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667-3A BATES TERRACE - BUILDING INSPECTION i� The Commonwealth of Massachusetts Department of uiPublic 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) 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) Q No.and Street City/Town Zip Code Name of Building(if applicable) .SECTION 2:PROPOSED WORK 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 ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes OD"' No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No E9� Brief Description of Proposed Wor �v_o lr�Cr2� m �h azrr n� Czn� 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❑ 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❑ 1-3❑ I-4❑ 1 M: Mercantile❑ 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 ❑ I 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 inden ' Zone: or on site stem❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazazds to Air Navigation: NIA Historic Conmussion Recic�� Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed ❑ Yes❑ or No❑ 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: SECTION 9: PROPERTY OWNER AUTHORIZATION Name_24and Ad ress of Property Owner ! - Name(Print) j No.and Street City/Town Zip Property Owner Contact Information:L.Q/A lent (/rV o,7 Title Telephone No.(business) Telephone No. (cell) -mail address If applicable,the property owner hereby authorizes t Name jStreet 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) f building is less than 35,000 cu.it of enclosed space and/or not under Construction Control then check here 13 and skip Section 10.1) - 10.1 Registered Professional Responsible for Construction Control Grp oaf Gf� Na goa.sor�/i�fr. 3�C3� m (Re istrant) elep one No. a-m address 61� R 'str lion Number /�y Street Address( Discipline Expiration Date City/Town State Zap p p 102/IGenera/l Contractor Co parry Name s /y�l r L . arm D—Almac Name of Person Responsible for Construction License No. and Type if Applicable 7/r'r may"44 / — C/n7X LI f ,L"1��7r� S efr et Address City/Town State Zip Telephone No. business Telephone No. cell a-mail addr s SECTION 11:I4'ORKERS'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 yssuance of the building permit. Is a signed Affidavit submitted with this application? Yes ur No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE - Item Estimated Costs:(Labor 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 6.Total Cost $ (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 info contained in this application is true and accurate to the best of my knowledge and understanding. Please print and sign name Title T o e No. Date - Street Address City/Town e Zip Municipal Inspector to fill out this section upon application approval: 5V/E Name VDate Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are 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) No. and Street city gown Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes Cl No ❑ Other (if applicable) 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"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural // 2 Foundation 3 Structural - 4 Fire Suppression - 5 Fire Alarm(may re uire repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other) t/- 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review t/ - 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investi ation 16 Energy Conservation Report 1/ 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance - - 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *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 anginal pemiit fee. Registered Professional Contact Information �onPvm� /3 rO� Name(Registrant) Telephone No. e-mail address ! /gyp ,� Registration Number �AXi A-fti—"" �4 � "T�r Discipline Expiration Date Street ress City/Town State zip - Name(Registrant) Telephone No, e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address - Registration Number Discipline Expiration Date Street Address City/Town State Zip . �la,csatchuacf[a- Department of public ' d1•t% Board of Buildin_ Reg-ulations and Standards Construction Supervisor License License: CS 42144 - CARL O DUMAS 10 BROOKHEAD AVE BEVERLY, MA 01915 Expiration: 6/29/2013 ( nnmisi"°rr 7r# 17037 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 ug Boston, M' assac setts 02116 Home Improvement C r rotor Registration Registration: 113869 Type: Private Corporation m s Expiration: 7/19/2013 Tr# 216609 KNEELAND CONSTRUCTION CO CARL DUMAS a 407 R MYSTIC AVE #34B W MEDFORD, MA 02155 y �rlI A S $ Update Address and return card.Mark reason for change. .. Ej Address ❑ Renewal 7 Employment ❑-Lost Card DPS-CAI 0 50M-04/64-G101216 License or registration valid for individul use only Office ofC`onsume°�usiness egu ahon g y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration; 1365g Type: Office of Consumer Affairs and Business Regulation TKWPNDCONI� Expiration: �013 Private CorporationlOParkPlaza-Suite5170Boston MA 02116 P. `? CARS DUMAS407 R MYSTIC JEQ -� MEDFORD MA 02155>, - ' Undersecretar of valid without signature y iV g ACORD" DATE(MM/DDNVVY) CERTIFICATE OF LIABILITY INSURANCE 12/28/2012 PRODUCER Phone: (978)562-5652 Fax: 978-562-7120 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ` WELSH&PARKER INSURANCE AGENCY,INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 131 COOLIDGE STREET,SUITE 100 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR HUDSON MA01749 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: All America Insurance Company 20222 KNEELAND CONSTRUCTION,INC. INSURER B: Commerce Insurance Company 34754 407 R MYSTIC AVENUE SUITE 34B INSURER C: Torus National Ins Co/Quaker Special Risk MEDFORD MA 02155 INSURER D: Quaker Special Risk INSURER 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 ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ASS ADD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR INSR GATE MM/00/VY GATE MM/OOIYY GENERAL LIABILITY CLP 7998068 08/01/12 08/01/13 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,000 PREMISES Eeoccurence CLAIMS MADE❑ OCCUR MED.EXP(Any one person) $ 10,000 A YES PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ IPCT AUTOMOBILE LIABILITY RNY760 01/04/13 01/04/14 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ B YES X HIRED AUTOS BODILY INJURY $ X NON-OWNEDAUTOS (Per accident) PROPERTY DAMAGE $ _ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS UMBRELLA LIABILITY 71184E120AL1 08/29/12 08/01/13 EACH OCCURRENCE $ 2,000,000 X OCCUR CLAIMS MADE AGGREGATE $ 2,000,000 C $ DEDUCTIBLE - $ X RETENTION$ 10,000 is WORKERS COMPENSATION AND TORWC STATU Y uMrs OTHER EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNEWEXECUTIVE ❑ E.L.EACH ACCIDENT E.L.DISEASE-EA EMPLOYEE $ $ OFFICERNEMBER EXCLUDED? (Mandatory In NH) n yes,de%rlbe under E.L.DISEASE-POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION KNEELAND CONSTRUCTION,-INC. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 407 R MYSTIC AVENUE SUITE 34B EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFF,BUT FAILURE TO MEDFORD MA 02155 DO SO SHALL IMPOSE NOOBLIGATION OR LIABILITY OFANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE �,lll/i4l � Attention: Karen Gedenberg ACORD 25(2009/01) Certificate At 51759 ©1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE DATE 5/24/2012 OS/24/2012 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: I£ the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. I£ 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 coTl£er rights to the certificate holder in lieu of such endorsement(s) RTACT Welsh 6 Parker Insurance vxoxe FAa Agency Inc sA LNa. E.m: (A/C. A.): 131 Coolidge St, Suite 100 A°.E.. g PRmasuft Hudson, MA 01749 C0ST.A TAR' _ Pap 18) AEFmNIM14 COVERAGE C p PNEDasR A: A.I.M. Mutual Insurance Cc 33758 Kneeland ConstructionInc EA 407R Mystic Ave Suite 34B T-P,E., Medford, MA 02155 Tauss¢ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED HAOeD ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIRDWRIT, MINH OR CONDITION OF ANY CONTRACT OR OTHER DOCUPEN'S WITH RESPECT TO WHICH THIS CERTIFICATE NAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERKS, EXCLUSIONS AND CONDITIONS OF.SUCH POLICIES. LDAITS SHOWN MAY HAVE BEEN R®UC BY PAID CLADES. POLICY NUMBER POLICY EFF POLICY EXP L4IIT5 •* TYPE OF INSURANCE o>v®/znxl ¢NvaI— GE!ffiUS. LIABILITY EACV OCCURATFUZ 6 ❑COM6RCIA1,GENERAL LIABILITY O NTEc ❑❑ 9[L A. Da(EM4cc==En.DO— ❑OCCVA eReN 6 ❑ !60 8SP IArry e e penvenl 6 ❑ E GEN'L AGGAECATE L IUT ER. E ❑EOIXI ❑PRNECT N. RWOCLS-CRR/Op Ana 6 6 AUTOMOBILE LIABILITY Co....ansaE LIMT E ❑mm-To Iva etmnc) ❑ALL C4M80-TOS cant IsJ Ipee Pecavvl 6 - ❑RCt WLCD AUT c O4I GT I!4]a0.T(pei ewieen!) 5 ❑xZ 'ID9. PRae. AmEa 5 IPe e 1 FIN..-OWNED ALTOS § El ❑..e IA L ❑ (CNR OLLMNENC6 E ❑EE ❑ CWM NAOE E ❑DEWRIELE 5 ' ❑P¢TEMfION E b MASERS COMPENSATION ® -AND E"P. IAYEES LIABILITY THE PROPRIETOR/PARTNERS/ E.L. EACH ACCIDENT 6 500,000 A EXECUTIVE OFFICERS ARE ® incl ❑ excl 7026261012012 ea. nlSaAac -PDLICT LIHET 6 500,000 04/26/2012 04/26/2013 E.L. nISKUE -EA EXPLOTEE 5 500,000 sM ETA / o¢sLATPTIOP a¢ aP6RATZONe OR...I' CERTIFICATE HOLDER CANCELLATION HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL=1ZCO==WITH EXPIRATION OATS THEREOF, NOTICE WILL BE DELIVERED POLICY PROVISIONS. vtxownCo NaePaccxTAa'x ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 6i7ashington Street Boston, MA 02II1 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibly Name (Business/Organization/Individual): _ Address: �t City/State/Zip: Phone#: Are yo n employer? Check the appropriate box: FE'Rmodehag (required): 1. I am a employer with _ 4. ❑ 1 am a general contractor and I truction employees (full and/or part-time)." have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the. attached sheet, ng ship and have no employees These sub-contractors have onworking for me in any capacity. employees and have workers' addition No workers' comP insurance comp. insurance.$ [ reqrequired.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised them I1.❑ Plumbing repairs or additions self. Y [No P m o 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.] *My 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 thatcheck this box must attached an additional sheet sbowing 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: 4/n L A&z//�l/./✓Z1!��- �[ / — Policy#or Self-ins. Liiccc.. #:7p//' 24 019 6/a Expiration Date: Job Site Address: /' (�/e1�� `7�3� City/State/Zip• 2 !9 . d v 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 Investieations of the DLA for insurance coverage verification. I do hereby certify under the pains and penalties ofpeijury that the information provided above is true and correct. Sienature Date 92 Phone# Of use only, Do not write in this area, to be completed by city or town official - City or Town: Permit/Licease # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector , 6. Other Contact Person: Phone #: