9-11 CHASE ST - BUILDING INSPECTION i
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The Commonwealth`of assachusetts
\ Department of Publ fb5 r�n P 3. 3
N Massachusetts St ateBuildin�l�Ytl 70 gR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
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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)
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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 ❑ 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 ❑ NoA
Is an Independent Structural Engineering Peer Review required? Yes ❑ No�f
Brief Description of Proposed Work:
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SECTION 3:COMPL TE 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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H. Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-111 R-2❑ R-3❑ R-4❑
So Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CrVIR 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: \I-\I Ii t ,u.< „..mksi,n K ,w,v.-1 r,m is:
.._._ .._..---- .._.
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
13 ,
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: �IT/
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in a6 matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if buildingis less than$5,000cu.ft.of enclosed space and/or not under Construction Control Then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mall address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2Genera ontr for
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Comp.7Y Name
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Name of Person R sponsi le for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No, cell e-mail address
SECTION 11:WORKEKS'CONNIFNSA'IION INSURANCE AFFIUAVI I' M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the' suance of the building permit.
Is a signed Affidavit submitted with this application? Yes - No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT F E
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
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)
S.Mechanical Other $ Enclose check payable to
6.Total Cost $ 7000 (contact municipality)and write check number here
SECTIO 13:SIGNATURE OF BUILDING PERNfIT 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 t ' e t of my knowledge and understanding.
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Please pr an m sign e / Title Telephon o Date
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Street Address I City/Town // State Zip
AG Municipal Inspector to fill out this section upon application approval: w
Name Date
p® _. .Massachusetts Department of Public Safety
Board OfBuilding Regulations and Standards"
License; Cs.M256
- Construction Supervisor
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` JOHN.J MAHONEY`
15TH 2OTH STREET,
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.NEWBURY MA 0195,1
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Expiration: :'
�r :Commissioner 01/08/ 01
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Construction Debris Disposa/Affjdavit
(required forall demolition and,.renova'don work)
In acCOrdanoe with the sbA edition of the State Building Code, 780 CMR, Section 11l.S Debit,
and the proWslons of A46L 00,S 54; Building Permit as is Issued with the
condition dwt the debris resu ft from this work shag be disposed of in a Property ltoense
waste deposit fadtity as defined by MGL c 111,S 15K
The debris will be transported by: _
(name of hauler)
The debris will be disposed of in:
(name of fadlity)
(address of facility) '7
Signa u e o pplicant
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'\ The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information // II //JJ P ase Print Legibly
Business/Organization Name: �r �k a 4 t�d (/vr KGO �C-
Address: G /C r tl ie v Id t'
City/State/Zip: �l{ J%4, Phone#: c9 3
Are you an employer?Check the appropriate box: Business Type(required):
1.[;4' I am a employer with employees(full and/ 5. ❑Retail
orpart-time).* 6. ❑RestaurantBar/EatingEstablishment
2.❑ I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] $• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required]** 11.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
*Any applicant that checks box p l must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box NI.
I am an employer that is providing workers'compensation insuraqce for in emp_loo s. Beeltow is the�°licy i formation.
Insurance Company Name: >T ��-��`��G� ( k jli*•Y/-/ C G' G/l� 'C"R,
s Address: S-T / r
City/State/Zip:
Policy#or Self-ins.Lic. Expiration Date:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and a piration 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 t e Plk for insurance coverage verification.
I do hereby certi r the pains and penalties of perjury that the information provided above is true and correct.
Si nature: Date: P &q C ao 6e
Phone#: 1, 1
Official use onl . 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. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mms.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,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 any 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 your insurance company's name,address and phone number along with a certificate 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 to 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). 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15
,a►co o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMMONV n
10/04/2016
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(les)must be endorsed. H SUBROGATION IS WANED,subject to
the terms and Conditions of the policy,certain policies may require an endorsement A statement on this Certificate does not Center rights to the
certificate holder in lieu of such endorssme s F'RODUCEIR cam,cT Elena Matarazzo
METRO BOSTON INSURANCE AGENCY PN°NE,Eaffi 617 BU-5480 AA Ie:
%Wg'Eag,- emtarazzo@metrot>ostminsumnm.com
96CENTRALAVENUE INSURERIS)AFFOROUIO COVERAGE NAICe
CHELSEA MA 02150 sauNERA: TRAVELERS PROPERTY CAS CO OF AM 25674
INSURED INSURER 4:
NORTHEAST INDUSTRIAL ROOF INC INSURERC:
INSURER D:
510RIVERSIDEAVE INSURER E:
MEDFORD MA 02155 1 INSURER F:
COVERAGES CERTIFICATE NUMBER: 91DO9 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 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
LIR TYPE OF INSURANCE 111101.Jim aR POUCYNN/aER Pmmwn FF IanmYYJ
Lama
COMMERCNLGENERAL UABILnY EACH OCCURRENCE f
CLAIMS-MADE ❑OCCUR PREMISES aavue f
MED EXPAny one person) E
NIA PERSONAL S ADV INJURY f
GENI.AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE f
POLICY JPERCT LOC - PRODUCTS•COMPx)PAGG f
OTHER f —
ALROMOBEELJABRJTY Ee M IN BINED SGLE UNIT f
- ecadant
ANYAUTO BODILY INJURY(Per p ) E
ALL OWNED SCHEDULED NIA BODILY INJURY(Par acatlen) f
AUTOS AUTOS
ED � NONOWNED PROPERTY DAMAGE E
AUTOS Par
E
WaRELLALNB OCCUR EACH OCCURRENCE E
EXCESS LIAB CLAIMS-MRDE NIA AGGREGATE E
DED RETENTION E
AND EMPLOYERS LIAIUrT PER TH-
ANDEMPIOYERS'IVIBxf1Y YIN X STATUTE ER
ANYPROPRIETCRIPARTNERIEXECUTNE E.L.EACH ACCIOENT f 1,000,000
A OFFICERNEMBEREXCLUDEDP WA WA WA 78JUB7H67950916 - 09/12I2016 09/12/2017
(Myyaan�nd�atory In Wl) E.L.DISEASE-EAEMPL E 1,ODD,DDO '..
O MRIKIOJ OF OPERATIONS t0or E.L.DISEASE-POLICYLIMIT f 1,000.000
NIA
DEBCRWTDN OF OPERATIONS I LOCATIONS!VEHICCLES(AGORDtel.AdOWWRM Sr uwmarWatwj"Nmemspew WrequNad)
Workers'Compensation benefits Will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts H the insured hires,or has hired those employees outside of Massachusetts.
This Certificate or insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this Coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.govllwdhvorkerscompensationfinvestigaflons/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
The Greenville Group ACCORDANCE WRN THE POLICY PROVISIONS,
187 Green St
AUTHORIZED REPRESENTATIVE
Jamaica Plain MA 02131
Daniel M.Ora�oy,CPCU,Vice President-Residual Market-WCRIBMA
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
PROPOSAL No. 16-242
NorthEast Industrial Roof Date 10-18-2016
510 Riverside Ave. Sheet No.2
Medford,Ma.02155
781.859.7523 E-mail :john@niroofcom
Proposal Submitted To: Work To Performed At:
Don Behnonte
9-11 Chase St. SAME
Salem,Ma.
We herebtipropose to furnish the materials and perform the labor necessary for the completion of
Roof to left in a watertight condition at the end of each workday.
Remove all debris associated with above said work on a daily basis from roof.
All work to be done in strict accordance with manufacturers written specifications.
Provide all lifts and/or equipment to complete said work.
Provide 15 year warranty on materials and labor.
This warranty shall be void should any thru roof devices be installed by others.
All material is guaranteed to be as specified. and the above work to be preformed in accordance with the drawin sand
specifications submitted for above work and completed in a substantial workmanlike manner for the sum of
Dollarl$7,000.001
with payments to be made as follows: In full upon completion
Any.Iteration or deviation fiom above spocificaunn.involving edm cons,will
Respectfully submitted
17-
be executed only upon wrinm oNars,and will became an artla charge over and
above the national..All Wcounerds mrmaead upon strkM aaadanaa or delays Per J HN J. MAHONEY
beyond our contml.Ownrcr to carry fire,tornado and other necessary insuance
Oanar to car*Y fir,tornado and char ne as a,insurance upon above work.
Workmnn's Competaafion and Public Liability Insurance on above work to be Note-This proposal maybe withdrawn b us if not accepted within 30 days.
takes out by NorthPan Industrial Roof Lac,
ACCEPTANCE OF PROPOSAL
The above prices,s eci ications and conditions are satis(actory and are hereby accomd.,You area authop4q to do ot work asspecified
Payment wil(be made as outlined above. Signatures-i/v
Date (C9 Signature
PROPOSAL No. 16-242
NorthEast Industrial Roof Inc. Date 10-18-2016
510 Riverside Ave. Sheet No. I
Medford,Ma.02155-4947
781.859.7523 E-mail :john@niroofcom
Proposal Submitted To: Work To Performed At:
Don Belmonte
9-11 Chase St. SAME
Belmont,Ma.
mikemealy@yahoo.com
We hereby propose to furnish the materials and per the labor necessare for the completion of
Remove all flashings to a workable surface.
Install wood blocking at perimeter to roof achieve new insulation elevation.
Install 1/2 inch high density polyisocyanurate insulation over existing primary roof.
Mechanically attach same.
Install fully adhered.060 epdm rubber membrane to insulation.
Create insulation sumps at all drains,flash same.
Flash all existing penetrations.(pipes,chimneys,hatches,etc.....)
Fabricate and install new 24 guage galvanized steel gravel stop with 30 year Kynar finish at roof perimeter.
Flash same.