11 CHURCH ST - BUILDING INSPECTION (23) The Commonwealth of Massachu
Department of Public Safety
.\Iassar Ilk sclts St, tcISuildingC!Jc(i80 \IIt)
v,.
Building Permit Application for any Building other than a ne-or all ' Dwelling
('Ibis Section For Of icial Use Only)
Building Permit Number Date Applied: Building Official: _._
SECTION 1: LOCATION(Please indicate Block k and Lot A fur locations for which a Kreet addre is not available)
�_��---------
No. and Street City/I-mvn Zip Code Name of Building(if applicable)
SECHON 2:PROPOSED WORK
Editionld MA State Cale used-__ If New Construction check here❑or check all that apply in the Iwo rows below
Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out clod submit:\ppondix I)
Change of Use ❑ 1 ChangeofOccup,utcy ❑ kher ❑ Specify _WdAx_—_--
Are building plans and/or construction Lit x'nntemS being sttppfied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required?O Yes ❑ No ❑
Brief Description of Proposed Work:_-- K 61W
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVA"rION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Chuck here if an Existing Building Investigation and Evaluation is enclosed (See 78O CkIR 1T) ❑
Existing Use Gruup(s): __— Proposed Use Gruup(s): __
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(sq. ft.)
Total Area(sq. fl)and Total height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-1 ❑ A 4❑ A-5 Cl I B: Business ❑ 1..: Educational ❑
F: Facto F-I ❑ F2❑ 11: IIi h hazard H-1 ❑ H-2❑ 11-3 ❑ 41-4❑ 11-5❑
1: Institutional I-1 ❑ 1-'_❑ 1-3❑ 14❑ i•'1: k, cantile❑ R: Residential R-ICI R-2❑ Ii-3❑ R4❑
S: Storage 5-1 ❑ 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:SI'I-E INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal•
PnbhC❑ Cu•ck it outside Flood T_onc❑ ImliC,IIC nunhicipai❑ A trench will not be Licensed Disposed Site❑
required ❑or trend) or specify' __-"- .._.
Privalo❑ or indrnlily Tame or!!n site system❑ permit is enclosed❑
`t
Railroad right-of-way: Ilaiards to ,\ir Navigation: --
Nnl Applicable❑ Is Structure within airport appna!i h area? Is their review completed'
or C nnaatt to Budd enclosed❑ 1 es❑ or.No❑ I S"ry❑ No ❑
tiFC1[ON 8:CONTENT OF(TR111lCAT1;OI'OCCUPANCY
..Flhi nu of Code: _. - -.. C',v Group(,), _ - -
I hoe,Ihr builJinl;rn!tain,m Sprinkler Sc+trm': Spry 1,11 Slipultlioiu:
or
SECTION 9: VROPIIR'I'Y OWNER AU'l"HORIZA1ION _
NamC Oml Address ut Prupvrty Owner - --
-
Name(Print) NO. b a,d Street City/Town - --"--------"-- Lip
P' crly Owner Contact Infurmati, pL ,.
Fitle I'Clephone No.(business) Telephone No. (cull) e-mail address
If applicable, the properly Owner hereby authorizes
--�--- Name - - Street Address --- City/Town State Zip
lO act On the property Owner's behalf, in all matters relative to work authorized by this building mn»it a ,plicatiun.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
'If building is less than 3S,0W cu.ft.of endorsed s ace and or not under Construction Control then check here❑and ski Svctiun 10.1
10.1 Re istered Professional Responsible for Construction Control
Name(Registrant) Telephone No. v-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Con,, Name nM�_C1< Cs s3yl
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Trio,hone No. business Telephone No. cell c-snail address
SECTION 11:tut]i f (r,'_,.t Alt 1 rn N iy•ul{.\U,.'i \i_p»,',\c-1 I. M.G.L.c.152 1 25C 6
A Workers'Connpensation 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 th•issuance of the building permit.
Is a signed Affidavit submitted with this a lication? Ye No 17
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and \laterials) Total Construction Cost(from Item 6) 5 r✓J
1. Building 5 dd Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical 5 appropriate municipal factor) -5
t, Plumbing $
J. ,Modianical (HVAC) 5 NOW: Mininuu» fee=5 (cootactt i�licipality)
i. .\Icrhaniral Other S Enclose check papdble to
n. r, talc„ t 5 --
�(� (contact municipality)and virile check number here
SECTION 13:SIGNA'TURE OF BUILDING PERMIT APPLICANT
14v catering m}' . »e below, I herrbv attest under the pains and penalties ry Of perju that all Of the mfOrmalion coolained in this
application is tnnu'C and dec ur.ne to the hest Of m1' knu,r ledge and understanding.
I'ICasr print nd si� ,name Dille Telephone No 4m'—t'
'trcCl :\ddn'ss Cily/Iowa G, to LiMunicipal Inspector to fill out this section upon applicationapproval:
Wane
CITY OF S,V-&Ni, Akss.ICF-iL:SETTS
9LLLOLYG OEP.1R msr
120 WA1 MLNGTON STxW, jw EtCC t
TIM (979) 143.9595
KlUBERLEY DRMOLL FAX(978) 740.9846
MAYOR TRO.�W Sr.PMtt S
DIRECTOR OF PLSUC PROPERTY/BCIIALVG COJpIfSs1O.%EA
Construction Debris Disposal Attidavit
(required for all demolition and rcnavation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.1
Debris, and the provisions of MOL c 40, S 34;
Building Permit >y
I I is issued with the condition that the dcbris resulting from
I I f, S I SOA.work shall be disposed of in a properly licensed waste disposal facility as defincd by 'VIGIL c
The debris will be transported by:
(n.una hauler)
The debris will be disposed of in
(name o— ((—t
f�ddrea o(faali iY)
"nirul (permit�pphc�nf
,life —�
Q-1-Y OF S,\LEN[, AkSSACHUSETI'S
a 13L'ILDING DEPART-,LENT
+'4''•� ` f�' 120 WASHLVGTON STREET, 3as FLOOR
TFL (978) 145-9595
Rea(973) 710.9844
ICI)(F3ERL.EY DRISCOI-L
NLAYOR T Hmus ST.PIEARB
DIRECTOR OF PUBLIC PROPERTY/BU1 .DNG COSNISSIONER
Workers' Compensation Insurance AlTidavit: Builders/Contractors/Electrician JPlumbers
A a ilicant Infarmatlnn //� Please Print Leaibl
.Nimic tBuritwvr UrWtniratiun lndiv/id{tr•J1: /C (��� �vtS
Address: r-� /// �rCi?-w(7r,�1 \ > �U�
City/State/Zip: /c✓I Phone# 5V=351'— �;,71'
A ynu an employer. Check t ppropriate box: Type of project(required):
I.( �I am a employer with 4. El am a general contractor and I b. ❑New construction
�otployees(full and/or pa time).• have hired the sub-contractor
2.❑ lain a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling
,hip and have no employees These subcontractors have 8. C] Demolition
working for me in any capacity,
workers'comp.insurance. 9. ❑ Building addition
i No worker'.comp. insurance 5. 0 we are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
J.❑ lain a homeowner doing all work right of exemption per MOL 11.❑Plumbing repuirs or additions
myself.(No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. (No workers' 1l.❑ Other
Gump, insurance nquired.J
;Any applicant dW ehmks box rl must alai fill oul thv wuliae below showing their workeoi compenutlun puli y infurmution,
I hvnemsnanv who whmit this aMdavit indicating they am doing all work and then hire outside conlmerom meat suhmit a new aMdavil indicting cuch. -
:c\imrxwn that check this box must anxhud are adoniorud-host showing the nano of the subaorumt am and their workvre'wmp.paltry infatamgoe.
lain an employer chat Is pruvfditrg workers'c'untprtisatlon Insurance jar my employees. Below Is the pollry andejob site
information. //� I
Insurance Company Natne: Vouxa,�a, 4JWE4/0
Policy 4 or Self-ins. Lie. 4: __ Expiration Date:
Job Site Address: �/f 66i1( � /.+ City/State/Zip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failuro to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 und/ur one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to M0.110 a Jay against the violator. Ile advised that a copy of this statement may ba furwardcd to the 0—cc of
Investigation oftitc DIA far Insurance coverage vcrlticatiun.
l du hereby certify rrndrr the paint d penuldex of
prrjury that the irrfunnutlun provided ab yr to truer rJ earrrrG
iicn.uur� /— '
Data: _
011iciul use oily. Oo uof write he this area, tabor completed by city uptown )fJ1ch J
City'le Tuwu: _ . . 1'ermiti7.lccnse 4
Issuing Aotburity (circle one): - --
L Ilourd of Ilealth !. ❑uildlnq Department 1.Cilyi rolvn Clerk 4. Electrical Inspector 5. Plumbing Inspector
i 6. Other
Contact Person:_ I'hone;k
r
Information and Instructions
>fassachuscus 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 ajoint 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 not 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 sub-contractors)name(s),address(es)and phone ntruber(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 confrm stion of insurance coverage. Also be sure to sign and date the amdavit. The affidavit should
he 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 as the appropriate line.
city or Town omcia(s
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 till in the permitilicense number which will be used as a reference number. In addition,an applicant
that mast submit multiple permitilicense 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(tome 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 bum 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
DeparCnent of Industrial Accidents
OfIIce of Iavestlgations
600 Washington Stint
Boston, MA 021 l 1
Tel. 4 617-727-4900 ext 406 or 1-877-NIASSAFE
2eviscd 5-26-05 Fax# 617-727-7749
svww.mass.gov/dia
ACC>R&
CERTIFICATE OF LIABILITY INSURANCE a/15/2 011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT A*RMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTEA CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER •
IMPORTANT: N the emtifieate holder Is an ADDITIONAL INSURED,the poliey(ies)'must be endorsed. N SUBROGATION IS.WANED,subject to
the terms and conditions of the policy,certain policies may require anendoreemeaL A statement on this certificate does not confer rights to the
certificate holder In lieu of such en s.
PRODUCER NAyB: Boynton Insurance FAX
Boynton Insurance Agency PHONE ffi 'k
rk (781)449-6786 uJE :(781)449-4269
.: 72 River Pa Street L. s.
i PILOOUCet 00004109
Needham AFL 02494 .INSURERM AFFORDING COVERAGE NAICe
DMUM3) IMSURERA34ex Speclalty
Kyron Inc. emeets:Bartford insurance
DBA Preserve Services INSURMC: - —
203 Washington Street,N256 IreuR�o:
Salem,MA 01970 INBUR9IE:
INSURER :
COVERAGES CERTIFICATE NUIMBEI :14-18 Union St. Condo 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 WTH 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.
LTR TYPEOFMBURANCE INVO FOl(CTNUYBER "M$pun FFF FJIP Lbw
OENERALLIAmuw EAaIOCCURRENGE S 1,000,OOD
2 COMMERCIAL GENERAL LIABILITY PREMISES Me a¢ nos) S _ 50,000
' A Crgr4S4AADE OCCUR 13300002122 /23/2011 /23/2012 AED E(P(A,V ore pnxn) _ S $,Do(
PERSONAL S ADV INJURY $ 1,000,000
_ GENERAL AGGREGATE S 2,000,000
GENL AGGREGATE UH(rAPPLIES PER PRODUCTS-COMPJOP AGG S 2,000,000
E POLICY PRO- LOC S
AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $
(EA aaa4Nd)
ANY AUTO BODILY INJURY(Perperaon) $
ALL OWNED AUTOS BODILY INJURY(Pa aocidwd) S
SCHEDULED AUTOS PROPERTY DAMAGE
HIRED AUTOS - (Pm ekaNm4) S
NON43YWIEDAUTOS S
S
UMBRELLA DAB
OCCUR EACH OCCURRENCE S
f
EXCESS a Cg LSawOE AGGREGATE S
OEOUCTIBIE S
RETENTION a - 4
B VIORIO:RSCOMPBISATION E WC6T2
6
OTN-
AND 9nK.OYERVLIABILITY YIN
i ANY ❑ EL.EACH ACCIDENT a 200,00
OFnCERMEimER IXCIUOEDY NIA 586OUB0523HOO910 /20/2011 /20/2012 E (AEMPLO(tlMym�leeo.rmNM) L019EA4E- S lOO 000
OESa( OPERATIONS ONPA - EL DISEASE-POLICY LIMIT S 500.000
OESCRIPIION OF OPERATIONS I L0cMONS I VEHICLE(Amen ACORD IN,AMeanM RA Seeauu*IT mam Spam m rwoArom
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE, EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Chestnut Place Natick Condominiums ACCORDANCE WITH THE POLICY PROVISIONS.
60 South Main Street
Natick, MA AUTHORIZED REPRESENTATIVE
Michael Merrill/NRM �k---4-
ACORD 26(2009I09) 01988-2W9 ACORD CORPORATION. All rights reserved.
iNS025(2 ww) The ACORD name and logo are registered marks of ACORD
-M isachusutts- Department o1 Public S ittt}
9 Boa"vl o1 Buddin_Rcgndations and Stand irds
Construction Supervisor License _
License: CS 93403
i SFcy
SEAN OCONNOR
b 26 CHESTNUT ST
SALEM, MA-01970 .
Expiration: 12OM13
Cinuniapiuncr' Tr#: 7996
77
{ficeJ� pp$°wer CTOR
O
' 1{OMEIMPROVEMENTCONTRA TYP°
_ on 123r*+r3 DBA
ExPiiravO 31612013
Preserve Painting
Sean O'Connor n —
203WASHINGTON'ST rctar9
Underse
�M,MA01970 _ .