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B-19-1089 - 0164R BOSTON STREET - Building Permit The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) GOBuilding Permit Application for any Building other than a One-or Two-Family Dwelling /O (This Section For Official Use Only) c1 Building Permit Number: Date Applied: Building Official: SECTION 11-LOCATION_(Please indicate Block#and Lot#for locations for which a street address is not available) ^ N-o:an is-Streets � , Building i. :: � ..-� " Zip Code Name of (if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used qtpi If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other iKSpecify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No iZL Is an Independent Structural Engineering Peer Review required? -- Yes ❑ No Brief Description of Proposed Work: G°�O $-A 1 S:"l,N� �' M rv►c m 0,A-e,i a A-S �N501c�' L:cisrz,ye �<y,✓L.al�� /ES ✓.iteO . yD /yz— &y+ ' <,Arivi.F r /tovvG75 4 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 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 ❑ A-4❑ A-5❑ T B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional 1-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile @d R: 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) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 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 rd Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:,�nm- e-5 permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Cominission Review Process: Not Applicable& Is Structure within airport approach area? Is their review completed? - or Consent to Build enclosed❑ Yes❑ or No.gl Yes❑ No ❑ SECTION 8: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: Boll ptVLAZO -it> SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) C6MQWV, No.and Street City/To Zip Property Owner Contact Information: mitt_ 9MW !WqM - Title Telephone No.(business) Telephone No. (cell) e-mail address Ifffe-ha plicable,the property owner hereby authorizes id CAI ls(-w Pa 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*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 COO Company Name Name of Person Responsible for Construction License No. and Type if Applicable On I)r tt,,.�� Street Address City/Town State Zi ?$l _q -- 1 G, ill e 55-M G 0 rdhy0Q 1)Q , 'O6'A') Telephone No.(business) Telephone No. cell e-mail address 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' suance of the building permit. Is a signed Affidavit submitted with this application? Yes ENo 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor z 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 $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) ',/ 5.Mechanical Other $ Enclose check payable to cV `� 6.Total Cost $ vm (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. VIC"AC. NollSkin Please print and sign name Title Telephone No. Date /X enieYpl se TX worq&Vi , ML CV0 U Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: DcL& 4 Name Date The Commonwealth of Massachusetts Department"of Industrial Accidents 1 Congress Street,Suite 100 Boston,LIMA 02114-2017 uV6� www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Pltimbers.. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information _ yy Please Print LelZibly Name (Business/Organization/Individual): Ii'1 V_cy'CLYIo Corp Address: G y-xA City/State/Zip: �,KaYS\-X�\e_k6 l�A&® hone#: "13` inn- CL000 Are you an employer?Check the appropriate box: Type of project(required): 1.9 1 am a employer,with employees(full and/orpart-iunej." 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no einployees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required] 3.❑I am whomeowner doing all work myself.[No workers'comp.insurance required.]t _._ 4. El Demolition 10❑Building addition 4.O 1 am a homeowner and will be hiring contractors to conduct all work on my property. [will ensure that all contractors either have workers'compensation insurance or are sole 1 LE]Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5. 1 am a general contractor and I h hidh sub-contractorslid thetthed sheet have re the listed on attached❑ 13.Dg Roof repairs These sub-contractors have employees and have workers'comp.insurance.; 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14'. Other 152,§1(4),and we,6ve no employees,(No workers'comp.insurance required.) — *Any applicant that checks box#1 must also till out the section below showing,their workers'compensation policy information. o Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new.affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If-the sub-contractors have employees,they must provide their workers'comp.policy number. I arts an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: memnap,5 In rA 00-- a<hool6n Dc - Policy#or Self-ins:Lic.#: Y V PA 527 013B 13 Expiration Date: Job Site Address: 4)U I sy City/State/Zip: Attach a copy of the workers'comp¢nsation policy declaration page(showing the policy number and expiration date). Failure to-secure coverage as required under MGL c. 152,§25A is a criminal violation-punishable by a fine up.to$1,500.00 and/or one-year,imprisonment,as well as.civil penalties intheform of a STOP WORK ORDER and a fine of up to$250.00 a day against the,violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA'for insurance coverage verification. I do hereby certify under thepains andpenalties ofperjury that the information provided above is]true and correct. Signature• Date: 9 f27/13 Phone#: Official use only.. Do not write in'this area,to be completed by city or town official. City or Town: Permit/Lice. nse:# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.CityTTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other_ Contact Person:. Phone#: r ACO CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDD"YYY) 09/24/2019 THIS CERTIFICATE 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. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Laura Wiesner NAME: C&S Insurance Agency,Inc. PHONE (508)339-2951 FAX (508)339-4811 _ AIC No Ext: A/C,No 190 Chauncy Street1P.O Box 406 E-MAIL laura@candsins:com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Mansfield MA 02048 INSURERA: Firemens Ins Co Of Washington DC 21784 INSURED INSURER B: Navigators Specialty 36056 RCH ROOFING CORP INSURER C: 120 ENTERPRISE DRIVE INSURERD: INSURER E: MARSHFIELD MA 02050 INSURERF: COVERAGES = CERTIFICATE NUMBER: 2019-2020 Master REVISION NUMBER: THIS IS TO CERTIFY THAT 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR _ DA AG O 300,000 PREMISES Ea occurrence $ MED EXP(Any one person) $ 10,000 _ A Y Y CPA5270131-13 08/25/2019 08/25/2020 PERSONAL&ADVINJURY $ 1,000,000� GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO ❑LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: AUTOMOBILE LIABILITY COMBINED SINGLELIMIT $ 1,000,000 - Ea accident ANYAUTO BODILY INJURY(Per person) $ - A OWNED rx SCHEDULED Y Y MAA5270132-13 08/25/2019 08/25/2020 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOSHIRED NON-OWNED - PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X UMBRELLA LIAB X OCCUR _ EACH OCCURRENCE $ 10,000,000 B EXCESS LIAB CLAIMS-MADE GA19EXC8222591C 08/25/2019 08/25/2020 AGGREGATE $ 10,000,000 DED I X1 RETENTION$ 0 $ WORKERS COMPENSATION PER/� STATUTE ERH AND EMPLOYERS'LIABILITY y/N 1,000,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE N/A Y WPA5270133-13 08/25/2019 08/25/2020 E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Rented or Leased Contractors Limit $105,000 A Equipment CPA5270131-13 08/25/2019 08/25/2020 Deductible $1,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Project:Roof Replacement Stop&Shop Store 005 17 Howley Street Peabody MA 01960 Ahold USA Inc.,its subsidiaries,divisions,agents,employees and directors and the Construction Manager are included as additional insured with respect to General Liability and Auto Liability. Coverage under such policies shall be-primary and non-contributory. A-waiver of subrogation applies to additional insureds on General Liability,Automobile Liability and Worker Compensation policies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Ahold USA,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. C/O Willis Towers Watson AUTHORIZED REPRESENTATIVE 275 Grove St Suite 2-300 Auburndale MA 02466 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ommonwealth of Massachusetts G I ® Division of Professional Regula Regulations and Standards 1 Board of Building -b rvisor Constr�lo �f3 F�cplres:0812612021 ; CS-103606 ry emu' elm I RICHARD C H OLLSTEI 1 ATLANTIC STREET MARSHFIELDA 02050 �p �l T a,�,k•^�'Teti � , I Commissioner , '� - r QPrY OF SALE4 wsACME M 120�BUO DOIG DEPAR71MNP �FIINGPONSMET,3=F7.00R IkL.(978)745.9595 RAMERLEYDRISODLL FAX(978)74a9846 MAYOR DIRECTOR OPPUBLICPROPERTY/BUI DMQpt,WSS IONER Construction Debris DisposalAffi davit(requiredfor al demolition & renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 D and the provisions of MGL c40,S54;Building Permit# ebris, is issued with the condition that the debris resulting from this work shall be disposed of in a Properly licenses waste deposit facility as defined by MGL c 111,S150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature o a plicant (today dat ) CITY OF SiUXINI, 1%ASSACHUSETTS BU¢Db`G DEPun.0 14T ' 130 W 1SHINGTON$'IREETs 3aD FLOOR T EL (978)74S-9595 F KIMBERLEY DRISCOLL FAX(978) 740-9846 MAYOR T HOMAS ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BVII.DLNG COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben Applicant Information Please Print i.eai Iv Name(BusinessrOrganization/individual): Address: City/State/Zip: Phone 1/: Are you an employer?Check the appropriate box: (r Type Of Project wuired): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner_ listed on the attached sheet.: 7• ❑Remodeling ship and have no employees These sub-contractors have S. Q Demolition working for me in any capacity. workers'comp.insurance. 9. Q Building addition [No workers'comp,insurance 5. ❑ We am a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MOL 1 I.Q 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' comp.insurance required.] 13.❑Other ra Any APp1lcW that chocks box N 1 must also fill out the section below stowing their wokken'compa cation policy infumsadon. 'I Im"cownem who submit this affidavit indicting 1*are doing all work and then hire otmide eonaaeeon must submit a new affidavit indicting such=Cunuaeton that check this box must attachod an additional shed showing the name of the sub.00ntnwton and their woken' trnation. romp.policy info 1 am an employer that is praviAWg workers'compensadon insurance for my employees. Below Is the paley and fob site informadois. Insurance Company Name: Policy k or Self--ins.Lic.tY: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to swum coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 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 DIA for insurance coverage verification. l do hereby certify under the pains and penalties of perlury that the information provided above is true and correct. Sienature: Date Phoned: Official use only. Do not write in this area,to be cornpieted by city or town 0 ciaL City or Town: PermIdUcense# Issuing Authority(circle one): _ I. Board of Health 2.Building Department J.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector 6.Other . Contact Person: ______ Phone#: