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10 BECKET ST - BUILDING INSPECTION R C:K S5-7 ->-t3- ILA - i o tt � �ccelvEo 11 -J"L INSPECTIONAL SERVICES The Commonwealth of Massachuseik �3 A B 29 Department of Public Safety AN Massachusetts State Building Code(780 CMR) ^ Building Permit Application for any Building other than a One-or Two-F it Dw in i (This Section For Official Use 0nly) - Building Permit Number: Date Applied: Building Official SECTION 1:LOCATION(Please indicate Block k and Lot H for locations for which a street ress is n e / 44" S,*l,*t al749 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2-PROPOSED WORK Edition of NIA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ 1 Repair Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑— Change of Ocaipauicy . ❑ Other O.Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 9 Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed bVOrk: f ir'! ' e• S ON Ap �eaire0 till ../ o it ---- -- b✓a.Ge ,re a 'c 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 CNIR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)8r 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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ I H: High Hazard H-t❑ H-2❑ H-3 ❑ H-4❑ jR4 ❑ 1: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-f 11M: Mercantile❑ R: Residential R413 R-2 EJR-3❑ ❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe belowUse. SECTION 6:CONSTRUCTIONTYPE(Check as a plicable) IA ❑ IB ❑ HA ❑ IIB ❑ IIIA ❑ I11B ❑ IV ❑ VA ❑ VB e 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 required ❑or trench or specify:Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: NO I lutr,ic C,m iw n it , I r tc,,: 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: (O t 1, M o. e t]3Vt3��fl SECT[ON9: PROPERTYOWNER AUTHORIZATION NanrL.'uii1=A'ddiiss�ofi Rr�p4itylbwncr F�r {� /�.I'W? ynTY(J rigO, S I lrUL d19i No.and Street City/Town Zip Property Owner Contact Information: 6,17_3?� 7W3, Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Addre .. :.,,Nr City/'Gown • . •7State YZtvy` to act on the property owner's behalf,in all matters relative to work authorized b this$Siritdtn ermit a hi'afiof. ' 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 O and skip Section 10.1 10.1q Registered Professional Responsible for Construction Control NZ.r� tr —Q S� yl hone s�C ?,fe-mail add es � Registration Number Cg Street Addresrs 6 City/Town State Zip Discipline Exp 11 Dc e 10.2 General Contractor .2 L axezc /C-- IeK @c � I Ox�/ Company Name / - l/ac��rd Name of Pers n Responsible for Construction License No. and Type if Applicable az Street A{dress City/Town State Zip Telephone No.(business) Telephone No. cell e-mailaddress SECTION 11:WORKERS'CONIPI NSA I[ON INSUNANCP.A]F'IDAVI'C 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 and Materials) Total Construction Cost(from Item 6) 1. Building $ O ,%d D 40 Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 2.QDO- ad, 1. Mechanical (HVAC) $ Note:Ntininmm fee=$ (contact municipality) S.Nfechanical Other $ Enclose check payable to r 6.Total Cost $.12-1000 (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. Va LQ t/ �rJli/<�r/ (old-�I� S�Pt Obi 2-I � 1 Please print and sign name Title Telephone No. Date Ni=--wM% mp, 07_i c Stre { klrSq,. o,L City/Town State Zip Municipal Inspector to fill out this section upon application approval: � 1 Name Dote • t Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor ' License: CS-071914 c „ VACHESEAV KUMOV'` ; 25 CHASE ST NEWTON MA OZ459' 'V 's s Expiration Commissioner 05/28/2015 �.T"�•T�""k-"fi'''b°"'Pa'"+'w.,u,.✓ a rriae ��iNrolealvaliR''�C�r�dfrrr�rl +� u Omit of Consumer AtTairs g Busihess R' uledoa MEIMPROVEMENTCONTRACTOR + : egistration: 128726 TYPa' ' j ' IPlraeon ,. 5116q 5, .,Individual': 9 , ✓an G'A. 1 ,a F VACHESEAV KUTIKOy K11T11(OV VAChIESEAV � �_�! `� 25 CHASE ST..: i Undeneereh N ON,MA 02159 ry: ' From:Betsy Cardona Fall: 617-7652216 To:Salem Fax: +1 (978)740-9846 Page 2 of 2 061111201411:04 CERTIFICATE OF LIABILITY INSURANCE DATE(MM°DhWYI 06/11/2014 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 be endarseu 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 endorlement(s). PRODUCER ALD Insurance Agency NAME: Dmitry Dukhon PHONE 'IFR% alc,Np EMI (617) 787 - 7877 N01:(617) 787 - 7876 60A Brighton Ave. ApOREas: mail@ aldinsurance.com Allston, MA 02134 — ._ —____._.._..____ INSUREq(91 AFFORDING COVERAGE____ NpICp -- __ INBuaER A:Underwra.ter's at Lloyds INSURED Vyachealav Kutikov DBA Complete Construction CO INSURER NSURER O 25 Chase St. Nate R D Newton, MA 02458 —' -------- --- INSURER E, INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSVED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHS'1ANDINO 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 CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _—_ NSR' �'�5}� LTR TYPE OF INSURANCE POLICTEF POLICY E%P—T """LIMITS —"-' INSR WVD POLICY NUMBER IMMIppIYyYq (MMIDDNYYI'1 LIMITS A GENERAL LIABILITY ILGL1021444 02/27/201402/27/2015 EAGH OCCURRENCE 5 1,000,000 X COMMERCIAL GENERAL UAOILITY -- j PREMISES IEa Occunmke) S 100,000 CLAIM5MA0E OCCUR MED EXP(Any one person) s 5,000 PERSONAL B AOV INJURY s 1,000,000 --- — --- GENERAL AGGREGATE 3 2,000,000 GEN L AGGREGATE LIMIT APPLIES PER: IPRODUCT$-COMPIOP ACG s 1,000,000 X POLICY PRO. LOC L_—_._. _.. JECT S AUTOMOBILE LIABILITY (Ea Stewed) -. 5 ANYAUTO 5ODLYIN111RY(Por person) $ ALL OWNED '.._._- SCHEDULED I—— AUTOS I AUTOS � � BODILY INJURY(Per 2GCtlenR 5 HIREDAUTOS ~i NONOWNED PROPERTfbTA'G� UTOS 5 (Par acclaanq I UMBRELLA LIPS OCCUR ._ EACH OCCURRENCE s EXCESS LIAR � '- .. - CI-AIMS-MADE AGGREGG ATE 5 OED l J RETENTION S s —'— B wC.AFAE COMPENSATION AND EMPLOYERS'LIABILITY 6Z2UB-9995M42-7-13 10/26/2013110/26/2014 X TORV LIMIT5y ER_ YIN ANY PROPRIETORIPARTNER.E%ECUTIVE OFFICERIMEMBER EXCLUDED' ❑ NIA �EL.EACH ACCIDENT 8 1,000,000 (Manaamryin Hill CIL. DII SEASE-EAEMPLOYEE s 1,000,000 lisle tlefulbeunder _ DESCRIPTION OF OPERATIONS Its E.L.DISEASE POLICY LIMIT S 1,000,000 I I I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES Patelh ACORD 101,Additional Remade SCMtlule,if more Spate ie repui,e,11 CERTIFICATE HOLDER CANCELLATION Emil Kraner 10 Becket St. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem, MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESEMAT t M ©1988-2010 ACORD CORPORATION, All rights reserved, ACORD 25(2010105) Tile ACORD name and logo are registered marks of ACORD CITY OF S U.E,%I, NaSSACHUSETTS BUILDING DEPAMIENT 120 \' ASHLNGTON STREET, 3co FLOOR TEL (978) 745-9595 F.sr(978) 740-9846 KIMBERf EY DRISCOLL V1iYOR THol us ST.PIFRItR DIRECTOR OF PUBLIC PROPERTY/BUTIDRG CONLMISSIONEt W'orlcers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A t tlicant Information Please Print Lepsibl &VAe_ d t Vitln L' tBusinesvOrganizadon.'Individu:d): Address: 2 (/ zjt:e 'i;, to 2- S'_�Ri City/State/Zip: Phone #: Are you on employer?Check the appropriate box: Type of project(required): 1.%J am a employer with ;j 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.4 1 ant a sole proprietor or partner. listed on the attached sheet. : y ❑Remodeling ship and have no employees These sub-contractors have N. ❑ Demolition working for me in any capacity, workers'comp. insurance. 9. ❑ Building addition INo workcn camp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 140 Electrical repairs or additions J.❑ 1 ata a homeowner doing all work right of exemption per MOL I I.❑ Plumbing repairs or additions myself. (No workers'cutup. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) t employees. (Nb workers' 13.❑ Other sump. insurance required.) •Anv applic:mt our duck,box ill must ulsu 011 cut the sectiun below showing their worken'compensation policy inilamaliun. r I Icmuuu'swnx who submit this aff4lavit indicating they ate doing all work and then hire outside contractors total suh nif a new arl?davit indicating such $'nnrwlun ihol cheek this box must anachal un additiUru l.hect showing the nwnc of tha subaonlnetun and their workers'comp.pulley inrommion. I ran an employer that Is providing Ivorkers'contpeitsailon insurancefor my employees. 801ory Is the pol&y mrd job site infiunlutfon. �( Insurance Company Name: /� �_ ) def pA Policy 4 or Self-im. Lic. H: Z U �' 7Q-�—ppiration Date: &9zr 2 Fo lub Site Address: �O eC.I—el ar' StY.L/—1 City/State/Zip: CN S 7 0 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failuru to secure coverage as required under Section 25A ot'MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine nF up to 5250.00 a day against the violator. Ile advised that a copy of this statement may lx furwirded to the Office of hivesligations ofthe DIA For insurance coverage verification. Ida hereby certify larder pains art penalties ojperjury that the information pro vfded obuve is true and correct. CPyIL1141re' Dater �r• /2 f �/ Phone 12 I;r O/jiciul rue only. Do ant Ivrile in this area, to be completed by city or lawn ajjic!"I City or PermitUcemae4 Is.,uiog Atit hurity(circle one): L Ltoard of Ilealth 2. Buildim, Ilepartnlcnt .i.City/rnwn Clerk J. Electrical Inspector 5. Plumbing Inspector 6. Other (:Intact CITY OF S:1LE.ti[, ttit.1S5.1CFIL'SETTS GLILDLN(; DEPAIVME,NT ,C4 Yrs' !_O WASHLNGT0N STREET, 3'0 FLOOR TEL (973) 745-9595 KENLOERLHY DRISCOLL F•LX(978) 7.10-99.5 ��,LiYo:2 T,-I0.NLU ST.PIF-qA, MxECTOR OFPLSLIC PROPERTY/aL:MOLYG CO-NNIS5I0,NER Construction Debris Disposal Aff1davit (required tear all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 Ci`,(R Debris, and the provisions of rbfGL c 40, 5 54; section l l 1.5 Building permit # is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as da6ncd by ,�((;L c l 11, S i SOA. T' //hedchris will be transported by: 1y U� (name ut hauler) The debris will be disposed of in ((name of(anlity) _7— '�- oC o z f (ailill'eS4 0Yr11CII1I�f / i G vynamrrutprrmit.rPPtieant �