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57-59 HARBOR ST - BUILDING INSPECTION (3) I� The Commonwealth of Massachusetts c - Department of Public Safety V�I( Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling ",°` ;::,''-. •' „_.< (This Section For Official Use Only) Building Permit Number:' - Date Applied: - Brrildirig Officials ?- SECTION 1:LOCATION(PI ease'indicate Block#and Lot#for locations foi which a street address iiss not available)�� -SCI & LX w :�- NOD:) �—Ic, zkbl) No.and Street - City/Town Zip Code Name of Building(if apphcable) {;SECTION 2:PROPOSED WORK Edition of MA State Code used J If New Construction check here❑ or check all that apply in the two rows below Existil Alteration ❑ I 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 a's part of this permit application? Yes ❑ No J Is an Independent Structural Engineering Peer Review required? Yes ❑ No. qa TJ Brief Description of Proposed Work: A ry V ,., SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY 7, Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): 'i , _ ; >`=:" 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.) ' SECTION 5:USE GROUP(Check as applicable)`, ` A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ 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 I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U. Utility❑ Special Use❑and please describe below: Special Use: - - - SECTION 6:CONSTRUCTION TYPE Check as applicable) IA ❑ IB ❑ " IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INPORMATION(refer to 780 CMR 111.0 for details on each item)j Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public Cl Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required El or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: 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: SECTION.9: PROPERTY OWNER AUTHORIZATION' Name and Address of Property OOwwnerer e(Print) No.and Stree City Zip Property Owner Contact Information: —y _Q Cox Title Telephone No. (business) Telephone No. (cell) e-mail address {If applicable,the property owner hereby authorizes tiOV.'Afl�t3C��_i(1��(lDA\7(l ` i,NokjJ Saute Street Address City/To State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. r• ' SECTION 10:CONSTRUCTION CONTROL(Please fill outAppend .2)`, '. If buildin is less than 35,000 cu:ft.of enclosed space and/or not under Construcfioa Control then check here❑and skipSection 10.1 10.1 Registered Professional.Responsible for Construction Control Name(Regis t) Telephone No. e-mail address Registration Number ae \ tw a \ at rn� Street Address City/To State Zip Discipline Expiration Date 10r..2 General Contractor 1 `IJyLZn�aoa" feu Company Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip _Jl�� Q 1. Telephone No.(business) Telephone No. cell e-mail addh9s 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? Yeso ❑ SECTION 12:-CONSTRUCTION.COSTS AND PERMIT FEE Item Estimated Costs:(Labor - and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ (� Building Permit Fee=Total Construction Cost x (Insert here 2,Electrical $ appropriate municipal factor)_$ 3.Plumbing $ - 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ a"1 (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 perj th4thematio contained in this application is-true and accurate to the best o my knowledge and understanding. �% 4 �Plea rint and si n e Titehone No. DateGf Street AddressCity/ wn ZipMumcrpal Inspector to fill out this section uponapplication approval: ... _ .... .. . ._ >.. game .,,. .., ate i CITY OF &kL&%Vl1 .NAXSSACHUSETTS BtiIIm wG DEPAP.TNMNT 120 WASHINGTON STREET,3" FLOOR 'SEr_ (978) 745-9595 FAX(978) 740-9846 KI1IBfiRLEY DRISCOLL MAYOR THOMAS ST.FIERRB DIRECTOR OF PUBLIC PROPERTY/BI:RMNG CON IISSIONER 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 c 111, S I50A. The debris will be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of facility) Sig tore of p mit applicant M date Jc6rivtr.dw NOTICE TO PROCEED Action for Boston Community Development(ABCD),administrator of the DOE Expiring Use energy efficiency program for low-income multifamily properties, is hereby authorized to have its contractors,employees,and other representatives access the property and perform the work contained in the attached Work Order, including final inspections.A copy of this document shall be carried by ABCD's contractors,employees, or representatives and presented upon request. By signing this Notice to Proceed,the applicant acknowledges that the benefits to the clients will be delivered as stated in the attached document. Applicant Information I Site Name: )r4l\ 6 G(L MC Street,City/Town, Zip: 1 (3 2 S S kAA o 61 °I Contact Name&Phone at Site: 3(G C Signature: 1� Printed Name: Title: Organization: CnG — Date: R" -2i - I Acknowledeed by ABCD's representative: UVr John Wells,Vice President for Real Estate and Energy Services,ABCD. Please sign and date two originals. Retain one for your records and return the other to: Grace Park ABCD 178 Tremont St Boston,MA 02111 fax: 617-357-4661 parka bostonabcd.ore z 6O . Two Adams Place ADVANrAGE Suite 100 ®®I N 1,0 k P ('K `�' Quincy, MA 02169 Date7/28/2011 kl AGENCY: Action for Boston Community Development, Inc. ABCD 178 Tremont St. Boston, MA 02111 HOMEOWNER: TOTAL Salem Street Properties WORK ORDER 57-59 Harbor St. Salem MA $23,227 Date`ofwalk-thr0LijK! 4/20/11 . .. - a _ - :a„ Job,Cost # 14037 =w` x � `� , t _ _ DESCRIPTION QTY. UNIT UNIT PRICE TOTAL PRICE DOORS Weatherstrip w/Q-Ion or equal 32 ea $43.00 1 $1,376 Automatic Sweep 32 ea $22.00 $704 MISC. MEASURES Basement air sealing 22 man/hr 1 $75.00 $1,650 Building Permit 1 LS 1 $428 $428 BASEMENT INSULATION Basement overhead insulation (Dense pack-9.5" - R32) 5,040 sq.ft. 1 $3.75 1 $18,900 Strapping/ Sheet Rock, taped & coat-for holes in ceiling 32 32 1 $5.28 1 $169 Page 1 of 1 t', The Commonwealth of Massachusetts. Departmeslt oflndustrial Accidents Office oflnvestigatlons x n 600 Washington Street F Boston,MA 02111 wwmmass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): , �,t�t��Cneg Address: City/State/Zip: c 'rnA. ci:m"A Phone.#:_ Are you an employer?Check the appropriate box: of project(requiredy:, 1.[A I am a employer with 10 4. ❑ I am a general contractor and I 6 employees(full and/or tim part- e).* have hired the sub-contractors ❑New construction 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity, employees and have workers' _ r co insurance.t' ._. 9�'❑Buildingaddition [No workers comp,insurance comp, 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 11.❑Plumbing repairs or additions . myself. [No workers' camp, right of exemption per MGL 12.0Roof repairs insurance required.]t c. 152,§1(4),and we have no . employees. [No workers' 13.0 Other comp.insurance regoiredt] Any applicant that checks box 81 must also fill out the scction below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-cohlraetors and state whether or not those entitles have employees. If the subcontractors have employees,they must provido their workers'comp,policy number. I out an employer'that is providing workers'compensation insurance for my employees. Below is thepolicy and fob site information. Insurance Company Name: \ 1"��-\ur�•>✓\ ��Y�su'� ��f4t_�'(\ »r.�r�� ti0� C ��\'��j,) '\�h� Policy#or Self-ins.Lic.#: CX>lv 4��)Q Expiration Date: l4 ZO Job Site Address: 5� ' S� Q(\ 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 free 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I'do hereby certify under the pales and penalties of erj that the inforntailon provided above is true and correct Si atuie: ` - Date: Phone#: Un , 1 `i FContactPerson: only. Do not write In thr a ea, to be completed y city or town offictat n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: I nco CERTIFICATE OF LIABILITY INSURANCE 6fi 020^9m/BDmrr 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 endomement(s). PRODUCER CONTACT Diane Shaw Fred C.Church,Inc. NAME: 41 Wellman Street PHONE 9783227272 FAX (978)454-1865 AIC Na E AID No): Lowell,MA 01851 E-MAIL dshawQfredcch m)c .com (800)225-1965 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC N INSURERA: Citation Insurance Company 40274 INSURED INSURER B: National Union Fire Insum ce Company of Pittsburgh,PA 19445 Advantage Weatherization,Inc Insurance INSURER C: Navigators Insunce Company Two Adams Place,Suite 100 Gemini Insurance Company 10833 Quincy,MA 02169 INSURER D: INSURER E: Stan Indemnity S Liability Company 38318 INSURER F: COVERAGES CERTIFICATE NUMBER: 18541 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. INSR I TYPE OF INSURANCE ADDLI MD POLICY NUMBER MMIDDY,y1 YY MFF MIDDIYYYY LIMITS LTRINSR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X DAMAGE TOR RENTED 100,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occumerce $ CLAIMS-MADE X] OCCUR VIED EXP(Any one person) g 5,000 D VUMA0000890 402011 402012 PERSONAL B AOV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY % PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Be accident $ ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED X SCHEDULED BBNT98 4/212011 41112012 BODILY INJURY(Per accident) $ UTOS X HIRED AUTOS X NON OWNED PROP c4enIDAMAGE $ X UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 5,000,000 E EXCESS Li CLAIMS-MADE BINDER 612CJ2011 6/20/2012 AGGREGATE $ 5,000,000 DED I X RETENTIONS 0 $ WORKERS COMPENSATION X WC STATdU OTH- AND EMPLOYERS'LIABILITY YIN T RYLIMIT ER B ANY PROPRIETCRIPARTNER/EXECUTIVE NIA 006430048 6/20I2011 6I20I2012 E.L.EACH ACCIDENT $ 1,000,000 OFFICERWEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yyes,tleacribe under 1,009,909 ❑ESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ $10.000,000 X of$5,000,000 C Umbrella NYIIEXC7111931V 6/2012011 6/20/2012 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addltlanal Remark.Schedule,If more space Is required) As required by Contract,Action,Inc.Keyspan Energy Deliveries and It's subsidiaries,National Grid USA and its subsidiaries antl NSTAR are included as Additional Insureds with respect to general liability only. Weath.mt.bon Projects. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORQED REPRESENTATIVE .� '("'" P ,f J A.� Client* 314b I Mat* 1 bb4l Cart Holder# ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD ,r �i,t.+xchuK9.s-f9egt ez etneut +t£Pislr�t, '+z ra+ 13+>.tit{t,f fiutfdirt;!.fU of ttotettiand'`rnr.r$ar is.� •�a�'a u�t=m, S4tn rv,rae�s i.F,e.st - Ltrerrse- CS 102978 '"°^•` ' Restnctecl to:. 00 j. .BRIAN MACHADO .47 MALBONE ROAD. ASSONET,MA 02702 ' ...-F^.----<-.�;..=` £krrn3rnr 526Y1013 r +rnn.3sF.ner� :fat::102978 1 „� ✓>/,e "✓�ia„cveaae�ralr! 7"/1+7,omrxc!<:oeCCla Office of Consumer Affairs&Business Regulation License or registration valid for individul use only C &OME IMPROVEMENT CONTRACTOR - before the expiration date. If found return to: {1 a , Office of Consumer Affairs and Business Regulation " F 7 Registration 166076 Type: 10 Park Plaza-Suite 5170 Expiratwn. 412112012 Supplement Card Boston,NIA 02116 ADVANTAGE WEATHER12A T-IO INC. - - _ BRIAN MACHADO c 1 TWO ADAMS PLACE QUINCY, MA 02169 Undersecretary Not valid without signature