6 FLYNN ST - BUILDING INSPECTION (3) CITY OF SMXINI, TNLxss xcHUSE=
BUHMNG DE.PARTIvE.iT
120 WASHINGTON STREET, Yo FLOOR
o TEL- (978) 745-9595
F..x(971) 740-9846
KINtBERLF-Y DRISCOLL
MAYOR THOMAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BuimING COMMISSIONER
APPLICATION FOR THE CONSTRUCTION, REPAIX RENOVATION, CHANGE MUSE OR
OCCUPANCY, OR DEMOLITION OF ANY BUILDING OR STRUCTURE
This Sectlad for OWIC1 l Use Only
Datw: -- I " / I c
Building Inspector
Est6ie"Pmqwt pates: Start: End:
Commits:
9.0 SITE INFORMATION
Ux abon Narns: G r n n S-t- Building:
Property Address: b (� /y n n St
SALpm IWv oi`�7o
Assessors Map/OWL LoUParc®t
y.Q QI 1 IWORMATION
2.1 Owner of Land
Name: *-7�yve13Eo,,2 cx,-
Address: 6 �� r n� S {��a e�•
.5Ct4N. ,y,r� 015 ��
Telephone:
2.3 Owner or lessee of building or sbrucfurs
Name: �E
Address:
Telephone:
3.0 AGENCY OR AUTNORITY AUTHORONG CONSTRUCTION
Agency Name:
Address:
Agency Project Number.
Project Manager Name: 7e1:
P
ROFESSIONAL DESIGN SERVICES:.
egisteredArchitect:e: Seal and Siignature
ess:
Tetephort®: fa�c
42 Re&Wed ftotasslonal ftglneers: (um a&umd Wm is it rammy aat attach b )
Name: Seal a w Soumm
A,Idress
Telephone: Fax
Afea:d.RasPonsimility:. `o
Name: Seal and Sigr4aare .
Address:
Telephone: Fax
Area of Responsibility:
Name: Seal and Signature
Address:
Telephon®: Fax:
Area of responsibility:
5.0 DESIGN AND CONSTRUCTION UTILIZING MGL C 112 SECTION SIR EXEMPTIONS
(See note below)
Contractor
Name: ' t v I i �Yv��ola �111
Address: (-o C'Z BOA
Area of responsibility: �, + �� '�P l (2o ro X!Kfl(11
'License Number. Fv c - l Y 5 s� 5 Date of Expirattorr
Telephone: J Fmc` 1. 0 4'? b)7 8�
Contractor
Name: ,
Address: ``\\
N�
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fax
Contractor
Name:
Address:
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fax
Note: for portions of work utilising exemptions of MGL c. 112 s.81R complete the section above.
Use additional sheets if necessary and attach to application.
r
FESSIONAL CONSTRUCTION SERVICES:
eral Contractor D A-7—yZr , a:
Telephone: CG7 ��7�P3 3 oS Fax:
Responsible in Charge of Construction:
7.0 CONSTRUCTION DOCUMENTS -to be prepared by applicant
Item J as Applicable
7.1 Plans (Note 1 this page) Submitted Incomplete Not Required .
7.1.1 Architectural
7.1.2 Foundation
7.1.3 Structural
7.1.4 Fire Suppression
7.1.5 Fire Alarm
7.1.6 HVAC
7.1.7 Electrical
7.2 Specifications
7.3 Structural Peer Review
7.4 Structural Tests & Inspections
Program
7.5 Fire Protection Narrative Report
7.6 Existing Building Survey
7.7 Workers Compensation Insurance
7.8 Other Documents (Specify)
(Energy Narratives, etc.)
Note 1 Areas of Design or Construction for which Plans are not complete at the time of
this application must be identified herein. Work so identified must not be commenced until this
application has been amended and proposed construction has been approved by the
Department of Public Safety District Building Inspector having Jurisdiction.
8.0 .COMPLETE TEAS SECTION FOR NEW CONSTRUCTION ONLY
For Existing Buildings Proceed to Section 9.e
Number of Stories above Number of Stories Below
Grade — Grade
Story Height Floor Area Per Floor
Total Building Height Total Building Area Above
above Grade Grade
Total Building depth below: Total Building Area Below
Grade Grade
Brief Description of Proposed Work:
8.2 USE GROUP AND CONSTRUCTION CLASSIFICATION (Now Construction Only),
USE GROUP',' ` USE GROUP SUB-CATESory° CONSTRUCTION
(�as a s appicabe . CLASSIFICATION
l
A , Assembly A:1' A-2 A4 A-4 1A
8 Business 1 B
E Educational 2A
F Factory F-1 F-2 2B
H High Hazard H-1 H-2 j j H-3 H-4 2C
I Institutional 1-1 1-2 1 1-3 3A
M Mercantile : 3B
R Residential R-1 ✓ R-2 R-3 4
S Storage S-1 S-2 5A
U Utility 5B
Mx Mixed Use Specify:
Sp Special Use Specify:
9.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
For new construction corn lets s ctlo
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor(sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
4,4
el
91 USE GROUP AND CONSTRUCTION CLASSIFICATION(Exlstdng;®uilddngs Only), i
EXISTING PROPOSED Change. CONSTRUCTION
USE Group(a) In CLASSIFICATION
Use Hazard Use , Hazard
(note sub-category) Group Index roup Index Ind" Nas applleata)
A Assembly 1A"
e Business 1 B
E Educational 2A
F Factory 2B-
H High Hazard 2C
I institutional 3A
* Mercantile 38
R Residential 4
S Storage 5A
U Utility 58
Mx Mixed Use Hazard Index
Sp Special Use
' Note: Include Hazard Index Modifier for Construction Type as applicable
9.0 CONSTRUCTION COSTS (see 790 CMR Appendix L)
Total Construction Cost Building Permit Fee Check Number
(1) =(1)x$0.001
3z) oa�
10.0 AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR BUILDING
PERMIT(when applicable)
on behalf of the eut74no State
Agency or Authority, hereby authorize,-_ f to apply
for the building permit for project number,
Sig ature Data
11.0 SIGNATURE OF 13UIL.DIN® PERmrr APPLICANT
o�y A I e)6-7
i S- grilature M Date
12. Certificate of Occupancy required an completion of project? _Yea - No
Inspectors Notes:
Jy
JAN-16-20Q7 TUE 10( 11 AM JENKINS INS. FAX N0, 7812459563 P. 01/01
ACORDTN CERTIFICATE OF LIABILITY INSURANCE ,°nre�ifiiom7rn
PRODUCER THIS CERn FICATE IS ISSUED ASA MATTER OK INFORMATION '
Wayne C. .lenkins Insurance Agy ONLYAND CONFERS NO RIGHTS UPON T HEC ERTIFICATE
5U Salem St HOLDER THIS CERTIFICATEDOES NOT AMEND,EMEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
P.O. Box 69
Lynnfield, MA 01940 _ INSURERS AFFORDING COVERAGE NAIC#
itysurR® INSURER A: Safety Insurance - _
-
Tremblay Contractors, Inc. INSURERS: Ohio Casualty
10 Colonial Rd Ste, #4 INS JRER c:AIG
Salem, MA 01970
INSURER P: '
INSVRER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOIWITHSTANDING
ANY RGOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC'r TO WHICH THIS CER9YFICATE 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,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCCD BY PAID CLAIMS.
INSR 0' —�- POl1CY NUMBER - _ PDUCYE 0711,E R]UCY F%P RRATION LIMITS
LT nR CG
GENERAL LWBILITY EACH OCCURRENCE S 1,000 L000
--DAMAGETOIiENTEO—'
g �X CCMMFRCIALGGNCRALUABILTTY IRRW52519022 4/15/06 4/15/07 PREM1SCSLI;IL curenco S - 50`00__.
__ CLAMS MADE IXIOCCUR MEDFXPIA^_Ln?_ _7 a _ 5,000
X bfpd, xcu, cunt_ PFRsoNuaAov INJURY s 1,000,000
X Contr. Protecti GENERALAGGREGATE , $ 2 _000,2�
GCN'LACGREGATE UMITAPPUES PER: PRODUCTS-COMP,OPAGG 1,000,000
POLICY X JET I LOO
AUTOMOBILELIABILITY COMBINED SINGLEUMR' g 1,000,000
A ANYAUTO 1500143 4/19/06 4/19/07 (�—Idwi) _ _
X ALLONFIEDAUTOS BOOILYINJURY $
(PH PMMI
X SCHEDULEDAUTOS - -INJURY
'-
X HIRED AUTOS ROPILY INJU
LPu AcdINJU
}( NON-OWNEDAUTOS -
-- PROPERTYDAMAGE 4
GARAGELIABILITY AUTO ONLY-FAACCID MIT 5
ANY AUTO OTHER THAN EA ACC
AUTO ONLY: AGG 6
E_xcESS/UMBRF"ALIAEILITY EACHOCCURRENCE S
OCCUR CLAIMSMADE AOGREGATB I
DEDUCTIBLE S
REIENTIDN
A
WORda ERSCOMPENSATIONAND ORy1 Ef?
(.' EMMOYERS'LIASILITY WC BM956 7/1/06 7/l/07 ELEACHACCIDENT 5 100,000
ANY FROM IETWUPART1,1 / ECUYN£ - 500,000
OYFFFICERA.IEMBEREVICLUOD1 E.L DISEASE-UEMPLAYEE S
IRsdLPRON5DJ5INbw E.L.DISEASE-POUCYLIMIT S 100,000
OTHER
DESIRIPTIONOFORERATIONSILOCH'RCNSIVCHCLESIFXCLUSIONSAPDPPSYE DO 5EMENT/SPECUWPROYIMONS .
Contracting operations:
CERTIFICATE HOLDER CANCELLATION
SHOULD ANYOFTHE ABOVE DESCRIBED POLICIBSBE CANCELLED PEFORE THE EXPIRATION
DATETHEREOF,THE ISSUING INSURER WILL EN DEAVOR TO MAIL 30 DAYSWRRTEN
NOTIC ETD YNRCERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TOO 050 SHALL
IMPOSENO OBLIGATION OR LIABILITY OF ANY HIND UPON THE INSURER,ITS AGENTS OR
REPRESENTMM.
AUTHORIZED REPRESSES
,A[
ACORD 25(200T/o8) 0 ACORD CORPORATION 1988
The Commonwealth ofMassaehusetts
�� Department of lndtistriaiAccidenu
Olffce Ot Inrestlot/ons
600 lrasltingran Street
Boston, Klass. 02111
Workers' Compensation Insurance Affidavit '
name I�o won. IA Tr'e-VIA do
location (b rG tciA 10-(
cry .5`Leh. Y\ro lLt7o ohnnett `t17t3�7�53aSZo
C3 1 am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
.� I am an employer providing workers' compensation for my employees working on this job.
i
is } 3 m.l::: r� .}- g .•i v n? r
s`t � .:(s {�F ♦� e'.;�; it a F � �r r .f
iddrmn'ZI:
dry
L.. .. an
s tc ! sH is
n
M
17 ( 4
m3urtin `• ai i5..`.,dae oFi, .4<. } ♦ Y .. . <}:'}., ;L e..x.. ... E t v
O 1 am a sole proprietor, general eontractor, or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
fgm nn n'Y n'Ime } £ `}e
3 � � ee
a. °i*^$i '�.s. � `' avF 3 "N @♦ e YZ t £ 'w4.4 � "}3s. a F r Y $ L�Ex t F sx k'e� v2
dry, r 1, .L K4 Sr s rx F r dbRIIS:M €*e3�\: ♦ }`' a Le34 F � x�a
- t ♦ S."♦ r r^�t s F F -�L s b sz' a'f < t}x F f'. t�--�•yx�� t tx
insu rnnce eo a.?5 3j C.,S�ts 4 > '��\�' r}F�.% nn4if r •l tsw"x`i ey°` i .4 'u9 v 3p ,.Y,�f 4° < 4s L
�'.:.� ay'� '�`o��t`£`•'�'�L�S' �r��<,£L°.L`Q'��a`a�z"Ty�lxsiE�s�ctt'£i �a..#za,.x?�'.}}Y�x c�a�xs a x 3F ws ,�.'s,C s _t e } _.
tom nn nnme, ,°�iP' ..,a1� xx.a.�� ;: *4:'..> " <� . .♦. ,£'jL x1t.S31 3,��� » s �? 4 r nyf a crH �L%di�"� r
{>—y �Y' '$ 4 } to h a-�' FI '�iFe } k` S .FSL 4 .xt♦}v,c:
' nddror
ftfr: F F q wk k`ri
h p s a
r..4 Y,rt e a Z6x(i ry. �Cv>'0 L F�', a'�. E• ,3 S !t'<Y t s ,
- oherlh ••a s Fi.onaks
9
kaddtn Mpe N allure coverage m required under Section 25A of&IGL 152 can lead to the imposition of criminal penalties are fine up to SI,5oo.00 and/or
one ycun'impmoamcnl as wall us civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of thin stntemenl muy-be forwarded io the O(rict of Invalig*liom of the DIA forteveruge verincarion.
I do hereby cerlifv under lilt pains and ptnalacs of perjury that the information provided above it true and correcL
Slgnalurc Date
Print name r - Phone N'
ofrw ial we enly� do not write in Ihia area to be completed by city or town omdal c,ry ur to.n: permiVliecmc 0 nBullding Department
=t QLiccnsiog Board !'
I]clmeh d,mmcdialc response is required C)SCIcomen's Orrice dry$ry
[)He*Ilh De pa rim cnt
tt conmU person: phone 9; nOthcr �}1�
pruN JN)qnl
Board of Building Regulations and Standards License or registration valid for individul use only
R
HOME IMPROVEMENT CONTRACTOR expiration before the date. If found return to:
Reglstlitlb�-' Board of Building Regulations and Standards
,.-445375 One Ashburton Place Rm 1301
ltplfa on _�/�' /2009 Tdf 126164 Boston,Ma.02108
Af 6te Corporation
'
ROGER A.TRE a TORS,INC.
ICI �E1',4.C*�N�tQ)J /f p
ROGER TREMBLl,Y
10 COLONIAL RD S I --
SALEM,MA 01970 Administrator Not valid witho t 5i nature
l ican#i �9N9 u 16N(;uPe RvIsOR
� Ns+mk>3 a53s43 ,�i
44.
31
Tr.no• 1 '
f f
i r glad l�1l�rAlR�er„, �
' ._+_:��..��.' .vim-�.�+--�.-�.•',_,.,',-,�__J. ..
Qq Z9� tip� �tS�dSpaCe ...r
{A<frYd$.9aryallY s°'. � .
�$nllft7 t4:possessa citftent egRbnof the t
Mas;406etts Sole Building.F,Qdl. .•,
is cause for revocation ofthis Ilcens ..
t .
$ 010 SAFE CALL CANTER: (008)344-7233
Application for Permit to:
Location
Permit Granted
6 kw�
Approved
of
6p;actor of Buildings C