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9C GRISWOLD DR - BUILDING INSPECTION (2) 1� -t��y, y The Commonwealth of Massachusetts 11 Department of Public Safety a.l� ' 4 '�' j \hn.,tchu.a•u.St,ur Buddm);lade(-80 C\IR)Sc•centh Edition \\I7 City of Salem Building Permit Application for an Buildingother than a I or 2-FamilyDwellin (This Srcnon For Official Use Only) Building Permit .Number: Date Applied: • t 1 Building Inspector U SECTION L L ATION (Please indicate Block s and Lot 0 for locat' ns for which a street address is not available) .No.and Street U C ih /Too 11V Zip Code Name of Building(if ipphcable) SECTION 2: PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ I Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Ckcupa y ❑ Uthrr ❑ Specify: Are building plans and/or construction ontments being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineer Per Review uir d7 Yes ❑ No ❑ p �j Brief Description of Proposed Work. b i/ 0 X SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s):Existing Hazard Index 780 CMR 34: Proposed Hazard IndexTF SECTION 4: BUILDING HEIGHT AND AREA Existing No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(xl.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a livable) A: Assembly A-I ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-0❑ - A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 O H-4 ❑ H-5❑ 1: Institutional 1-1 ❑ I-2 ❑ I-3❑ I-4❑ M: Mercantile O R: Residential R-10 R-2 ❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and leasFite,") elow: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a livable) CIA ❑ IB ❑ IIA ❑ Its IIIA ❑ IIIB ❑ IV ❑SECTION 7: SITE INFORMATION (refer to 780 CNIR I11.0 for details on eacI "Trench Permit. ris Removal: Water Supply: Flood Zone Information: Sewage Disposah1 Pubhc❑ ( heCA tfoul'tde Fla,d Lune❑ IndiC.nemumapal ❑ A trench will not hr Unpo�al �ilr Cl rryutrad ❑or trench -r .pectic: I'ncMe❑ �rt indentdc Zone: _ or on ode+c•tem ❑ permit t.vnclo,ed ❑ I Itailroad right-of-way: Hazards to Air Navigation: xl \ I li•b n, t nnii.-„ ,i \nt \i•phc.tbir❑ I.�tntaum o,nhm ,report.ipprn.tdt.vr.t' I.their Jr'ietc ml•IeI.J� . rin�rnt o. Rwld endt••ed 0 1 1"o ❑ I 1'110 \o ❑ SECTION 8:CONTENT OF CERTIFICA TE OF UCCCPANCY I .lilim •Ilnly _.__— l-c l�nntpi•t. fti`r of l .n �lntcuon: ,__ t lccup.un l.• a.l ire l I.,,a ' il,,,.. Ihr bmlJup;:ont.tut nit SFvtn Alrr M.lent,. `penal�lipulauom .. —_��q�� y^� V 1 / 1(• 4 , I � ` SECTION9: PROPERTY OWNER AUTHORIZATION s -.V,t*)ie. I .\ddrra>1{I I'ruperty Own 1�Obe l AeaA C Grswold \)K: � r yc � � eL Mck� 0lCC? 6 Name(Print) No. and Street l Ih /rot+'n Lip Pruperlc l)cv tier Contact Information: ride Telephone No. Ibustnr>s) relephone No. (cell) e-mail .iddre" I(applicablr, the property m ner herebv .)uthunte i Name Nra•et Address Cih•/Town State Zip ❑i art on the +no +vrh uw tier'.brh.df, m Al matters n•lativr to work authonn•d by this bwlJin •permit a + +licauun. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If tnuldin•is L>s than li,000vu.It.tit encillxd++ace and/or twl under Con>tru.tion Control then check here O and .k, +Scown it)1) l0.1 Re istered Professional Responsible for Construction Control Name(Registrant) Telephone No. a-mail address Registration Number Street Address - City/Town State Zip Discipline Expiration Date 10.2 General Contractor GNi-,Um/aco,,q S �e.��+,mot', . CO , �(.� c Coin YN mCl Nar*y�a,(Perwn R, �+pyns�yle for Cun�lructiu License No. and Type if Applicable _( rKCuM C nY)J12 )cTt[1� CO- l r)c. �iC� SWaml��r, iil A- 1 --7 02�� 0 Street Address City/Town State Zip Ik'L-S9J 3) 3 5 YLl Telephone No.(business) 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? YeS09- No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE AMF� sts:(Labor rials) Total Construction Cost(from Item 6) _$ 1. BuildinBuilding Permit Fee =Total Construction Cost x _(Insert here 2. Electnc appropriate munici al factor)_$ 3.4. MechanNote: Minimum fee=$ (contact municipality) 5. MechanE"low check a tble to L� 6. Total Cost p•y d O (contact munici alit )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Hv rnten ng my n,tmc below, 1 hereby attest under the pains and penalties tit perlury that all of the in(nrmation .,,nt.imed in this application is trUe and accL rat to the beta ofmy knowledge and understanding. �4✓ d �rRUun� i wed -CLcc� � Jv/e/_ 7b( �9a.-3jjs TRro I'Iyy'',,i.. pnt t anJ .lk;n netne � Iitle __ frleph,mr Ito �W mP�rnT �c� Sat CM MC-�' 6 IQ-) O }Iwct 1 dr"' Cac, Town Ip I Muiucipal Inspector to till out this section upon application approval: N.unr Ila tr I ) CITY OF SALEM, UxsSACHUSETTS • BI 11.01I JG DEPARTUMNIT 130 WASHINGTON STREET, 310 FLOOR TEL. (978) 745-9595 FAx(978) 740-9846 KIN(BFRr RY Dtvscou MAYORTHotitns ST.PtEaas DIRECTOR OF PUBLIC PROPERTY/Bt;II.DLNG COSWISSIONER 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 1 l 1.5 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 c 111, S 150A. The debris will be transported by: Gt')S��tC k Ion CJ - s:,e) r (name of hauler) The debris will be disposed of in : upk-�\^ Sa e Co P, !; n (name of facility) Ht �h lal� �1 +A✓ � Soilct-t rl A,, —� (address of facility) signature of permit applicant date a�nd,��rd,k The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Groom Construction Co. , Inc. Hanle(Business/Organizatiodtndividual): Address: 96 Swampscott Road Salem, MA 781 -592-3135 City/State/Zip: Phone.#: Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with 7 5 4. ❑ I am a general contractor and I / have hired the sub-contractors 6. ®New construction Rep/4c:wi er// employees(full and/or part-time). G�,n�1a 1 12.❑ I am a sole proprietor or partner-_ listed on the attached sheet 7. ❑Remodeling s ship and have no employees These subcontractors have g. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp,insurance comp. insutance.t 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L[3 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] !My applicant that checks box#1 rust also fill out the section below showing thck workers'compensation policy information. t liomoownes who submit this affidavit indicating they art doing all work and then hire outside contractors must submit a new affidavit indicating such. i tContractors that check this box must attached an additional sheet showing the rsme of the subcontractors and state wheatcr or not those entities have employees. If the subcontractors have ermploy=,they must provide their worirers'comp.policy number. i lam an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual 1 Pohcy#or Self-ins.Lic.#: WC2-1 1 1 -25971 3-01 9 Expiration Date: 3-10- 17 Job Site Address: C) G�r S W o Ci /State/Zi o cn 0 ty p: Sll Ma c�ta� 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 tip 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 cerd _under thepains and penalties ofperjury that the information provided above is true and correct. j SigtuttureC� tom. ✓t. Date Phone#: 7 f/—S?-2- .313S i OjlJctal use only. o not write this area,to a complete 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 j Contact Person: phone#;. j Client#: 635598 GROOMCON ATE(MM/DDffYYY) ACORD. CERTIFICATE OF LIABILITY INSURANCE D10/31/2010 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 NAME: USI Ins Sery of MA, Inc PHONEo Ext781 938-7500 (A/C,No): 781-376-5035 A C N 12 Gill Street E-MAIL ADDRESS: Suite 5500 CUSTOMER to If, Woburn, MA 01801 INSURER(S)AFFORDING COVERAGE NAIL If INSURED INSURERA: Liberty Mutual Fire Insurance C 23035 Groom Construction Cc Inc INSURER B: Everest Indemnity Insurance Com 10851 96 Swampscott Road INSURER C: Liberty Insurance Corporation 42404 Salem, MA 01907 INSURER D 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 SR TYPE OF INSURANCE DDL UBR POLICY EFF POLICY EXP LIMITS LTR NSR D POLICY NUMBER MM/DDIYYYY MM/DD/YV A GENERAL LIABILITY YV2Z11259713030 03/10/2010 03/10/2011 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence s300,000 CLAIMS-MADE lxl OCCUR MED EXP(Any one person) $5,000 PERSONAL B ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY X PRO LOG $ A AUTOMOBILE LIABILITY AS2Z11259713020 03/10/2010 03/10/2011 COMBINED SINGLE LIMIT $ E.acadent) 1,000,000 X ANY AUTO BODILY I NJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULEDAUTOS PROPERTY DAMAGE X HIREDAUTOS (Peraccidem) $ X NON-OWNED AUTOS $ B UMBRELLA LIAR OCCUR 71C8000112101 03/10/2010 03/10/2011 EACH OCCURRENCE $1O OLIO 0-00 EXCESS LUIB X CLAIMS-MADE AGGREGATE $1D 006 000 DEDUCTIBLE $ RETENTION $ C WORKERS COMPENSATION WC7Z11259713010 03/10/2010 03/10/2011 X WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE V 1 NIA E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE EA EMPLOYEE $1,000,000 Ues,describe under SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Robert Crean ACCORDANCE WITH THE POLICY PROVISIONS. 9C Griswold Drive Salem, MA 01970 AUTHORIZED REPRESENTATIVE P . ©1988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009109) 1 Of'! The ACORD name and logo are registered marks of ACORD #S4969398/M4567299 PC6JA