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4 CANAL STREET - BUILDING JACKETIrCN �� ST U ".� ettp of *aIem, A1aq!5aCbUq;ett!5 h. o Office of the Citp Council Citp CaCC .COUNCILLORS-AT-LARGE ELAINE F. MILO WARD COUNCILLORS PRESIDENT 2017 CHERYL A. LAPOINTE 2017 THOMAS H.FUREY CITY CLERK ROBERT K.MCCARTHY ELAINE F.MILO HEATHER E.FAMICO JERRY L.RYAN STEPHEN P.LOVELY ARTHUR C.SARGENT, III DAVID W.EPPLEY JOSH H.TURIEL BETH GERARD STEPHEN G.DIBBLE January 17, 2017 Mr. David Jenks President, Domino's Pizza 100 Conifer Hill Drive Suite 402 Danvers, MA 01923 Dear Mr. Jenks: At a regular meeting of the City Council held in the Council Chamber on Thursday, January 12, 2017,the City Council voted by roll call vote (7 in favor, 4 opposed) to grant permission to Domino's Pizza located at 4 Canal Street to operate business hours from 10:30 A.M. until 1:00 A.M. Monday— Sunday, seven(7) days a week. Very truly yours, De Y C, �CJawi�2 CHER L A. LAPOINTE CITY CLERK Cc: Police Chief Solicitor Building Inspector Board of Health SALEM CITY HALL• 93 WASHINGTON STREET• SALEM, MA 01970-3592•WWW.SALEM.COM Certificate Number: B-16-340 Permit Number: B-16.340 Commonwealth of Massachusetts City of Salem This is to Certify that the Small Retail Building located at Building Type ..........................................................................4 CANAL STREET...........................--............................................... in the .....................................City,of Salem .................................. ................................................. Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY Domino"s Pizza DOMINOS This Permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires ...............................Not AppticaMl .. unless sooner suspended or revoked. Expiration Date Issued On: -Tuesday, September 06, 2016 Commonwealth of Massachusetts 3 City of Salem A < 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x.1641 x Return card to Building Division for Certificate of Occupancy - Permit No. B-16-340 PERMIT TO BUILD FEE PAID: $0.00 DATE ISSUED: 4/25/2016 This certifies that M D J REALTY TRUST BARDARO PAUL TR has permission to erect, alter, or demolish a building 4 CANAL STREET Map/Lot: 340478-0 as follows: Other Building Permit REMOVE CURRENT TILE, CEILING, WALL FINISH & REPLACING WITH NEW. REARRANGING EQUIPMENT, COUNTERS & ALTER PARKING AREAL DOMINOS Contractor Name: David George DBA: CLASS A CONSTRUCTION Contractor License No: CS-069616 4/25/2016 Building Official Date This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official may grant one or more extensions not to exceed six months each upon written request. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. HIC #: "Persons contracting with unregistered contractors do not have access to the guarantyfund"(as set forth in MGL c.142A). Restrictions: Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. Cor" ",*nwealth of Massachusetts ` y of Salem p �� a Y 120 W ashin�;. '� £rd Floor Salem,MA 01970(978)745-9595 x5641 Return ca 1l`�'� fing Division for Certificate of Occupancy Structure CITY OOMEEM BUILDING PERMIT Excavation PERMIT TO . *,- POSTED IN "HE WINDOW Footing �@ IN I�CTION RECORD Foundation FraminVL Mechanical Insulation INSPECTION: BY DATE Chimney/Smoke ber Final D PI m-�a� P ing/Gas � -/ -/i� Rough:Plumbing Rough:Ga � Final 7 ' 'L Electrical Service Rough Final /T� (1 (7�T LOLL-- LT/�/�/�-L �'l�/G� /1f(✓ �.Z �/�(o' Fire DepartmentCGS/DZ �f/�—�— /�/.�ZL� �r"1 �.2— Preliminary Final(,,, l ^f:'9.1 Health Department Preliminary Final �o `STREET PERMIT m, S2 Citp of *alem Office of 3nopector of Nuilbingg Gily 7fa/l l 20 Jermisslon is!iere6y yioen toL &(-Ail e le . Io occupy`orpu /��, - / rposes 'z in fron!of¢sial¢ ! [ G rn� X /I/� 7PId o`sidema of slreel. Jf11S perm!!is lmrledlo -(/ ar -`�` '/�20 su6'ec!!o Ise r' provisions a�l�te ordinances andsla es in re/alion!o cSlreels andlSe 9nspeclion andGonslruction of.Zuildinys in I e Gil(ofcSa(em. 2),.mr o�?L6!rc c$arn/car }pJ(/J�'„ I1� � y/`J/ 9i�nrpec�lo/ol'"..�8'oild/nge LICENSE OR PERMIT BOND BOND NO. S-850756 KNOW ALL MEN BY THESE PRESENTS THAT WE, Boston Pie Inc. of 100 Conifer Hill Dr Danvers MA 01923 as Principal, and NGM Insurance Company a Florida corporation with its principal office at 4601 Touchton Rd East Ste 3400 Jacksonville, FL 32245-6000 as Surety, are held and firmly bound unto City of Salem in the sum of One Thousand and 00/100 Dollars ($ 1,000.00 ), for the payment of which sum, well and truly to be made, we bind ourselves, our personal representatives, successors and assigns,jointly and severally, firmly by these presents. The condition of this obligation is such, that whereas the Principal has obtained, or shall obtain, a license or permit from the Obligee for Street Permit Bond at 4 Canal Street, Salem MA 01970 for the term commencing on the 12th day of August 2016 and ending on the 12th day of August , 2017 NOW, THEREFORE, if Principal shall faithfully observe and comply with all terms of the underlying license or permit, and all Ordinances, Rules and Regulations, and any Amendments thereto, applicable to the obligation of this bond, then this obligation shall become void and of no effect, otherwise to be and remain in full force and virtue. The Surety may, if it shall so elect, cancel this bond by giving thirty (30) days written notice to the Obligee and the bond shall be deemed canceled at the expiration of said period; the Surety remaining liable, however subject to all the terms, conditions and provisions of this bond, for any act or acts covered which may have been committed by the Principal up to the date of such cancellation. PROVIDED, HOWEVER, that this bond may be continued from year to year by certificate executed by the Surety hereon. Regardless of the number of years or terms this bond remains in effect, and regardless of the number and amount of claims that may be made, the maximum aggregate liability of the Surety is limited to the penal sum of the bond. SIGNED, SEALED AND DATED on this 12th day of August 2016 Boston nc. By av d Jenks NGM Insurance C mpany By .iV"cde'&I?P Qom' Nicole Bobocea Attorney-in-Fact 68-QQ-0002a-05 ®NGM INSURANCECOMPA14YPOWER OF ATTORNEY A memGer of The Main Street Amer GmuC S-850756 KNOW ALL MEN BY THESE PRESENTS: That NGM Insurance Company,a Florida corporation having its principal office in the City of Jacksonville,State of Florida,pursuant to Article IV,Section 2 of the By-Laws of said Company,to wit: "SECTION 2.The board of directors,the president,any vice president,secretary,or the treasurer shall have the power and authority to appoint attorneys-in-fact and to authorize them to execute on behalf of the company and affix the seal of the company thereto,bonds,recognizances,contracts of indemnity or writings obligatory in the nature of a bond, recognizance or conditional undertaking and to remove any such attomeys-in-fact at any time and revoke the power and authority given to them." does hereby make,constitute and appoint Nicole Bobocea its true and lawful Attorney-in-fact,to make, execute,seal and deliver for and on its behalf,and as its act and deed bond number S-850756 dated Auqust 12, 2016 , on behalf of **** Boston Pie Inc. "** in favor of Cityof Salem for One Thousand and 00/100 Dollars($ 1,000.00 ) and to bind NGM Insurance Company thereby as fully and to the same extent as if such instrument was signed by the duly authorized officers of NGM Insurance Company;this act of said Attorney is hereby ratified and confirmed. This power of attorney is signed and sealed by facsimile under and by the authority of the following resolution adopted by the Directors of NGM Insurance Company at a meeting duly called and held on the 2nd day of December 1977. Voted:That the signature of any officer authorized by the By-Laws and the company seal may be affixed by facsimile to any power of attorney or special power of attorney or certification of either given for the execution of any bond,undertaking, recognizance or other written obligation in the nature thereof; such signature and seal,when so used being hereby adopted by the company as the original signature of such officer and the original seal of the company,to be valid and binding upon the company with the same force and effect as though manually affixed. IN WITNESS WHEREOF,NGM Insurance Company has caused these presents to be signed by its Vice President,General Counsel and Secretary and its corporate seal to be hereto affixed this I1th day of January,2016. srwlnmr„a NGM INSURANCE COMPANY By: �---- y � Bruce R. Fox 'nnnrrnapgry,eo`° Vice President,General Counsel and Secretary State of Florida, County of Duval On this 11th day of January,2016 before the subscriber a Notary Public of State of Florida in and for the County of Duval duly commissioned and qualified,came Bruce R.Fox of NGM Insurance Company,to me personally known to be the officer described herein,and who executed the preceding instrument,and he acknowledged the execution of same,and being by me fully swom,deposed and said that he is an officer of said Company,aforesaid:that the seal affixed to the preceding instrument is the corporate seal of said Company,and the said corporate seal and his signature as officer were duly affixed and subscribed to the said instrument by the authority and direction of the said Company;that Article IV,Section 2 of the By-Laws of said Company is now in force. IN WITNESS WHEREOF,I have hereunto set my hand and affixed by official seal at Jacksonville,Florida thisl lth day of January, 2016. Twhe Am PN” NOTARY PUBLIC .,, STATE OF FLORIDA Canenk FF918177 Explreo/01312019 I,Nancy Giordano-Ramos,Vice President of NGM Insurance Company,do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney executed by said Company which is still in force and effect. IN WITNESS WHEREOF, I have hereunto set my hand and affixed the seal of said Company at Jacksonville,Florida this 12th day of August , 2016 1 - 'e. WARNING: Any unauthorized reproduction or alteration of this document is prohibited. TO CONFIRM VALIDITY•of the attached bond please call 1-603-358-1343. TO SUBMIT A CLAIM: Send all correspondence to 55 West Street, Keene,NH 03431 Attn: Bond Claim Dept. or call our Bond Claim Dept. at 1-603-358-1229. COMcheck Software Version 3.6.0 Envelope Compliance Certificate 2001 IECC Section 1: Project Information Project Type: New Construction Project Tide: RETAIL CENTER Construction Site: Owner/Agent: Designer/Contractor: 142 CANAL STREET ANTHONY GATTINERI DANIEL DiLULLO SALEM,MA 142 CANAL STREET NOMINEE DILULLO ASSOCIATES, INC TRUST 16 CRYSTAL STREET 5 CRANBERRY LANE MELROSE,MA 02176 LYNNFIELD,MA 01940 781-662-3498 dilulloinc@comcast.net Section 2: General Information Building Location(for weather data): Salem,Massachusetts Climate Zone: 13a Heating Degree Days(base 65 degrees F): 6268 Cooling Degree Days(base 65 degrees F): 489 Vertical Glazing/Wall Area Pct.: 10% Building Type Floor Area Retail Sales,Wholesale Showroom 10980 Section 3: Requirements Checklist Climate-Specific Requirements: Component Name/Description Gross Area Cavity Cont. Proposed Budget or Perimeter R-Value R-Value U-Factor U-Factor Roof 1:Metal Roof with Thermal Blocks 10980 30.0 9.0 0.034 0.058 Exterior Wall 1:Metal Frame, 16"o.c. 7800 19.0 0.0 0.114 0.085 Window 1:Metal Frame with Thermal Break:Double Pane with 780 — — 0.350 0.575 Low-E,Clear,SHGC 0.71 Door 1:Air Lock Entry 84 — — 0.350 0.134 Door 2:Solid I<=50%glazing) 63 -- — 0.480 0.134 Floor 1:Slab-On-Grade:Unheated,Vertical 4 R. 384 — 5.0 -- -- (a)Budget U-factors are used for software baseline calculations ONLY,and are not code requirements. Air Leakage, Component Certification, and Vapor Retarder Requirements: Lj 1. All joints and penetrations are caulked,gasketed or covered with a moisture vapor-permeable wrapping material installed in accordance with the manufacturer's installation instructions. Li 2. Windows,doors,and skylights certified as meeting leakage requirements. Ll 3. Component R-values&U-factors labeled as certified. 4. Insulation installed according to manufacturer's instructions,in substantial contact with the surface being insulated,and in a manner that achieves the rated R-value without compressing the insulation. 5. Stair,elevator shaft vents,and other dampers integral to the building envelope are equipped with motorized dampers. ❑ 6. Cargo doors and loading dock doors are weather sealed. 0 7. Recessed lighting fixtures are:(i)Type IC rated and sealed or gasketed;or(ii)installed inside an appropriate air-fight assembly with a 0.5 inch clearance from combustible materials and with 3 inches clearance from insulation material. Project Title: RETAIL CENTER Report date:04/01/09 Data filename: C:\Program Files\Check\COMcheck\142 Canal Street.cck Page 1 of 2 :r O 8. Building entrance doors have a vestibule equipped with closing devices. Exceptions: Building entrances with revolving doors. Doors that open directly from a space less than 3000 sq.ft.in area. Ll 9. Vapor retarder installed. Section 4: Compliance Statement Compliance Statement: The proposed envelope design represented in this document is consistent with the building plans,specifications and other calculations submitted with this permit application.The proposed env pe system has been designed to meet the 2001 IECC,Chapter 8,requirements in COMcheeck Version 3.6.0 and to empty with the mandory requirements in a egwre ants Checklist. Zgglel- .�Ih✓L(n Pis / Q Name-Title /-7/tC,/;, MC,7� Sign re Date Project Title: RETAIL CENTER Report date: 04/01/09 Data filename: C:\Program Files\Check\COMcheck\142 Canal Street.cck Page 2 of 2 �coNulrg9 CITY OF SALEM DEPARTMENT OF PLANNING AND ��'cIMINE� ; COMMUNITY DEVELOPMENT KIMBERLEY DRISCOLL MAYOR 120 WASHINGTON STREET♦ SALEM,MASSACHUSETTS 01970 LYNN COONIN DUNCAN,AICP TEL:978-619-5685 ♦ PAX:978-740-0404 DIRECTOR April 19, 2007 David Jenks Dominos Pizza 4 Canal Street Salem, MA 01970 RE: Illegal Banner Sign at 4 Canal Street Dear Mr.Jenks, It has come to my attention that you have hung a banner sign at Dominos Pizza, 4 Canal Street. I am writing to remind you the only temporary signs permitted by the Salem Sign Ordinance are signs that pertain to special sales or events and hung inside your storefront's windows. All exterior signs require a sign permit and without a permit are illegal. Therefore, the banner sign located 4 Canal Street is an illegal sign and must be removed immediately. If the sign is not removed immediately, I will forward this matter to the Building Inspector who will enforce the penalties and fines under Sec 3.36 of the Salem Sign Ordinance and 780 CMR Sec 3102.4 of the State Building Code. If you need any help navigating the sign permit process, please contact me. Should you have any questions regarding temporary signs or sign permitting, I can be reached at (978) 619-5685. Sincerely, Kirsten er� CDBG Planner Cc: Thomas St. Pierre,Building Commissioner Councillor Matthew A.Veno BUILU _ate CITY OF SALEM \ _ `o SALEM, MASSACHUSETTS 01970 PERMIT �9`���r1ME Oen "Ji4E: 1 96 204-199b DATE 19 PERMIT NO. APPLICANT DAVID LE[If+(Hi_ ADDRESS �`�'-Jii[-E^ T PARK R:D 1575 (NO.) (STREET) (CONTRS LICENSE) CITY STATE_ZIPCODE TEL.NO. PERMITTO 1'_ ERA T ION RES I `h" "' i O STORYLi�FI hTi JOlrTPdl ;+ f� i NUMBER OF 0 DWELLING UNITS TYPE OF IMPROVEMENT) NO. (PROPOSED USE) + 41n + :_ a,lgi TREET ZONING [ATILGATION)�EN AND (CROSS STREET) (CROSS STREET) SUBDIVISION MAF -74 LOT C1478 BLOCK gg -1'�'40.jbbQ1 `ii:! FT BUILDING IS TO BE FT.WIDE BV FT.LONG BV FT.IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION (TYPE) REMARKS' E_IND'..�i'1 T i` A5 -'=1: Lij_f.N3 SU�'MI ✓•'I ED I'-IOR LObI.L lV U' '-'T ''.F��,. I'I. M. FYI Y 1 ni'1 . 15( AREA OR PERMIT VOLUME ESTIMATED COST 7. 200FEE $ 11"• "I!' (CUBICISQUARE FEET) OWNER NiRE3 DAVID Ekl-,)2 (OXWOOD CIR PEABODY h'!A BUILDING DEPT. ADDRESS BY THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF.EITHER TEMPORARILY OR PERMANENTLY,ENCROACHMENTS ON PUBLIC PROPERTY.NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE.MUST BE APPROVED BY THE JURISDICTION,STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL INSPECTIONS APPROVED PLANS MUST BE RETAINED ON JOB AND THIS CARD KEPT WHERE APPLICABLE SEPARATE REQUIRED FOR ALL CONSTRUCTION WORK. POSTED UNTIL FINAL INSPECTION HAS BEEN MADE. WHERE A PERMITS ARE REQUIRED FOR 1.FOUNDATIONS OR FOOTINGS. ELECTRICAL,PLUMBING AND 2.PRIOR TO COVERING STRUCTURAL CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH BUILDING SHALL MECHANICAL INSTALLATIONS. MEMBERS(READY TO LATH). NOT BE OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 3r FINAL INSPECTION BEFORE OCCUPANCY. POST THIS CARD SO IT IS VISIBLE FROM STREET B ILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPaQVALS Au BOARD OF HEALTH GAS INSPECT40N APP VALS IF TING AP R L ' � cWL _ 1-j -. OTHER CITY ENGINEER vly- 2 n C WORK SHALL NOT PROCEED UNTIL THE FPERMITWILL BECOM E NULL AND VOID IF CONSTRUCTION WORK IS INSPECTIONS INDICATED ON THIS CARD INSPECTOR HAS APPROVED THE VARIOUS RTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED CAN BE ARRANGED FOR BV TELEPHONE STAGES OF CONSTRUCTION. D ABOVE. OR WRITTEN NOTIFICATION. Business Certificate Citp of *stem) Anzacbuoettz v6t:`O Q 99 3 P11N6� DATE FILE _ C �S Type:',-IkNew Expiration Date ❑ Renewal, no change Number 95-292 ❑ Renewal with change In conformity with the provisions of Chapter one hundred and ten, Section five of the Massachusetts General Laws, as amended, the undersigned hereby declare(s) that a business is conducted under the title of: win uo'S PIZZA ac �uA-L—STf� FT� type of business PAZ Z Iq V E)c by the following named person(s): (Include corporate name and title if corporate officer) Full Name Residence B03 7-0/J PIE, /NC 802 FoXwoo'-'p� ei eoz,5 , 193 �l Situ es --- - -------- ---- ---------------- ------------------------------------ p ---- ---------- ---------------------------;------ on //�S 19Zs the above named person(s) s) personallyappeared before me and made an oath that the foregoing statement is true. _ ----- G_ ------------' ----------------------------------------------------- CITY CLERK Notary Public (seal) Date Commission Expires Identification Presented State Tax I.D. #0`/- S.S. # (if available) In accordance with the provision of Chapter 337 of the Acts of 1985 and Chapter 110, Section 5, of Mass. General Laws, business certificates shall be in effect for four (4) years from the date of issue and shall be renewed each four years thereafter. A statement under oath must be filed with the town clerk upon discontinuing, retiring, or withdrawing from such business or partnership. Copies of such certificates shall be available at the address at which such business is conducted and shall be furnished on request during regular business hours to any person who has purchased goods or services from such business. Violations are subject to a fine of not more than three hundred dollars ($300.00) for each month during which such violation continues. 1 b `s < 50 RECEIVED g t '6PECTIONAL SERVICE, The Commonwealth 11 �4h1 I S 4�h} Department of Pu ic Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling O (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: lv SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) tI y Cft�.r9•c 5re S�Li<�+'1 a/97o �am��©s BcJS,. J No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2.PROPOSED WORK. Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building Repair❑ Alteration Addition❑ 1 Demolition kY(Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ I Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 9 No 13 is an Independent Structural Engineering Peer Review required? Yes ❑ No lk Brief Description of Proposed Work: 05000N4 Cc�2L'ErUT %/L f� CfrL/tit y, /,y79[C Firfr$N R� R£PL�t0B`N4 rwr•rF+ N£c.) 2e�fee�fv4gi�y £ou Pih£tiT e�� s NL7£ie £fF 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): oe2r5rT Proposed Use Group(s): Es 7— SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 14100 1 nloo I Total Area(sq. ft.)and Total Height(ft.) /3 r V/00 /3 7 SECTION 5:USE GROUP(Check as applicable) 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❑ H-5❑ I: Institutional 1-1 ❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ 1 R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ I Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) CL IA ❑ IB ❑ IIA ❑ IIB ❑ III A ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit: Debris Removal: Water Su ply: Flood Zone Information: Sewage Disposal, Licensed Disposal Site❑ Public Check if outside Flood Zone Indicate municipal A trench will not be P s required kor trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: : i�\I I. t ri,t.Cgnunisv>n i{.g.�� I r ncs: 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 of Code: Use Group(s): Type of Construction: Occupant Load per Floor: _ Does the building contain an Sprinkler System?: Special Stipulations: ST► I nS b P P I C- ��� ( t I aU Tt '�1}oV clt�l�p R'Ls ST • t r� S U t�j e. DAvLo .5 • tot 1 - qc-> jL) - t�4 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 1h6U ,�s s NKs <Trrf) /oo C70n1(jeEe (61_�12 640IJie In4 0i9Z3 Name(Print) No.and Street,, City/Town Zip Property Owner Contact Information: usi£E G�7 .9o� VY13 97$-77?_ ?6VXX10 �r►u,��t?os�6�vPr£.com Title Telephone No. (businephone 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 fill out Appendix2) - If budding 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 10.11 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor - - OcASS f} C'ovSTec>ciiiy/� Company Name 1L)6-Lz G g C's 006 96/e/ Name of Person Responsible for Construction License No. and Type if Applicable $y Fo,2£51 10,44 X n ,4 o/OO/ Street Address City/Town State Zip A_ % 1135 l�A()E /90 G InsN.c0--4r Telephone No. business Telephone No. cell e-mail address - SECTION 11:WORKE.RS'COMPENSA'110N INSURANCE AFFIUAVl'I M.G.L.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No ❑ SECTION 12•.CONSTRUCTION COSTS AND PERMITFEE Estimated Costs:(La Item bor S SUU and Materials) Total Construction Cost(from Item 6)=$ -3, 11 1. Building $ /0 5 06 Budding Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ 00 > appropriate municipal factor)=$ 3. Plumbing $ 0,3,UC)O Note:Minimum fee=$ 14�85o 4. Mechanical (HVAC) $ (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 h y attest under the pains and penalties of perjury that all of the information contained in this application is true and accura tot a best o ow dge and understanding. 1 (II�Z 0W;.,rE 13t. h)tM'a,os 6�)_ 9d8yyi3 Please print and sign nnme Title Telephone No. Date /do �4y✓'Cie of�2 Street Ad ress City/Town State Zip r Municipal Inspector to fill out this section upon application approval: Name Date t Commonwealth of Massachusetts Sheet Metal Permit I'll AUG -2 A II Date: l Permit # �� L Estimated Job Cost: S & 000 . 00 Permit Fee: $ V Plans Submitted: YES NO Plans Reviewed: YES NO Business License # Applicant License # (�I Business Information: Property Owner/Job Location Information: L Name: (, /� �z� dn kC Name: /DOn W19 S ' 7 2Ls� Street: ' / S�l�/, u�c U/tom_ 17 Street. 7 �t�G9c�� s City/Town: /.�n </-4cG(-/ ,/lfprJ�1 Q/SXCity/Town: ����GY� , `;1 felephone:7 Tb �Y��7 00� Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO_ s„rnu�:i J-1 i�[-1-unrestricted license J-2 / NI-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less Residential: 1-2 family Multi-family Condo/ Townhouses_ Other Commercial: Office Retail_TIndustrial_ Educational _ Institutional Other Square Footage: tinder 10,000 sq. ft. _ over 10,000 sq. ft. Number of Stories: Sheet metal work to be a m eted: New Work: _ Renovation: HVAC Metal Watershed Rooting_ Kitchen Exhaust System Metal Chimney/ Vents_ Air Balancing_ Provide detailed description of work to be done: { r INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes❑ No❑ r " If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit Issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES_ NO Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑ Master Title ❑ Master-Restricted ;;;a City/Town ❑Journeyperson Signature of Licensee Permit# 2;10 ❑Journeyperson-Restricted License Number: Fee$ ❑ Check at,.vww.inass.gov/dpl Inspector Signature of Permit Approval 1 . The Commonwealth of Massachusetts Department oflndustrialAccfdents I Congress Street, Suite 100 Boston,MA 0211 4-2 01 7 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ARplicant Information p� ` Please Print Le bl' Name(Business/Orrganiution/Individuat): �/Y&/ Q5,41 iu Address: `U/,ga S /i✓l(t r?ci 1o/l7 City/State/Zip: �i�GGc( y Phone#: r d c� Are you an employer?Check the appropriate box: F project(required): 1.❑I am oyer with employees(full and/or part-time).• New construction 2. am a sole proprietor or partnership and have no employees working for in Odeling any capacity.[No workes'-comp.insurance required.] 3. I am a homeowner doing all work myself. molition ❑ [No workers'comp.insurance required.]t 4.❑1 am a homeowner and will be hying contractors to conduct all work on m ilding addition Y ProPertY. I willensure that all contractors either have workers'compensation insurance or are sole ctrical repairs or additions proprietors with no employees. mbing repairs or additions 5.❑I ama general contractorand I have fiired the subcontracmrs listed on the attached sheet.These sub-contractors have employees and have workers'comp.insurance.t of repairs6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. er 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#]must also fill out the section below showin their workers'coin g pen ors policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContracmrs that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub=contractors have employees,they must provide their workers'comp.policy number. I am an employer.that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 tinder 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 hereb r the�a i d s o er npr v�{' ,'-trtrue and correct lCSignature- Date: Phone#• gZ64�/ L only. Do not write in this area,to be completed by city or town opicialn: Permit/License# ority(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son' Phone#: