11 CHURCH ST - BUILDING INSPECTION (29) o
rrnvc
The Commonwealth of Massachuselft&PECfF(ENAL SERVICE
Department of Public Safety
Massachusetts State Building Code(780 CMR) , 19 30 A 8: 5
Building Permit Application for any Building other than a One-or Two amr y Dwelling
(`}n. (This Section For Official Use Only)
J Building Permit Number: Date Applied: Building Official:
YQ SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
rnA ol'? -rO
No.and Street City/Town Zip Code Name of Building(if applicable)
1 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
Il-� Existing Building❑ Repair'y I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
-- Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Q'
Is an Independent Structural Engineerin Peer Review re wired? 1 Yes ❑ No SK
Brief Description of Proposed Work: 0✓ �5�.• -�-• .
5 h � .:h L
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: Factor F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ 1 M: Mercantile ❑ R: Residential R-111 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 ❑ IV ❑ TVA ❑ 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 El
Check if outside Flood Zone❑ Indicate municipal El trench will not be P
required❑or trench or specify:
Private❑ or indentify Zone: or on site system El required
is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Revicw Process:
Not Applicable e Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Yes ❑ or No Er Yes ❑ No 0
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?: b Special Stipulations:
�T- Tiz> A<V)>✓x ('0136
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Meo1 k.� 11 6%L41c�9,4 y18 soke'A "A- bIg70
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
V%AV%AT 17b__Wz�_ 04D 9'i$ ` A,140 'STMcptAi--Feayt. Le.0
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 all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 ca.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Lo�+ns - �saava�� - `a 1.997 twrt e40w,� P ALr el lc CS- Da�('1$ZI
Name(Registr nfj Telephone No. e-mail address Registration Numbe
It Cva.,s ( rA4 \ .� ^IAA 00Y5 CS al 116
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
vast-"��4
Name of Person R ponsible for Construction License No. and Type if Applicable
Street Address City/Town (' State Zip
512 (uSS? 6�-jl_ �J4D 141 �� At✓v L (a��l
Telephone No. business Telephone No. cell e-mail add ess
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=
3.Plumbing $ Wn
4.Mechanical (PfVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 9 (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. /
Please print and s, name �* Title Telephone No. Date
Street Address City/Town Ze
Zip
Municipal Inspector to fill out this section upon application approval: ' 0 �/��/
Name Date
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) N/ 4
No. and Street City /Town 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 ❑ 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 require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investi ation
16 Energy Conservation Report
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 original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State Zip
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration Date
Registration Number
Name(Registrant) Telephone No, e-mail address
Discipline Expiration Date
Street Address City/Town State Zip
APHZ CAMPENFRV, AELC
CONTRACTING-COMMERCIAL-RESIDENTIAL -SPECIALV.tNGIN rINISH CARPENTRY
PROPOSAL
Client: Sham McDuff' June 2F,2014
11 Church Unit 4418
Saiern, MA 01970
Job Description: JOB N
PO#
RF: HP Acemilde Bathroom Remodel
• Deino tn'the vxistmg shower cutiosUrc,she,Nver floor, batbroom floor and remove the vaylity,and dispose.
• SUPPI) &install new nillber pan and intal floor in Shower.
• SUIVY& 11IS1,111 DUrriCk on Shower wall,.and subjuarc on hagiroorn floor,
c There nlay be a small threshold at bathroom entrance and a straof camp into shower.
• Supply I"' install!)a%-, the for floor and wails in shower and tile for haffiroona floor,
Supply&install new vanity with sink Lop.
• SUPPly&install new wilet in sane location
• Painting Of6tahroom,
Dully licensed and insured.
All refcreucvs witl be supplied upon mqucst
Ali utility costs-supplied byownlel.
All constrnedrnr will meet local building codes.
Excludes cost of unfom%c-en conditions
Proposed Price 9,955.00
Any alterations or deviations froth the above specifications with regard to price or style will be allowed
through b0d,Written&.verhal connnunicadon.
Payment will be 301/ojae to order materials and serum fullnits R)HoWad by progress payments
ACCEPTANCE OF PROPOSAL;
CLIENT: 2!�T`11 ;n , 01
CONTRACTOR,
DATE:
CITY OF SALE:LI, iNLAiSSACHUSETTS
• B1;ILDIING DEPARTMENT
130 WASHNGTON STREET, 3w FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
1CINiBERLEY DRISCOLL
MAYOR THOAtAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BCIIDING CO%MSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
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 defined by MGL c
111, S 150A.
The debris will be transported by:
►''lac s—S,.4\,
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signa a of permit applicant
L� » I►s
date
debrisaffdm
aCITY OF &U.F. 311AXSSACHUSETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET, 3"n FYOOR
TEL (978) 745-9595
FAX(978) 740-9846
ICI\IBERLEY DRISCOIl
MAYORTHONIAS ST.PMM
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONetISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant information Please Print Legibly
Name (BusitxssOrganization/Individual):
Address: Z ct e),c.kt.5 aA
City/State/Zip: 5Ao- Tf!S 04 01967Phoned: 9� G 7y
Are you an employer?Check the appropriate box: Type of project(required):
1.0 am a employer with_ 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: ? [�12emodeling
ship and have no employees These subcontractors have S. ❑ Demolition
workingfor me in an capacity. workers'comp.insurance. g Y p ry• ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13.❑ Other
comp. insurance required.]
•Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
f 1 Imrn:ownen who submit this affidavit indicating they am doing all work and then hire outside cominctonl most submit a new affidavit indicating such.
'Contmetots that check this box most attached an additional sheet showing the name of the sub4ontractas and their workers'comp.policy information.
l am an employer that Is providing workers'compensation Insurance for my employees. Below is thepo/Icy andJob she
information.
Insurance Company Name: Uri tht'Vl_ +jtxtanGe Lo .
Policy#or Self-ins. Lie. #:. A W(—31199-71 Expiration Date:
Job Site Address: II Ch l �SV• yn.k *L)i8 City/State/Zip: S41ew.y rands 0147D
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 S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may he forwarded to the Office of
Invesligmiom;of the DIA for insurance coverage verification.
l do hereby revunder lire pains and penalties of perjury that the information provided above is true and correct.
m;t tre• Date:
Official use only. Do not write in this area,to be completed by city or low"oJJicial
City or'rown: Permit/l.icense#
Issuing Authority(circle one):
1. Board of llealth 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: __ ____ Phone#:
OP ID: LR
`0CC o` CERTIFICATE OF LIABILITY INSURANCE DATE s,4r�s)
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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. 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 endorsements).
PRODUCER Phone:781-593-9393 2O 5CT
NAME:
Soderberg Insurance ServiceSDO Fax: 781-599-7338 PHON Ee200 BroadwaA❑❑ c Ert
Fax No:
Lynnfield M0194000 E-MAIL DRESS:
Douglas 6.Soderberg PRODUCER
C MERIDO:APEXC-2
INSURERS AFFORDING COVERAGE NAIC N
INSURED ApeX Carpentry LLC❑_I INSURERA:State Auto Insurance Companies
John Spagnoli❑❑ INSURER B:State Auto Insurance Companies
29 Bates RoadDo
Swampscott, MA 01907 INSURER C:State Auto Insurance Companies
INSURERD:Guard Insurance Group
' INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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.
INSR I TYPE OF INSURANCE POLICY NUMBER MMIDD MWDDNYYY CY UP UNITS
GENERAL LIABILITY EACH OCCURRENCE $ 11000,00
B X COMMERCIAL GENERAL LIABILITY BOP2668100 03/19/15 03/19116 -PREMISESEenee $ 50,00
CLAIMS-MADE OCCUR MEDEXP(Any one person) $ 5,00
PERSONAL BADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 2,000,00
POLICY 01
PRO JFrTLOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00
BAP2347139 03/19/16 03/19/16 (Ea accident)
A MY AUTO BODILY INJURY(Per person) $
ALL OWNED AUTOS BODILY INJURY(Per accident) $
X SCHEDULED AUTOS PROPERTY DAMAGE
$
X HIRED AUTOS (Per accident)
X NON-OWNED AUTOS $
UMBRELLA DAB X OCCUR EACH OCCURRENCE $
C EXCESS LAB CLAIMS-MADE CXS2107708 00 03/19115 03/19116 AGGREGATE $ 4,000,00
DEDUCTIBLE $
RETENTION $ 0 $
WORKERS COMPENSATION X TWRSTATLaM�S OTH-
ER
AND EMPLOYERS'LABILITY
D ANY PROPRIETOR(PARTNERIEXECUTIVEYI❑N NIA APWC348472 06/02/16 06/02/16 E ,EACHACCIDENT $ 500,00
OFFICERIMEMSER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,00
It yes.descnbe wrier 500,00
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
of Salemi7❑ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City ACCORDANCE WITH THE POLICY PROVISIONS.
Salem, MA 01970
AUTHORREO REPRESENTATIVE
Douglas G.Soderberg
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
IYIGJJQ I.UJCLLJ -UCIIGI III ICI II UI rUUIIU JGICty
Board of Building Regulations and Standards
Construction Supervisor
License: CS-024784
LOUIS A SPAGNIJLI JR
71 Evans Road
Marblehead MA 01945 g
o o ' Expiration
Commissioner 01/2112016 '
Office of Consumer Affairs and Business Regulation
k 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 123150
Type: Ltd Liabilitv Corpol lion
Expiration: 12tl7/2016 T i 259331
APEX CARPENTRY LLC
JOHN SPAGNOLI
29 BATES RD
SWAMPSCOTT, MA 01907
Update Address and return card.Mark reason for change.
- Li
Renewal Employment) Lost Card
G SCA 1 20M-Ml I
C%/e�iavrwrornoea///r o�"✓fl runc/utett
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
Pa"' ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
o.— registration: 123150 Type: Office of Consumer Affairs and Business Regulation
,Xxpiration 12/17/2016 Ltd Liability Corpoiati 10 Park Plaza-Suite 5170
_ Boston,MA 02116
APEX CARPENTRY'LLC
JOHN SPAGNOLI
29 BATES RD
SWAMPSCOTT,MA 01907-
Underawretary Not valid without signature