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5 FOREST AVE - BUILDING INSPECTION (2) CTTY OF SMEN4 Nl L1SSACHUSET'TS BI:mDLNG DEP,LRT%mNT \ 130 WASHINGTON STREET,3t0 FLOOR T EL (978)745-9505 ��� ✓ E?kx(978)740-9846 KtaffiERLEY DRISCOLL MAYOR T Ho"ST.Pwj= DIRECCOR OF Puauc PROPERTY/nuumiNG com% ioNER APPLICATION FOR THE CONSTRUCTION;REPi[lkR9WVATN.CHANCE IN-VAE OR OCCUPANCY, OR DEMIOUTION OF ANY BUILDING OR STRUCTURE This lfeettos.torOffleW Use Only . , Pernt ,Pno : ',. W D t Dstes Start End: Cammonts: to SITS INFORMATION Lneadw Nams H012,7e, Building: Properly Address: Assessor.Mapdelodc LotlParcet ... -. INFOriATiON 2.1 Gamer of Land N am: ' v a n h� -)a 5 >�� A c�or Ieasee of buiidit or struetmrr Name: e - Addrosx. A�r 7 OC 14- (ej /- 5 3.0 AGENCY OR AUTHORITY AUTHORMING CONSTRUCTION Agency Name: Address: Agency Project Number. Project Manager Name: To 4.0 PROFESSIONAL DESIGN SERVICES:: 4.1 Registered Architect:,` ` Name: Seal and Signaiure Address: 4.2 Registwed Profess,lo+al Engineer (La:idd ft*d*ft rn9m5WY and.aft b appii W*q ) Name / � seal alit}�9 ►' :r Telephone: Fax A� NCI11R .W Ri V Address: Te a Fax Area of Responsibility: Name: Seal and Signature .` Address: Telephone: Fax Area of responsibility: 5.0 DESIGN AND CONSTRUCTION UTILWNQ,MGL 4,1111 SECTlON.81R EXEMPTIONS (See note below) Contractor Name: Address: Area of responsibility: Cii erisdi`Number' „' -Date of Expiratiorr n. Telephone; . F . Contractor ., - - Naittet•, x Address:_ Area of responsibility: Ucense Number. Date of Expiration: Telephone: Fax Contractor Name: John Ger Address: /�oi4i�7 Area of responsibility: Ucense Number. ®Z J` Date of Expiration: 3 -Q-D't Telephone: Note: For portions of work utilizing exemptions of MGL c. 112 s.a1R complete the,secgat above.. . use additional sheets d necessary and attach to application. r NAL.CONSTRUCTION SERVICE#t ntractor ewa Jl � Telephone: 1 Q— gQ® Fax: Responsible In Charge of Construction: . din E-6 few 7.0 CONSTRUCTION DOCUMENTS -to be prepared'by applicant item d as Applicable 7.1 Plans (Note 1 this page) Submitted Incomolete Not Reaulred 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 WAC 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 forwhich.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 THIS SE�ONFORN��:CON�.TRIJI iOh'ONLY For: ting BuildI ngs Proceed to.SectlAn 9.0 Number of Stories above '' 'N&ri6er of stories Below Grade Story Heighi F Area Per Floor Total Building Height Totfl.Building Area Above above Grade Total Building depth below.;- Total Building Area°Below' Grade Grade Brief Description of Proposed Work: 2P ,EtC i (�l) W l i dak25 No ( qe5 8.2' USE GROUP-AND:CONSTRUGTION CI:AS$IEICAT[ON tNe Cotlstructtott;Oaly}.. X S GR UP S :E0 O r CONSiTl3�1QN ,�.�,.�� � � �� � •ar. CLASSIFICATION lA . B Business 18 : E Eduptional 2A► F Factpry F-1 F-2 2B H Hk*'Haza f H-1 H-2 H-3 H-4 2C 1 Institution( 1-1 1-2 1-3 3A M Mefcakle* 36 R . Residential; 0-1 R-2 R-3 4 S Storage S-1 S-2 5A , U J Utility 51, Mx Mixed Use Specify. Sp' Special Use Specify: 9.0 CONSTRUCTION COSTS (Sea 780 CMR Appendix L) Total Construction Cost BUMN Permit Fee Check Number (1) _(1)x $0.001 10.6 AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR BUILDING .PERMIT (when applicable) on behalf of the auduxt lne State Agency or Authority, hereby authorize. Jahv) r5 iLec to apply for the building perrNt for project number. .S P Alag o e- s ture Date 11.0 SIGNATURE OF BUILDING PERMIT APPLICANT Name f -1(-0 Sfg-natbre Date 12. Certificate of Occupancy required on completion of project? _Yes No Inspector's Notes: The Commonwealth ofMassaehusetts Department oflndustrialAecidents Office of Investigations. 600 Washington Street' e Boston, MA 02111 www..masxgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electncians/Plumbers Applicant Information D Please Print Legibly Name (Busi/ness/Organiizzati`on/Indivi/d�ual): I�L°.N�)4JC((, Pt7/C�l Address: G V ,67,fi/7�) �`"�� / \ p City/State/Zip:A) , �! on2 i !�lq Phone #: ( ,`�9� ) —�QO® Are y u an employer? Check the appropriate box: Type of project(required): 1. I am a e to er with 4. ❑ I am a general contractor and I mp y Sk 6. ❑ w construction employees (full and/or part-time).' have hired the sub-contractors listed on the attached sheet t 7• Remodeling 2.l� I am a sole proprietor or partner- ' ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. workers'comp. insurance. y y p ty. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑ 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: t Hotruownm who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such [Contractors that check this box must attached an additional sheet showing the name of the subcontmetors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. n M Insurance Company Name: J.t" //G l `�/rke oeli - —T�h Policy#or.Self-ins. Lic,##: /J�_ gdI,�JC Expiration Dated^/J—�'f��,t� Job Site Address: t LI' r �T �`tL/a'wc, City/State/Zip: 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 $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. Be advised that a copy of this statement may be.forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce u der[thee pains a/nd penalties of perjury that the information provided above is true and correct Sienafore �YJ"l� Date lC0 -� Phone#(5O \ C gB1/7n—o 7n(?o Official use only. Do not write in this area,to be completed by city or town official. City or Town: . Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Information and instructions Massacbusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...everyperson 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 a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,parinersbip,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 evidenceV compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor 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-contractor(s)name(s), address(es) and phone number(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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be 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 on the appropriate line. City or-Town Officials -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 fill in the permiVlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license 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 home 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 burn 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 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE vpvicea r-nc Fax#617-727-7749 License or registration valid for individul use only Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR before the expiration on daft. 1(found return Board of Building Regulations and Standards ReQtS�Tallon i14960�,j One Ashburton Place Rm1301 kR1r511on {1/24/2008 Boston, Ma, 02108 ,l I `�t Type ��(ivate Corporation RENEWAL BY . JOHN ESLER 78 TURNPIKE ROA2_�`' � WESTBORO, MA 01581 Administrator Not valid without signature �/oe 1°aoanmoxue¢(OE �..�.aearr�/ri�eel� . BOARD OF BUILDING REGULATIONS � py License CONSTRUCTION SUPERVISOR NunnbeK&SS� 27425111 Bi!a963 . (lU�s0i4rgd07 Tr. no: 8556,0 _ Re§4r{FYp[ d JOHN K ESLER 78 TURNPIKE RD WESTBORO, MA 01$B�-? Commissioner Jan 02 2007 15: 26 - JPNMcKeone4Ins 734 662 8101 P. 2 ACORD CERTIFICATE OF LIABILITY INSURANCE os�lzn�s PRDDDeaI - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Joseph McKeon ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE JP McKeon Insurance Agency, Inc. HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 y, ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 333 Ann Arbor, MI 48106-0333 INSURERS AFFORDING COVERAGE NAIL X Renewal by Anderson INSURERA; rtfDrd Insuranoe Company J&L Windows, Inc. INSURERS: 104 Otis St INSULTER C: Northborough, MA 01532 NSURER FD: INSURER E; COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAW. NCR ADIn. POLICY MOSIER POLKYEFFECTRE POLDVEXPIRATION LIMrt8 B GEERALLIABUTY HER8856650 9/7106 917107 EACH OCCURRENCE $ 1000000 COMMERCIAL GENERAL LABILITY PREMISES Ee Pomme 1 100000 CLAW MADE ©OCCUR MED EXP(My one on $ 10,000 PERSONALS ADV INJURY E 1,000,012 GENERAL AGGREGATE E 2 CDO D00 GEN'L AGGREGATE OMIT APPLIES PER: PRODUCTS-CONIMPAGG $ 2000 DOD JECT POLICY PTtO- LOC A AOTOMOBILELIAGI 35 MCC XD 6388 1011/05 1011107 COMBINED SINGLE Lima $ 1.000,000 ANYAUTO (EeemNMl) X ALLOVJNEDAUTOS BODILY INJURY SCHEDULEDAUTOS (PwPN,w) 1 HIREDAUTOS BODILY INJURY NON-O NIED AUTOS IPer OoddenO 1 W PROPERTY agAAGE $ IPa eedeenq GARAGELIABIUTY AUTO ONLY-EA ACCIDENT E ANYAUTO OTHERTNAN EAACC $ AUTO ONLY: AGO 1 BXCESSNMBRELLALNSILIW EACH OCCURRENCE I OCCUR CLAMS MADE AGGREGATE j i DEDUCTIBLE 1 RETENTION S $ A wo msCOmPIMATIONAND C35 WBGNC88611 111107 t111108' WCSTATU- oTH- - EMPLOYER!•UAmun _ E.L EACH ACCIDENT E 500 000 ANY OFROERMENBER EXC�LUDEw%ESTrVE - E.L DISEASE-EA EMPLOYEE $ 500000 I/ eI it"IWl SI IAL PRCNBIONB below E.L.DISEASE-PCLICYLIMR E 500.000 OTHER - DEWRPTIdI OF OPERATIONS I LOCATIONS I VEHICLES I EX0.USLONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE 0ISCRBEO POLICIES BE CANCELLED BEFORE THE E%PNATION INSURED COPY DATE TNEREOF,THE MSUING WELBER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO TIE CERTIFICATE HOLDER NAMPO TO THE LEFT,BUT FAILURE TO DO 80 SHALL IMP ' O OBLIGATION OR LIABILITY OF ANY KIND UPON TIE NWRER,ITS AGENTS OR RESEN TW& ' OR?P REPRESENT TIVE ACORD 25(2001108) OACORD RATION 1988 'al Mtn '1!i la rt WoodNtnyl•CorrposheFrame >4xh { a )NA Doupl Dual eH unC Low E U 4=aetor(U.S)A-P Solar Heat Gain Coefficient 1 33 0830�D „ Vl iICde Tr3n;mittance 0 . 48 H L. C 2 56J11 100-00231 , �,f RY uiiti� M' (.191 I i CITY OF S11I.&Ni, INLkSSACHUSETTS Bt;ILDL C;DEPARTJIENT ! 120 W ASHINGTON STREET,3w FLOOR o� TEL (978) 745-9595 FAX(978) 740-9846 IU\IBE u-SY DRISCOLL MAYOR THomAs ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COSWIISSIONER 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 e 111, S 150A. The debris will be transported by: (nam f hauler) The debris will be disposed of in : /6 (name ot facility) (address of facility) signature of permit applicant date a�nri,,traa Application for Permit to: Location Permit Granted - - i App ved. PAZ } t a Inspector of4vildings s E } C