32 CHURCH ST - BUILDING INSPECTION (2) r CA< L � 33C�
1 $ t 5Ll ro
I L{—01 1 S INSP RECEIVEO
The Commonwealth of Massachusetts -" ;, i -r -' r
l ' Department of Public Safety t 101R MAY 29 P R 5
Massachusetts State Building Code(780 CM11R)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use On! )..
Building Permit Number: Date r\#plied: Building Officiate
SECTION 1: LOCATION(Please indicate Block#'arid Lot#for locations for which a street address is not available)
3a eh t�i, rT take, &A a If-7o
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA Sta ilding l�te Code used If New Construction check here❑or check all that apply in the two rows below
• Existing Bu Repair❑ 'Alteration ❑ `^;Aildfitim'O'' Demolition❑ (Please'fill out and submit ApP enilix'l)
Change of Use ❑ 1 Change of Occupancy.e❑ Other O'Specify:: A,"-4 _;,. P 1rr,L ! 1e*,. e
Are building plans and/or construction documents being supplied as part of this permit a lication? Yes ❑ No 2'�
Is an Independent Structural Engineering Peer Review required? Yes ❑ No Pr
Brief Description of Proposed Work: r wA- dlr _ rr
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here d 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 Fluor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.) -
SECTION 5:USE GROUP(Check as a plicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 Cl H-5❑
1: Institutional I-I ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use'.
'+ SECTION 6:CONSTRUCTION TYPE(Check as a plicable)
[A ❑ III ❑ IIA ❑ 1I6 ❑ IIIA ❑ 11IB ❑ IV ❑ 1 VA ❑ VB ❑
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:
PP Y A trench will❑u[be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ z, '
q.
Railroad right-of-way: Hazards to Air Navigation: Nin ic.e I wcv":
Not Applicnblc❑ c Is Structure within airport approach Wren? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No s Yes❑ IN ❑ "
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building containan Sprinkler System?: Special Stipulations:
so 7r./tan')Q
SECFION9: PROPERTY OWNER AUTHORIZA'CION
ress-
NtJ� A!�rlJ iiW" r1'ap.ei�r�Ojvncr
1 W IA& ra b,Ye, 4 3d-elLNut4Si ro/sn 04it
Name(Print) No.and Street City/Town Zip
I ;, ;I `� PS YfA +@l
rProperty pOwner Contact Information:
. N �JAA GSM
Title r Telephone No.(business) Telephone No. (cell) fkr�'e-mail. dress
If applicable, the property owner hereby authorizes
P✓l0'V11 'fT ae e156a.
Name Street Address City/Town Stale Zip
to act on the property owner's behalf,mail matters relative to work authorized by this but(ling permitapplication.
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 checkhere O and ski Section 10.1
10.1 Registered Professional Res onsible for Construction Control -
None(Registrant) Celephone No. e-«...il addre3s J y Registration Number
._9 Wq,
Street Aduress - Ciiy{/dwn Stat? . zip Discipline Expiration Date
10.2 General Contractor
.<r. S y
Conte. y Name
�a .-. b �� sa C s " D S 1/ Jr',-9 UH le rrr.''re t e Ir�ll�d� 1 S
Name of Person Responsible for Construction License No. and Type if Applicable
�;A2 PJIfSIP sr 011(.o
Street Address �, C' /Town State Zip
c 1�-�- -)66s I -94- 63?--> �A�Zt3��9soa^ r9.h�
Telephone No. business Telephone No. cell eadc ess
SECTION 11:WOMF15'COMPENSATION.INSUNANCE V tit)/Vvrl M.G.C.c.152.§ 25C 6
A Workers'Compensation insurance Affidavit from the blA 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 $
1. Mechanical (HVAC) $ Note:blininnnt fee=$ (contact ality�
5. Mechanical Other $ Enclose check payable to r
P�Y�
6.Total Cost $ t�3 S� (contact municipality)and write check number here
SECT'IO 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:md accurate to the best of my knowledge and understanding.
Please print and sign name p Title Telephone No. Date
jp ✓ ' - r 1stS� olSco
Street Address City/ own State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
J
CITY OF SALEI,[, ;tiLASSACHUSETI'S
BLII.DL,IG DEP.IRT ZNT
,^ 130 WASHNGTON STUET 3w FLOOR
TtL (973) 745-9595
KIMBERT EY DRISCOLL FAX(978) 740.9844
NLAY02 'ng0.%r.A.s ST.PMRRI3
D I.ZECTO tt OF PUBLIC PROPERTY/8t:M-DLNr-CON EMISSION ER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMIR section It 1.5
Debris, vid the provisions of t1MCM c 40, S 54;
Building permit N this work shall be is issued with the condition that the debris resulting From
l l 1, S I SOA. disposed of in a properly licensed waste disposal facility as defined by ,vI(jL c
The debris will be transported by:
ti
✓M - i r✓(lq
I I1at11C Ut hauler)
The debris will be disposed or in
(namaorP dity)
(aJJres.t ot�edify)
signaNre ot't rmit.lppticant
Luc --
CITY OF S U.EM, tiL-1SSACHCSETTS
/ ' t BUILDING DEPARTNIE—NT
120 WASHLNGTON STREET, 3w F.00R
TEL (978) 745-9595
RuK(978) 740-9846
KI\IBERL.EY DRISCOLL
,NL,YOR THowis ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO'%NISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Nan1C (nosiness Urganiratiem'Individual): ��-j7�y�(2.
Address:
City/State/7ip: Phone tt:
Are you an employer?Check the appropriate box: 'type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• - have hired the sub-contractors
2.❑ 1 nna a sole proprietor or partner- listed on the attached sheet. f 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working tin me in any capacity. workers'comp, insurance. 9. ❑ Building addition
[,No workers'comp. insurance 5. ❑ We are a corporation mid its
required.) officers have exercised their 10-❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 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
cutup. insurance required.)
•Any applicant tluat checks box NI must also rill out the section bM low showing their worker'cumpensmion policy inlbrmation.
'I6,mw)wms who submit this atriidavit indicating they are doing all work and then hire outside contractors moat nuhmit anew airdavo indicating such.
k:......mien ihul check this box most anrchcd an additiuwl sheet showing Ilm mm�o of the stub-Contradoro and their wmrkeo'comp,pultcy information.
/ant an employer that is providing workers'contpeasatlun insurance for my employees. Below is the policy and job site
inforinution.
Insurance Company
Policy g or Self-itts. Lic.0: Expiration Date:
Job Site Address: Ciry/State/Zip:
Attach a copy ofthe workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of%,IGL c. 152 can lead to the imposition ofcriminal penalties of a
line up to S1,500.00 untl/or one-year imprisonment,as well as civil penalties in the forth of u STOP WORK ORDER and a fine
of up to 5250.Oo a day against the violator. Be advised that a copy of this statement may ba furwardcd to the Office of
Investigwians of1he MA for insurance coverage verification.
/no hereby certify under the patens and penalties of perjury that the infuriation provided above is true and correcC
Senn°re Date: .
Phone t
Ojjic/ul use only. Do not write in this area,to be completed by city or Iowa ajjfciaL
City or Tuwn:
Issuing Authority(circle one):
1. Board of Ilealth 2. Building Department 3.Cityfruwn Clerk 4. Electrical luspector 5. Plumbing Inspector
G.Other
Contact Person: -... ----- Phone ts:
CCIl ® DATE(MMIDOIYYYYI
V CERTIFICATE OF LIABILITY INSURANCE 1/3/2014
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(les)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 endomement(s).
PRODUCER CONACTNorwell Construct South
Eastern Insurance Group LLC PHONE aC No:
77 Accord Park Drive "MAI L
Unit Bl INSURE 5 AFFORDING COVERAGE HAD
Norwell MA 02061 INSURERAAcadia Insurance Company 1325
INSURED INSURER B:
Aspen Roofing Services, Inc. INSURERC:
58R Pulaski Street INSURER::
INSURER E
Peabody MA 01960 INSURER F:
COVERAGES CERTIFICATE NUMBER3daster 2013 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.
IN SR TYPE OF INSURANCE POLICY NUMBER MMIDCY EFF Is IU YEXP LIMITS
TR
GENERAL LIABILITY EACH OCCURRENCE 5 1,000,000
X COMMERCIAL GENERAL LIABILITYDAMAGE To "TED S 250,000ITY PR MI Ea occunenca
A I CLAIMS.MADE OCCUR PA0362034-13 2/31/2013 2/31/2014 MED EXP(Any one rsbn) S 5,000
PERSONAL B ADV INJURY 5 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPR)P AGG S 2,000,000
PoLICY X PRO' LOC 5
AUTOMOBILE LABILITY COMBINEDE, odden) LE LI It MIT 11000,00
A X ANY AUTO BODILY INJURY(Par person) 5
ALL OWNED M
SCHEDULED 0368197-13 2/31/2013 2/31/2014 BODILY INJURY(Per accident) S
AUTOSAUTOS
NON-OWNED PROPERTY DAMA S
HIREDAUTOSAUTOS Peraccidenl
Unina,rred motorist 81split emit 5 100,00
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE S 2,000,000
A EXCESS LAB CLAJMS.MADE AGGREGATE 5 2,000,000
DED I X I RETENTIONS 0368198-13 2/31/2013 2/31/2024 5
WORKERS COMPENSATION IWCSTATUI 11FTR-
ANDEMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE Y7 MIA E.L.EACH ACCIDENT 5
OFFICERIMEMINK EXCLUDED?
(Mandatory In NH) EL DISEASE-EA EMPLOYE $
If s.4asal0eunder
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
Evidence of Insurance
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Evidence Of InsuranceACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Ronald Cleaves/BC4 //
ACORD 25(2010105) IJ 1988.2010 ACORD CORPORATION. All rights reserved.
I1,1302R eomnnsim Thu annrin rranac and lnnn vu roniNurod mv4c of Annprs
14
p/,2411:1�:08 AM PST (GMT-8) FROM: 100005-TO: 1978531.7667 Page: 2 of 2
�--,s
. '4o?�Rbr CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDMTY)
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(iss) 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 EASTERN INS GROUP LLC CONTACT NAME:
77 ACCORD PARK DRIVE PHONE oXXD: _..._..,._-- FPx1vCNot _
NORWELL, MA 02061 ----.-
E-MAIL ADDRESS:
INSURER(SI AFFORDING COVERAGE NAICi
WSURERA:
INSU EO
ASPEN ROOFING SERVICES INC WSURERB:
58R PULASKI STREET PISURERC:
PEABODY MA 01960 INSURERD:
INSURERS:
WSURERF:
COVERAGES CERTIFICATE NUMBER: 18852949 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 REOUCED BY_PAID CLAIMS.
INSIRLIP TYPE OF INSURANCE IINSR ADD suwe e POLICY NUMBER MMND EFF MMIDDAnYYY LMITS
GENERALLIABWTY EACH OCCURRENCE $
DAMAGETO I
COMMERCIAL GENERAL LwelllTv PREMISES Ea ocwrcenc S
CLAMS-MADE ❑OCCUR i MEDF (Any One Pa4M) 5
PERSONAL A ACV INJURY S
GENERALAGGREGATE S
GII AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $
POLICY PRd Led $
AUTOMOBILE UIVEILRY CO BINEDSINO ELIMIT
Ea a2idrn17 5
ANYAUTO BODILY INJURY(Pw Person) S
ALL OV/NED SCHEDULED AUTOS AUTOS BODILY INJURY(Per eccdenU
NON OWN
RR pp 5
HIREDAUTOS AUTOS ED PP8CPe C&d1AMAGE S
5
5
UMBRELLA UAB OCCUR EACH OCCURRENCE 5
EXCESS UAe CLAIMS WADE AGGREGATE IS
DIED RETENTION $
S
S
A WORKERS COMPENSATION WC2-31S-384042-013 12/31/2013 12/31/2014 WCSTATU- -
AND EMPLOYERS'LIABILITY YIN ✓ TORV LIMBS
ANY PROPRIETORPARTNER,EXELUTIVEr-NI
E.L.EACH ACLIDEM $ 1000000
OFFICEBLMEMBER EXCLUDED? NIA
(Mandatory in NH) E.L.DISEASE EA EMPLOYEE 5 100000
a yes,desabo under
DESCRIPTION OF OPERATIONS bobw E.L.DISEASE-POLICY LIMIT S 1000000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Mlach ACORD IDI,Additional Remarks Schedule,H more apace ie Inquired)
Workers compensation insurance Coverage applies only to the workers compensation laws of the state MA.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANYOFTHEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Aspen Roofing Services THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
58K PUlaski Street ACCORDANCE WITH THE POLICY PROVISIONS.
Peabody MA 01960
AUTHORUED REPRESENTATIVE
Jeff Eldridge
01988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2D10/05) The ACORD name and logo are registered marks of ACORD
'ER- oo.: 18652949 CLLEFS CODE: 1570510 Dxb .... omonc 1/6/$O14 11:1]:J5 AN Paso 1 q` '
This Certificate cancels and supersedes ALL previously issued cert.Licates.