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32 CHURCH ST - BUILDING INSPECTION (4) `Y The Commonwealth of Mas Sr V ICV Department of Public Safety Massachusetts State Building Code(7 N Y ,1,b I�: Ulf Building Permit Application for any Building other than or two- ami y Dwelling 0 (This Section For Official Use Only) 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) �3.2 C'.Vlu--nA 5t .5a 1 it 0 1910 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❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) l Change of Use ❑ Change of Occupancy ❑ Other L°J'Specify: V P,vl a Ct= W i el L{ O vv S Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No EK Is an Independent Structural Engineering Peer Review required? _ I Yes [INo Gk' Brief Description of Proposed Work: ICP I GtCe— C' x S TI yl W�✓l o vv S C Z �l� .�7aL Glcld n C0Ia —tD +�/tCLtcl ckisf��vt� • 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: Facto F-1 ❑ F2❑ H. Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1 ❑ I-2❑ I-3❑ I-4❑ 1 M: Mercantile❑ 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) IA ❑ IB ❑ IIA ❑ IIB ❑ HIA ❑ IIIB ❑ 1 IV ❑ I 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: Public 6 Check if outside Flood Zone Indicate municipal A trench wLnot be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ required'H or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable� Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No 6-;-- Yes❑ No u'Y 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: VARt SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Proy,pPerty Owner f katt j-4Ida l7✓1V4 3R C.bU vLa SG �e vet Oig7 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: r�r't�CU' �d9r. 97� � �9 Z 97�' 47l y955 � Ctlq�r� F'ue�zt�, V->c + 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) building is less than 35,000 cu.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 IJIA - WIV1c1J✓V rzoIG r Mc�� Name(Registrant) Telephone No. e-mail address Registration Number HtG 2 .5- P-7 T Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor r-)ovn/ c t7�7 sty, tk Cij l 6y1 Company Namejc' T Q (1 ✓ �a-) —1)o V\./ ��� L) �eJ � l 5 - 7-9 - 1 -7 Name of Person Responsible for Construction License No. and Type if Applicable 95 2vciK �► A ol4�l7 Street Address City/Town State Zip �- (o�- (Q -, (D 1(° cff+'1--Vyl C(J VV t , ll�Q c n h , C om r1�t Telephone No. usfness Telephone No. cell e-mail address 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 O�No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor (('' and Materials) Total Construction Cost(from Item 6)_$ mo _ 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) 5.Mechanical Other $ a� 9 0 V Enclose check payable to 6.Total Cost (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. VCti le✓� >✓�N e �(�-2 . it I�r Please print and sign name Title Telephone No. Date �? rCi.✓V G� n� 5 yt f h (f�J u Street Address LJ City/Town State Zip Municipal Inspector to fill out this section upon application approval: 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) 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) f Appendix 1 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. 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"�'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 Existin Bu ding Surve 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. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Please follow this link for construction control forms to be used by Registered Design Professionals. Appendix 2 (For total demolition only) 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 No. and Street City /Town Zip Name of Building(if applicable) Assessors Map # Block# and/or Lot# 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) SECTION 4. PROPERTY OWNER AUTHORIZATION I Name and Address of Property Owner PM(L PI i ly*,.j 3 2 Ct4 U e2l- S Sr4CfLfi t a i17� Name(Print) No.and Street City/Town Property Owner Contact Information: I LT �� Pt'i�'?Hv�=_ CVT _Lks-SSt y PrPi 7 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 owners behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please lilt out Appendix 2) (If budding is less than 3s,000 cu.ft.ofenckwd space or not under Cautsuchan Control 0eneherk hat 0 and s ' Section10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town Slate Zip Discipline ExpiratiADote 10.2 General Contractor Company Name Name of Person Responsible for astruction License No. and Type if Applicable Street Address City/Town State Zip Telephone No. business Telephone No, cell e-mail address SECTION 11:4'l) KEIS'CAAIPt A"PION INSURANCh At 6 A rl' M.G.L.c.152 9 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 0 No G SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and hiaterials) Total Construction Cost(from Item 6)-$ 1.Building S Building Permit Fee-Total Construction Cost x_(Insert here 2 Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note.Minimum fee-$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ 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�nd accurate to the best of my knowledge and understanding. 'lid Cbr�'i� G`fDYS— G Z-lvX� brb sir /L Please print and sign none Titles_ clephone No. Date AP (Z J er a/1 H v o Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Dale i The Commonwealth ofMassachusetts Department oflndusmaAccidents 1 CongressSireety Sufte I## Boston,MA 02114 2017 www.massgov/dia WWorkers'Compensation Insurance Affidavit:BuiMers/Contractors/Electriclans/Plumbem TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print >s b Name(Busines�sI)rganizaationQndividual): es —(�}�'l/ d �-✓ Address:_ !S City/State/ZipS'"X'7 eSCO-/%-/-IA 01`16'7Phone#: Col 7-6$b 6 t & E�hm ae employer?Check the appropriate boa: m a employer with employees(full and/or . E olproject(required): pan•time). New construction m a sole proprietoror partnership and have no employees woddng formeinY spaci7'•[No workers'comp.scrommce required) emodeling m a homeowner doing ail work myself.(No workers'comp.irouance requved)t Demolition a homeowner and wt71 be hiring eonmactors m conduct as work on my property. I vriUBuilding additionne that all contractors tither have workers'compensation msurence oraresoleElectrical repairs or additions prietors with no eaPloyes.a h ribing repairs or additions gerKml eotrtractor and 1 bew hired the subcontractors listed on the attachedsheet.se aub•enntractms have employees and have workas'comp_vitumce,i oof repairsare a cotporatiun and its ofticm bove= miredthewrightof semptien ps MGL a ther§I(4),and we have no employes.IN workers'camp.inmmscsx tequircd1 #Any applicant that checks box#1 mst also fill out the section below showing the6 workers'compensation tien. Homeowners who submit this affidavit indicating they are doing all work and then him outside comacti must submit new.affidavit end'tCen"Mn that check this box must attached an additional sheet sho eating such. employees. V the sub<onbactors have employees,they must wn�the name of the suh-coffiauors and state whc&w or not those entities have Provide their wotkm'comp.Policy number. lam an employer,chat is providing workers'compensation insecrancefor my ensphyeex Below is thepolicy andjob site Information. I Insurance Company Name: 14AIL,fi.2S Policy#or Self-ins.Lic.M 42 f(J tJ aZ6 Y I T, Expiration Date: Job Site Address: City/Stat Attach a copy of the workers'compensation policy declaration c21p. Page(showing the po1My number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I elo hereby ce►#fy under the pains andpendties ofperjury that the information provided above is true and correeL Signature, Phone M [E6.0ther - lit only. Do not write in this area,to be completed by city or town o,�etal To PermlVLicense# hority(circle one): ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector on• Phone#- A CERTIFICATE OF LIABILITY INSURANCE DA 5,larzals' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIRCATE 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 endorsement(s). PRODUCER CONTANAME: Allie Aponas TGA CROSS INSURANCE Ai N o Eal: (781)914-1000 j No1: E-MAIL as onas t across.com ADDRESS: P g _. 401 EDGEWATER PLACE STE 220 INSURE S AFFORDING COVERAGE NAIL is WAKEFIELD MA 01880 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 INSURED INSURER B: DOW ETHAN DBA ETHAN DOW GENERAL CONTRACTING INSURERC: INSURER D: 95 ROCKLAND STREET INSURER E: SWAMPSCOTT MA 01907 INSURER F: COVERAGES CERTIFICATE NUMBER: 54053 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 TYPEOFINSURANCE J U um e POLICPOUCYNUMBER MMMIIDDYEFF POLICY ExP MMUDD/YYY LTR LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ AMA CLAIMSIdADE ❑OCCUR PREMISEE TO RENTED S Ee ocwrrenw $ MED EXP(Any ene person) $ N/A PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY PRO- LOG PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOSILELUIBILITY COMBINED SINGLE LIMIT $ Ea ao9tlent ANY AUTO BODILY INJURY(Per Person) $ ALL OWNED SCHEDULED AUTOS TOS NIA BODILY INJURY(Par accitlenU $ AU NON-OWNED PROPERTYDAMAGE $ HIRED AUTOS gUTOS Per socidard UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DELI I I RETENTION$ $ WORKERSCOMPENSATION AND EMPLOYERS LIABILITY YIN X STATUTE ER A OFFCERIMEMSERREXCLUO p ECUTIVE WA WA WA 6HU65B26419915 05/18/2015 05/18/2016 E.L.EACH ACCIDENT $ 100,000 INandalory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 U yes,describe under ) DESCRIPTION OF OPERATIONS below w CTUT, E.L.DISEASE-POLICY LIMIT $ 500,000 &,,4j I L J) NIA DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Berne"Schedule,may be attached U more apace Is requln:d) Workers'Compensation benefits Will be paid to Massachusetts employees only.Pursuant to Endorsemen WC 20 03 06 B,no authorization;is given to pay clam forte tD employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of 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 Verincati0n Search bad at www.mass.gov/MM/workers mpensation/investijationst- Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of ACCORDANCE WITH THE POLICY PROVISIONS. Salem AUTHORIZED REPRESENTATIVE Salem MA 01970 Daniel Cr�y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD