ permit v,unclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I:\ I h,L-ri, c nvu,,,nm It,,,, Pn r,•:
\ -tAl•phcaldc Er— I,Strun uru,.ohm aul+ort oppiuedt.vra' I,Ihuu n•%let, nonplcted'
a 1 ,m,rnt t„ Bud.! end,1.rd ❑ I Vv,❑ �,r Xu� 1'r,❑ \u ❑
SECTION 8:CONTENT OF CERTIFICA FE OF OCCUPANCY
LIL'l nnipi,r'. Q ri pv„t C„n,truawn: _ . Occupant l o,id per l 1,,,.r
thebmldui,p 10111,110.111 Spnnklrr 7v,trm': b �pvcwl?npttLrimm
i
AfeI J
0
SECTION 9: PROPERTY OWNER AUTHORIZATION
NamvL,md Addre•ssol PrnpertY Owner
4(;c—k- Sece435 330 Gyne wc)r Lynn M/t
.Name(Print) No.and Street C ily/Town Lip
wi r 'o act lnlorm.niun:
Title Telephone No. Ibusmrssl Telephone No. (cell) r-mad address
If applicable,the property owner hereby authorizes
Name Street Address Citv/Town Stare Zip
to act on the pro ertc owner's behalf, m all matters relatoe to arork authorized 6 this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
111 buildin p is kms than}3,1x1(1 cu.ft.of enclovd space and/or not under Construction Conlrul then check here O and ski+Sediot+10.1)
10.1 Re istered Professional Responsible for Construction Control
DPL Arr.&cry7YI.331_YS-Y/ 4oz7
Name(Registrant) Telephone Nu. r-mail address Registration Number
2 West S- Y.,. • C• WWme.+ l MA 02r96
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
/'/r}e t.EoOGee ere/ Ce n'fr-c craws F,vC
Company Name:
Ss-T^ tf MRcCEoO CS 37tS8
Name of Person Responsible for Construction / License No. and Type if Applicable
Z 9t. wcvm.Jr71 13-10- a, fv.+ 62.(70
Street Address City/Town State Zip
787 J71- 92oe _ZtSa Sc.tr@r97c 6/e a.d'ne . " ,
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERSCOMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506))
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 13 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Ein
r
Total Construction Cost(from Item 6) =$ 2 9'S,ooca
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=$
3. Plumbing S4. Mechanical (HVAC) $ G Note: Minimum fee=$__(contact municipality)
5. Mechanical (Other) $ Encloxse check payable to
6.To tat Cast S Z Yf o 00 ("',tact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 herebv attest under the pains and penalties of perjury that all of the information contained in this
applicaltun i>��ttrue and accurate hp the b/est of my knowledge and understanding.
S .,r /T My 6 d r d+ ne / eall< r 75'7 .Y7/ . 9 7—oP '//i5'i 6.
I'Ica.c prim-.Ind�i�;n name title iadcphone\o. Date
_2.9C WCynnoJf* S7` �oc'k An C( i1* 024?70
Atreel Wdre" Cit%;Town . tate Zip
Sl u o lci pal Inspector to till out this section upon application approval: J1
\a Da e
I i
Client#:491898 MACLEGEN
— ATE(meb
ACORD., CERTIFICATE OF LIABILITY INSURANCE 0310312010
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
USI Ins Serv.,of MA Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
12 Gill St.,Suite 5500 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDFn RY THE POI IQIFR RFI OW
P O Box 403
Woburn,MA 01888 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Hanover Insurance Company 22292
MacLeod General Contractors,Inc :
296 Weymouth St.,Unit C INSURER INSURER B
B
RorklRnd. MA n.2s7n
- - -- - INSURER D:
.SURER E:
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 MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONCITIONS OF SUCH
POLICIES nCCPFGATF I IIAITS SHOWN'MAY HAVE EEEN REDUCED BY ciVC
TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POCYEXPIRATIBN
LTR NSR DATE MM O D LIMM ODIYY LIMITS
A GENERAL LIABILITY ZBN517446800 03101110 03101/11 EACH OCCURRENCE S1000000
XCOMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 500,000
�OCCUR MED EXP
CLAIMS MADE (Any one penton) 115.000
PERSONAL B ADV INJURY $1.000.000
GENERAL AGGREGATEj$2 000 000
GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $2000000
POLICY
FX]IRI % LOC
A AUTOMOBILE LIABILITY AWN5130044 03/01/10 03/01/11 COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) S
X SCHEDULED AUTOS (Pel person)V 020,000
X HIRED AUTOS
BODILY
X NON-OWNED AUTOS (Peri aci )
denRV $40,000
PROPERTY DAMAGE $1,000,000
(Per acddem)
UAKAGE UABIUI
ANY AUTO UTO O
ANLY-EA ACCIDENT $
OTHER THAN EA ACC $
AUTO ONLY: AGG $
A EXCESSIUMBRELLA LIABILITY UHN517455100 03/01/10 03/01/11 EACH OCCURRENCE $5000000
X OCCUR CLAIMS MADE AGGREGATE $5 000 000
,
DEDUCTIBLE $
X RETENTION $0 $
A WORKERS COMPENSATION AND WHNS130080 03/01110 . 03/01/11 X WC STATU- OTH-
EMPLOYERS'LIABILITY FR
ANY PROPRIETORIPARTNEMEXECUTIVE E.L.EACH ACCIDENT $500,000
OFFICERIMEMBER EXCLUDED'
E` clsensE�EA EMPLOYEE s500,000
r SPECIAL PHUVISIUNS below E.L.DISEASE-POLICY LIMIT I$3UU,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
ol....r.".y v:,..--r r..... rc:! Ie!_:vC, Cf Subr_.._t:"foT r_____, , _:Lar......:ar. ._ a
"� � �Ha• L.u,u y � IIcSpEC152O
WOr1T normal t0 nameti IRSUredS operations.
CF_RTIFICATF_HOI_DF_R__ _ (:ANCFI I ATIOM
a"UULU ANT VT INC XU V VC uEta,m NCU YV UI Icb tlC CANILLLEU CEfUft I HL[XPIHAI IDN
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30_ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
..._.. ._ F�.IT 1.TiJ,
ACORD 25(2001/08)1 Of 2 #S4266989/M4264671 GZGCD 0 ACORD CORPORATION 1988
T�
Board , .I Building i�'egulat o11c .:ad Stan(!.:nls
On.� Ashburt Place - R( rn 1301
oston, M.. . ;achuseti . i 2108
(.-ristructioo �,uperviso: I .icense
Lice CS: 3165E
Restric( 00
Births 9/12/1962
Expiral Tr4 5497
COTT A t ! MEOD
7 BEREAf- AY
WEYMOL: I, MA 021 f
1 to Address ane o .rn card.Mar:. .,on for change
;:tress ❑ Re -. Lost Ci,- i
nPSCg1 (y 50M �� 6�PC6490
Bu+c[ Department of Sd
Board of Buildin_Re-ndatiou and Standards
-
' � —� ` '• tConstruction Su "isor License
�CpMMEf1CiAL D�3�,�°E.iS LICENSEEr'�'"`�`�"
r�x�,PPq License: CS 31656
'•`�574349180dtzsww�a 1 - Restricted to: 00 �-
} y�J"y W
M
ff UP.. (f' 'K G06 y1pF S,S9 .
W2-2014 09 12 19 SCOTT A MACLEOD
f�dpes xes. xcr sv 11+0° „z it 6EREAN WAY
pi6` r BL 507 M {
I PAAC4EOD I ,ijf' .« r .n S WEYMOUTH, MA 02190
1713EREAN WAY -
'EYMOUTH;MA - � 4 y. `..'•""' i �,
Expiration: 9/122011
' ?` smin /P ( i ni.rain�r Tr4: 2677