B-19-700 - 0033 UPHAM STREET - Building Permit The Commonwealth of Massachusetts
\ Department of Public Safety f l �
f Massachusetts State Building Code(780 CMR) i- '"+2 3
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
/ Building Permit Number: Date Applied: I Building Official:
to SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
33 Upham St Salem
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
(�1 Edition of MA State Code used , 9th If New Construction check here❑or check all that apply in the two rows below
V_j Existing Building® Repair❑ Alteration C1 Addition❑ 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 ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
interior rehab of 2 existing side by side units on 2nd & 3rdfloor of a 2-112 s ory,
unit building . New work will consist of demo, new Kitchen, bath and bedroom
lavni ts, PlPrtrirnl_ mechanical_ Renlare winnows I
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) Cl
Existing Use Group(s): H Proposed Use Group(s): -
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 2-1/2 S M E
Total Area(sq.ft.)and Total Height(ft.) SA E
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H. High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ TR. 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 ❑ IV ❑ 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❑
Private❑ or indentify Zone: or on site system❑ required®or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 13 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No N 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:
�t� [ 'G 0 C.AI� y F, v ,
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
RCG 17 Ivaloo St Somerville 02143
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Jim Gagnon -6-1-7-LP-E$315 617 512 228.6 jgagnon@rcg-Ilc.com
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Scott Allison 58 Glad Valley Dr Billerica MA 01821
Name Street Address City/Town State Zip
to act on the p operty 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 buildinp 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
Peter Pitman 97.8 744 8982 pfpitman@juno.com 8749
Name(Registrant) Tele hone No. e-mail address R s ation Number
32 Church St Eem MA 01970 rchitect 8/31/18
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Supreme Builders
Company Name
Scott Allison CS 069628 Unrestricted
Name of Person Responsible for Construction License No. and Type if Applicable
58 Glad Valley Dr Billerica 01821
Street Addre s City/Town State Zip
_ 781-953 6036 scott@supremebuilder.net
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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes■ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor = 251 000.00
and Materials) Total Construction Cost(from Item 6) $
1.Building $ 174,000.00 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ 28,000.00 appropriate municipal factor)_$
3.Plumbing $ 28,000.00
4.Mechanical (HVAC) $ 21.000.00 Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 251,000.00 (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-.s true and accurate to the best of my knowledge and understanding.
Scott Allison Contractor 781-953-6036 6/26/19
Please print and sign name Title Telephone No. Date
58 Glad Valley Dr Billerica 01821
Street Address City/Towne State Zip
Municipal Inspector to fill out this section upon application approval: .2-
ame Date
r
The Commonwealth of Massachusetts
Department of Industrial Accidents
m v Office of Investigations
1 Congress Street, Suite 100
t` Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Supreme Builders & Design,lnc
Address: 58 Glad Valley Dr
City/State/Zip: Billerica, MA 01821 Phone#: 781-953-6036
Are you an employer? Check the appropriate box: Type of project(required):
1.❑■ I am a employer with 2 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑■ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.+
required.I 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LEJ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance: required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:A.I.M. Mutual Ins.
Policy#or Sel -ins. Lic. #:83771 Expiration Date:7/21/19
Job Site Address: 33 Upham St City/State/Zip:Salem, MA
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$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$250.00 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: J Date:6/26/19
Phone#: 781-9536036
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other_
Contact Person: Phone#:
SUPRE-1 OP ID:JM
CERTIFICATE OF LIABILITY INSURANCE DATE(MM
09/07/DDIYYYY)
/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOLES 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 dogs not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER 978-686-2266 NAMEAC T Jen Magazzu
Foster SullivanlnsuYanceE] PHONE 978-686-2266 FAX 978-686-6410
163 Main St.0 aC,No,Exti: (A/c,No):
North Andover,MA 11845J E-MAIL ss:certificates@ fostersul ivangroup.com
Foster Sullivan Insurance LLC
INSURERS AFFORDING COVERAGE NAIC 0
INSURER A,Merchants Mutual Ins.Co. 23329
INSURED Supreme Builders&Design Inch INSURERS:TRAVELERS INSURANCE CO 19046
58 Glad Valley Driven MERCHANTS INSURANCE GROUP 12775
Billerica,MA 01821 INSURER C:
INSURER D
INSURER E•
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTF:Y THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOPNITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MA" BE 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 TYPE OF INSURANCE DDL U D POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSD WVD MM/DD MM/DDIYYYY
C X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE ❑X OCCUR CMP9156153 07/09/2018 07/09/2019 DAMAGE TO RENTED 100,000
PREMISES Ea occurrence $
MED EXP(Anyone erson $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY C]PRO- ❑LOC 2,000,000
JECT PRODUCTS-COMP/OP AGG $
OTHER: $
A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT - 1,000,000
Ea accident $
ANY AUTO MCA1001684 07/09/2018 07/0912019 BODILY INJURY PerPerson) $
OWNED SCHEDULED
AUTOS ONLY X AUTOS BODILY INJURY Per accident $
X HIRED X NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Per accident $.
$
C X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000
EXCESS LIAR CLAIMS-MADE CUP9149088 07/09/2018 07/09/2019 AGGREGATE $
DED I X _RETENTION$ 10000 $
B WORKERS COMPENSATION
PERT OTH-
AND EMPLOYER: LIABILITY YIN - STLITEE
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ WCAR ISSUED BY MA CARRIER E.L.EACH ACCIDENT $
FFICER/MEMBER EXCLUDED? N/A
Mandatory in NH) E.L.DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25(20f16/03) @ 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Commonwealth of Massachusetts
Division of Professional Licea -
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Information and .Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to th'.s statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or imlalied, oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into anv contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned ,o the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts:
Department of Industrial Accidents
i Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE
Revised 7-2013 Fax # 617-727-7749
www.rnass.gov/dia