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1-2-3 GERRISH PL - BUILDING INSPECTION (2) ro 2g933'° f RFUIVED The Commonwealth of MU§RiiM VAss r Department of Public Safety Aiassachusetts State Building Code 015CM I l A i l: O b 1 Building Permit Application for any Building other than a One-or Two-Family Dwelling ^V (This Section For Official Use Only) 1 Bu0ding Permit Number. Date Applied: Building Official: I� SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) and Street City/Town Zip Code Name of Building(if applicable) L� SECTION 2:PROPOSED WORK 1 Edition of MA State Code used_ If New Construction check here Cl or check all that apply in the two rows below Existing Building❑ Repair I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No x Is an Independent Structural Engineering Peer Review required? Yes ❑ No x Brief Description of Proposed or • � spy see., Z X ra! i�-p (/✓/ .,-. SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE FOR OCCUPANCY Check here if an Existing Building inveytigation and Evaluation is enclose-d(See 780 CMR 34) ❑ Existing Use Group(s): /!7 [Jar 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.) � $ LL` SECTION 5:USE GROUP(Check as applicable) Ai Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I❑ F2❑ if: High Hazard H-1 ❑. H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1❑ 1-2❑ I-3❑ W❑ M: Mercantile❑ R: Residential R-10 R-2 R-3 O R-4❑ S: Storage S-1❑ S-2❑ U. Utility❑ Special Use❑and lease describe below: Special Use: - - SECTION 6:CONSTRUCTION TYPE(Check as a licable) IA ❑ IB ❑ IIA ❑ IIB ❑ II[A ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780.CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposa Trench Permit: Debris Removal: Public Check if outside Flood Zone❑ indicate municipal A trenc ill not be Licensed Disposal Site❑ require or trench or specify: Private❑ or indentify,Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: hazards to Air Navigation: \I,A I li_hori It,_ic,. Not Applicable$( Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No$( Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition o(Code: Use Gruup(s):_ Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: _ CA, SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner C� rroJN PkI /-2 -3 C-.Z-,r-l-fJAi 5G/c W.f 94A- 0/ 9 ? o Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 0wntr 7r�,aWL-c. ��/ -9�3or�� �h� l/56l�drlZ�s,•ne Title Telephone No.(business) Telephone No. (cell) e-mail address If a licabb e,the proper2'owner ereby authorizes G Grc� *o sak/ i!/l�d Olg70 Name Street Address City/Town State Zip to act on the property owners behalf, in all matters relative to work authorized by this budding permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less thin 35,000 cu.ft.of enclosed space and or not tinder Construction Control then check here 0 and ski Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. c mail add ss Registration Number Street Address - City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable G A /4 ion ,Q Yuf! C. MA -0�i (7 Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'CONIVENSA'I ION M.C.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 ❑ SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) TotalConstruction Cost(from Item 6)_$ "U 1. Budding $ A 000 Building Permit Fee-Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3. Plumbing $ d. Slechanical (HVAC) $ Note:Minimum fee=$ (con'tictttmunicipa ity) 5. Mechanical (Other) - $ Enclose check payable to �/ . < _ 11 6.Total Cost $ 3 (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 he best of my knowledge and understanding. CA awe c t 7F/ _953 o//7 7 / /S Please print at tgn name Title Tele one N Di to l� .4xe . AAA, _ -try' Street Address City/Town State Zip i Municipal Inspector to fill out this section upon application approval• � Name Date The Commonwealth of Massachusetts f Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,AM 02114-2017 www.massgov/dia Workers Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FD.ED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print lAalbly / Name(Business/O,gamzationnndividual): �i 'l /t'_� . Address: GB i -r 1 s�, P L , city/state/zip: 1tW1 /VLQ l q?O Phone#: ? X 19 5 3 d / y �11 n employer?Check the appropriate box: Type of project(required): a employer with employees(full and/or part-time).• 7. ❑New construction 2.❑I am a.sole proprietm or partnership mW have no employees working forme in g, E]Remodeling MY capacity.[No workers'comp.huivance required] In I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9: �Demolition 10❑Building addition 4�1 am a homeowner and will be hiring contractors to conduct all work on my property. I will - emure that all contractors either have workers'compensation insurance or are sole I LE)Electrical repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.n I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance) Other �/p a) 6.�We are a corpomtioo and its officers have exercised their right of exemption per MGL c. 14.❑ —i 152,§](4),and we have no employees.[No workers'comp.insurance requited.] -Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and it=hire outside contractors must submit a new affidavit indicating such. lConractors that check this box must attached an additional sheet showing the rnme of the sub-contractors and state whether or not those entities have - employees. Ifthe sub-contractors have employees,they must pmvido their-workers'comp.policy m®ber... Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andfob-site information. JJ�[ ! /�/J A�1 f /7 ,�/ - Insurance Company Name:A, / /" r ' ''` d iy r 4ns. l/- / ✓ Policy#or Self-ins.Lic.#: 60/,2 a 7 7 a/3/(,f�cc SQJSd r Zirimtyn DateC 7/15 /c- Job Site Address: j� '3 ✓g rI t� City/Stste/Zip: UC4�G�f !�� Q/ 71 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required older 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 do hereby certify under tthepains and penalties ofperjury that the information provided above is true and correct. Signature:' A,-I, Lih(.J Date, Phone#• 7 0-I —55.3 —6-1 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 Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person 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,partnership,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 evidence of 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 permit/license number which will be used as a reference number. In addition,an applicant that rrurst 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 dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: - The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017. Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia OP ID: DC ,4�oiro M(MMIDD)YYYY) CERTIFICATE OF LIABILITY INSURANCE °A07/1612015 07l16l2015 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(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 endorsement(s). PRODUCER CONTACT David Bruett John J Walsh Ins Agency,Inc vHo a FAX P O Box 4407 ac No Exl 978-745-3300 ac xo: 978-745-9557 Salem,MA 01970-6407 noDRess:dbrupq@waishinsurance.com David C Brueft PRODUCER CUSTOMER ID e:9HILL04 INSURER($)AFFORDING COVERAGE NAICS INSURED Hill Properties,Inc. INSURER A:A.I.M. Mutual Ins. Companies Michael Hill INSURER 9:CNA 6 Albion Avenue Stoneham, MA 02180 INSURER C: INSURER O: 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. I TYPE OF INSURANCE POUCYNUMBER MMIDCYEFF MMIMEXP D LTR OMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 _DMU`�GE TO RENTED B X COMMERCIALGENERALUABLITY 6012277213 07/15/2015 07/16/2016 PREMISES Ea ocamence $ 300,000 CLAIMS-MADE FK OCCUR MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE UMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 2,000,00 X POLICY FI PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(PW person) $ ALLOWNEDAUTOS BODILY INJURY(Per acadmt) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (PER ACCIDENT) $ NON-OWNED AUTOS $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERSCOMPENSATON X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMIT ER A ANY PROPRIETORIPARTNERIEXECUTMEY� NIA WCC5005013417 05/19/2015 0511912016 E.L EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L DISEASE-EA EMPLOYEE $ 100,00 U yea,dmaibe under DESCRIPTION OF OPERATIONSbelm E.L DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD I OI,Additional Remerl¢Schedule,N more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City Hall 93 Washington Street Salem, MA 01970 AUTHORIZED REPRE$ENTAnTW�E _ ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD QT'Y OF SALEA MASSAaREEM ` BUILDING DEPARTA ENT 120 WAS1MgGTONSMREET,3'OFWOR M L(978)745-9595 KINDERLEYMOGOIL FAX(978)740.9846 MAYOR 7)109�fAs ST.PI, DIRECTOR OF PUBLTCPROPERTY/BI IILDING cOw&Ss7OmR Construction Debris Disposa/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 c40, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) 65 ervbW ea dy , l� (address of facility) — LcGh Signature of applicant :. e o S A�,\y{ Date yTM ' 1