0005 NICHOLS STREET- COLONIAL TERRACE, BPA-13-829 The Commonwealth of Massachusetts
Department of Public Safety
p' Massachusetts State Building Code(780 CMR)
����� Building Permit Application for any Building other than a One-or Two-Famil w 1'
,; _ _ � : � .: .. '°_, ;`(This.SectionFor,Oficial,Use.Only),), ,s,'�
o Builditig Permit Numb&.. .Date'Applied r `Btiildin9Offutab`
vx SECTION:1:LOCATION.(Please indicate Block and I1oE#for locations for'which a'street address is-n ttavail'able)'
ln� t7 IZffcGL2 S4uDec.,^ D(9X0 Co.nwtuM,
it No.and Street City/Town Zip Code Name of Build4g(if applicable)
x= f7 SECTION 2:PROPOSED WORK "
Edition of MA State Code used -�r-"'"•^`"� If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair'V 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 W No ❑
Is an Independent Structural Engineering Peer Review required? /� Yes ❑ No ❑
Brief Description of Proposed Work: 1-r ( '"f Wo l]o e� ¢ Ffcx kl-e S
�P ink �nSl ll VG� �i Ire 1�5� �I ✓Vew ��R7oLs kkha .1
SECTION 3i:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,,OR
CHANGE IN USE OR OCCUPANCY_a'>;`
Check here if an Existing Building Investigation and Evaluation is enclosed(See780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
i SECTION.4:.BUILDING-HEIGHT ANDAREA'. �;,�,. '. "
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(Checkas`applicable),
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ElH-5❑
I: Institutional 1-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile 0 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) a -
IA Cl IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780,CMR 111.0 for details on'each item)-'
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal.❑ A trench will not be P
Private❑ or indentify Zone: or on site system O required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Pra:ess:
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 and Address of Property Owner s
Jak y—e-1A ROJV� 9 cho�n�P�
Name(Print) No.and Street City/Town -- Zip
Property Owner Contact Information:
Title C>e--&re,— Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
l�a,,� 9 TT ck cr ScxM,e_ -
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.
«k SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
Ifbuildin s leas than 35,00b w.ft:of enclose ace'aiid/or not uaderConstruction�Control then cfieckhere[Tand'skin Section 101 "c `
-Al Registered Professional Responsible for.Construetidn Control',",,
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10:2 GeneraLContractor'
bp' 20 s Cc f.Jrc,c-4 ` ,, . L L c
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
119 1 M AA IC e k I t/fAei kr Sfe 6 cir l...o i r4 c> <o
Street Address e4 3 S3 City/Toikn State Zip
Telephone No. business Telephone No. cell e-mail address
��
'.SECTION'll?kVORKLRS'.CnMPENSATION YCVSGi2AnCE'AF}IDAVIT'MG.L:c.152.. '25C6 '¢,'
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 $ Sc,� c) Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HV AC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 3 o, sp 0 (contact municipality)and write check number here
,SECTION 13:;'SY - . ..
,- GNATUR.E 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. / r�
SPIros Oft 2.5/ J �/'c'� L�f Yy �C�`1�5C/ C(7fS- (L _ o it SAW
Please print and sign name y� Title Telephone No. Date
fol _A (; eX iufr,�i kc Sf�1� 353 llvs(rp�C �an� /� C9 lss� �
Street Address City/Town State Zip
Municipal Inspector:to'fill outthissection upon appltcation-approval
Name Date
DRIZOS CONTRACTING, LLC
Spiros Drizos
MANAGER
spirosdrizos@yahon.com
101-MIDDLESEX TURNPIKE11 TEL (978)4602241
sic f,353 FAX(781)221-2245
BURLINGTON, MA 01803 11�
I/�dL," ���
CITY OF Siu.EJ I %Lliss,ICI-I SETTS
BUILDING DEPARTMENT
+ 120 WASHIINGTON STREET, 3"FLOOR
TEL (978)745-9595
fir
i<I.,CB Ri RY DRISCOII. "j�{OSLISST.FI&QRIi
,MAYOR
DIRECTOR OF PL'OLIC PROPE0.TY/8IaLDLNC COJINIISSIONER
Workers' Compensatlon insurance AMdav)t: Builders/Contractors/Electrlcians/Ptumbers
Appllcant information Please Print Legibly
Name(OUSInvti9OfbaniradaNlndlvidual): Df 1 �S Lp/�T`rnl tt�� f L L C
Address: lc�� (M��fll�Szx ?���pl'k� SFe b .435 -?
City/State/Zip: �� �—n lYhl� o( So3 Phone#: 0( — 4 y'D _ A d4
\rq you an yer!emplo Cheek the appropriate boas 'type of project(required):
I.t�pl I am a employer with �— 4• 0 1 am a general contractor and 1 6. []NOW construction
mnpinyees(full and/or part-time).* have hired the sub-e:onlncton
2.0 fain a sole proprietor or partner- listed on the attached shout 1 7. (Remodeling
ship and have no employees These subcontractors have V. 0 Demolition
working for me in any capacity. workers'comp.Insurance. q, 0 Building addition
(No workers'comp,insurance S. 0 We are a corporation and its
required.) officers have exercised their10.❑Electrical repairs or additions
).0 I ant a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)r employees.We workers'
eump.invurancercqulrcd.) l].00ther
;Any appik:ni that checks has.r l must else fill out the=11uo below showing their workats'eampmradun pufiry ineurmatlon
If wisuwncm who,ulmtit this amdavit indicating they an doing all wait and then hire""side canitoorms must submit a rtew,anidavil indicating such.
:Cone .ten that check ibis best must attached an addidaul Abod showing the memo of the rulFednIncture end tho4 wurkeo'ramp.pulley informed on.
l urn tin employer that is pray/ding)porkers'rampgossadon Grsurenee jar my employees: Below is the polfcy and Jab site
infarmutlon,
Inwrauce Company Name:
policy a or Scif-itn. Lie,/fit: Expiration Dote' �"
Job Site Address: Io o yF7S'�n S I_ CityJSl2Wzip:�l I0'1 A
A Itach a copy of the workers'compensation policy declaration page(showing the policy number and explratlon data).
Failure to sucure coverage as required under Section 23A of NIGL a IS2 can lead to the imposition of criminal penalties of a
line up to S 1,500A0 undlor one-year imprisonment,as well as civil penalties in the)'arm of a STOP WORK ORDER and a line
of up to 3230.00 a day against the violator. Its advlgcd that a copy of this.rtatement may bet furwarded to the OlYce of
Investigmdmts of tlta DIA fur insurance coverage veriticalion.
/du lttreby certify under rhr pullAs,and prnu(/l'ies ulper/cry rliut Ike ln�urnmrfar provided above is true and correct
ii"nature 504LOS OLL V/MCs.NGOCf' I)utd: -q A �)
Phone,* C�� t/, — Lylo� — � � � (
U/)iciu(use achy. Oo oat writs in rh/s urrry to bit completed by city of town offlelu,
!
City of Town: ._ _ PcrmitlT.Icctae,� I
Issuiog,\utlturity (cirelo one):
1. IJoard of lieailh L Iluildinq Department 1. City/fawn Clork J. fileetrical Lupector 5. Plumbing Impector
6. Other
Contact Nr ion: ._. . . Phone ri:
= ' CITY OF S:1LzNf; NL1SSACHUSETI'S
Bt: LONG 0Ep.1A•I1t&NT
120 C -UNLYGTON STREET, 3"O FLOOR
�^ . 3,y T EL (978) 745-9595
!<IJtDERL.BY DRISCOLL FAX(973) 7.10-9345
NLAY01 'ftlOS('l$ST.ptEAAB
DIRECTOR OF PLOUC pROPEATY/8LRDLNG COJLNi1SS1ONEA
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section l 11.5
Debris, and the provisions of Ib1GL c 40, S 54;
Building Permit !2 is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c
l 11, S 150A.
The debris will be tra tsported by:
(namc ut'hauler)
The debris will be disposed of in
(name at'tacaity)
(address at'ta.ility)
olynamrc of Pernut applicant
S l �
dale —
. rlil..Ili l.'l
I
� 2013 03:42 7812212245 DIRECT
i • on - 93585 P. 002/002
,.:X: RE'' CERTIFICATE OF,LIABILITY INSURANCE OPID: Pp
PATBIMEUD
THIS CE 11FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 04/08/13
11
CERTIFH TE DOES NOT AFFIRMATIVELY OR T NEGA HOLD NEGATIVELY A ER. THTHE I
MEND Fit BEL04V. rHIS CERTIFICATETEND OR ALTER THE
CO
OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE IISSUINGNSURER(S13Y)AUTHORIZE
RFEPRES i ITATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORT. T: If the ions of
holder Is an AOp1TiONAL INSURED, tha pollcy(1es)must be endorsed. If SUBROGATION IS WAIVED,subject
A the renn nd conditions of the policy,certain Policies may require an endorsement A statement on this certlflCate does not confer rights to th
Certlflcal I wider in lieu of such endorsemen s.
PRODUCER 781-935-8480 coxTacr
100DeS nclie tsurarTce Agcy,Inc 781-8335645 worEl¢
100 Uniaa Park Drive ae xe.
Woburn,1 I 101801 AVONLSe,
DRIZO.1
INSURED 3rizos Contracting,LLC - INaORERIS)AFFORINN CDVERgG6 NAICa
3 Towline Road INSURER A:SeleaDve Insurance Company 12572
3urlington,MA 01803 INSURERe;Carrier Will Send CerUflcate
INSURER C I Saftly Insurance Co. 39464
WSURER D I
INSURER E:
COVERAO 15 INSURE
CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS T : CERTIFY THAT THE POLIOIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIO
INDICATE NOTWITHSTANDING AYBEISSUED
O ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI
CERTIFIC , E MAY BE ISSUED OR MAY PERTAIN• THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT EC ALL THE TERM ,
EXCLUSI( 1 'D AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.INSR TYPE OF INSURANCE R
GENER I .LAMTY POLICY NUMBER UC ETIP LIMITS
A X CC IERcwL GENERAL LIABILITY S1986400 08102/12 08/02/13 EACH OCCURRENCE S 1,000, 0
;IAIMS•MADE a OCCUR REM19SES EAeaeunenra $ 100, 0
MEDEXP! onePerm%
PERSONALBADVIWURY $ 1,000, 0
$LEGATE LRVTAPPUES PER GENERAL gOGREGAT6 S 3.000. 0
GEN'LF :
P[ Y21PR0. LOC PRODUCTS-COMPIOPAGO S 3,000 0
AUTON W LLLPRJTY IT
An UTO
COMBINED SINGLE MMIT
(6A aeddenn $ 11000 00
.
AL WNW AUTOS BOOaY1NAIRY(PKIDANnl $
C SC I OULEDAUTOS 5058177 07/02M2 07/0213 RODILY INJURY(Pw wXiad) $ -
X W11 )AUYOS PNOPERTYDAMAGE $
X NL . ]WNEDAUTOS (Parawidan)
$
X UA :ELLA Lwa $
X OCCUR
gg l)pE EACH OCCURRENCE $ 2,000 QQQ
A CLAIMS•MAPB TBA AGGREGATE $ 2,000 0
DID cnBLE 04/D8/13 04108h14
NTION $
9
WORK/ I COMPENSATION t
AND El + OYFFS LIABILITY B . �� E Ur X
FFKE EMBER EXCLUDED? y WIC STATU• OTH-
NIA MA-WC23 1 5 3 821 3 0131 2 ORMT/1Z OW07/13
w.(Ma : .ae NHI DIRECT FROM CARRIER EL EACH ACCIDENT $ 60000
N yyaSsO.R nM wdar OPERATIONS E.I.DISEASE-EA EMPLOY $ 50000
OE$CR � ION OF bgow
EL DISEASE-POLICY LIMIT $ 50000
OESCRIPTIOA 1 OPERATIONSILOCATIONSIVEHICLES wAMM ACOAO tOE,AddlHeml peAtallu HcneaNAlf q epaeeleregmrop Spiros N.I rRITS Is not covered under the Workere Compenaatlon policy"
Salem HOA : np Authority Is listed as additional insured witA resppeect to GL
Project A i ting&Foundation Repairs at 687.2 Community Builtling
CERTIFIC I 'EHOLDER CANCELLATION
SALEMH1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED SEFO
Salem Housing Authority THE EXPIRATION DATE THEREOF, NOTICE WILL Be DELIVERED 1
27 Charter Street ACCORDANCE WITH THE POLICY PROVISIONS.
Salem,MA 01970.3699
AUTHOR26D REP - ATNE
®1988-2009 ACORD CORPORATION. All rights reserved
ACORD 2 ; 2009/Og) The ACORD name and logo are registered marks of ACORD
t Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supcnisor
License: CS 106890
c �
SPD2OSDRIZOS;` s•
3 TOWNLINE ROAD
Burlington MA 018031 1
.
1,7`
Expiration
Commissioner 05/22/2016
1