60-64 GROVE ST - BUILDING INSPECTION 1
. � l
The Commonwealth of4s�F ,�
W
Department of Public Safety
A1assachusellsState Building'CoJg,(�7�&) Ij,�e— A FQ
Building Permit Application for any Building other t �jrrl-A ILF&welling
(rhis Section For Official Use Only)
BuBJfng Permit Number. Date Applied: Building Official:
.gyp SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.:md 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 c eck all that apply fit the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ 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 ❑
Is an Independent Structural Engineering Peer Rev reyui o Yes ❑ N ❑
Brief Description of Proposal Work: `M.0 1\�11 t d`� 6Y C-6 ¢?e�C
,p S 6,ta-
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANCE IN USE OR OCCUPANCY
Cheek here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0
Existing Use Croup(s): Proposed Use Group(s)-
SECTION 4.BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ClA4 ClA-5 O B: Business ❑ E: Educational ❑
F: Facto F-I❑ F2❑ - H: Hi h Hazard H-1❑, H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional W❑ 1-2❑ 1-3❑ 14❑ M: Mercantile Cl R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S.1 ❑ . S-2 Cl U. Utility❑ Special Use❑and please describe below:
Special Use:
SECTION&CONSTRUCTION TYPE(Check as applicable) - -
IA [] /B ❑ IIA ❑ If6 ❑ ILIA ❑ IIIB ❑ I IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CINR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ InJicah municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zune: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: 41.-\I list��riy i'o�nnus+ion Itc�nw,['r�x,i_..:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Budd enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Cock Use Croup(s): Type of Construction: Occupant Load per Floor:
Does the building,contain an Sprinkler System?: Special Stipulations: _
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
aM "� 60-6 GrO J-e st -h le v 1 Gt 61 -5�
Name,- treet - City/Town Zip
Property Owner Contact Information: 3� 30s
_ robe,'
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,�the property owner hereby authori
co
e •*t tK
Nmne Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this budding ermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space anJ or not under Construction Control then check hem O and skip Section 10.1
10.1 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
Comps zO 7 ;az
N Responsible fur Construction License No. and Type if Applicable
> 38W
S eet Address - City/Town State Zip .
? V_3(.,0 13 Oc-_ ub�ei coAo C-a->"/)6'vtq a
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSA""PION INSUNANC1i AFFIUAWI' 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 budding permit.
Is a signed Affidavit submitted with this application? Yes 0 No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Totd Construction Cost(from Item 6)_$
1. Budding $ Building Permit Fee=Total Construction Cost x_(Insert here
Z Electrical $ :appropriate municipal factor)_$
3. Plumbing $
d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipali )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under thtjStaips and penalties of perjury that all of the information contained in this
a placation is true anJ accurate to the be of my I viler ge anJ understanJing.
GpC� � J+rl Yta� y'j�? 360 130�
Please print al 1(�n( 2 ("� Title Telephone No. Date
Street Address n\� Cily/Town fate Zip
.i�J� L 4„
\lunicipai Inspector to fill out this section upon application approval: 1
Name Date
OTY OF SALEA WSSAML SE M
BxnDMDErAR7W
- IZO WA2WYMMSM=T,3PROC t
7kL('978)745.9595.
KDOERLEYDRiSMIZ PAX(978)740-9846
MAYOR 1 ST. 'n=
DnmcrcitcrpBucpxCrER7Y/BuLomOW Amcmm
Construction Debris Disposal.AfddWit
(required for all demolition and,renovation work)
1n accordance with the sixth edition of the-State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL coo, S 54; Building Permitfl isissued with the
condition that the debris resulting from this work shall be disposed of in a property lirensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
eq�Sp v-\
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of;facility)
Signtzf applicant
ate
y ss Rf M... :•y Public
OKam,.
' Massachusett.'Department of Public Safetyx:-.f
.� Board of BuAding Regulations and.Standards ,�
Y. License: CS-047527
Construction Supervisor
ROBERT J HUBBAf�D~
�k. 3
PO BOX 388 .� ..
BEVERLY MA Oj9 f .
Expiration:;;
;..aAr
Commissidner - 07/1312017
Construction Supervisor
Restricted to:
Unrestricted-Buildings of any use group which contain
_ less than,35,000 cubic feet(997
space. cubic meters)of enclosed
Failure to Possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
DPS Licensing information visit: W W WAASS.GOV/DPS
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 26158
POLICY NO. AWC-400-7031459-2015A
PRIOR NO: I AWC-400-7031459-2014A
ITEM
1. The Insured: Cabot Company Trust
DBA:
t Mailing address: P O Box 388 FEIN:'"-""'2497
Beverly, MA 01915
Legal Entity Type: Trust or Estate
Other workplaces not'shown above: See Location
2. The policy period is from 09/09/2015 to 09/09/2016 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated - Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTEA 832309
INTER SEE CLASS CODE SCHEDU E
v
Minimum Premium $550 Total Estimated Annual Premium $4,311
GOV GOV Deposit Premium $4,535
STATE CLASS
MA 9015 State Assessments/Surcharges
$3,896.00 x 5.7500% f// $224
This policy, including all endorsements, is hereby countersigned by &lea 08/18/2015
Authorized Signature Date
Service Office: Carmen-Kimball Ins Agency Inc
54 Third Avenue 48 Beckford Street
Burlington MA 01803 Beverly, MA 01915
WC 00 00 01 A(7-11)
Includes copyrightetl material of the National Council on Compensation Insurance,
used with its oermisslon.
A.I.M. Mutual Insurance Company
Insured: 7031459 Producer: 01034-001-001
Cabot Company Trust Carmen-Kimball Ins Agency Inc
P O Box 388 48 Beckford Street
Beverly, MA 01915 Beverly, MA 01915
Insured FEIN: `="'2497 Issue Date: 08/18/2015
Policy Number: AWC-400-7031459-2015A Endorsement Effective Date: 09/09/2015
Policy Period: 09/09/2015 - 09/09/2016 Endorsement Number:
CLASSIFICATION CODE SCHEDULE
Policy Unit: 001
Unit State Code: MA
Policy Unit Name: Cabot Company Trust Billing Plan: Annual
Classification Class Payroll Rate Estimated
Description Code No. Amount Per$100 Premium
CARPENTRY NOC 5403 If any 9.86 0
CARPENTRY - DETACHED ONE OR 5645 If any 8.06 0
CARPENTRY- DWELLINGS -THREE 5651 22,880 8.06 1,844
BUILDINGS NOC - OPERATION BY 9015 68,640 2.99 2,052
Manual Premium 3,896
Excess Employers Liability 1.00% 39
EEL Minimum Premium Adjustment 11
Premium Subject to Exp Mod 3,946
Standard Premium 3,946
Expense Constant 338
Terrorism Act Surcharge 27 i
Total Estimated Premium 4,311
DIA ASSESSMENT 5.75% 224
Total Estimated Premium & Surcharge(s) 4,535
Insured ClassCodeSch(04/11)