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64 64 1-2 HARBOR ST - BUILDING INSPECTION The Commonwealth of Massachusetts tp # Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling ;q('I1usSechon.F6r;Official:Use Only)` Building Permit Number Date Applied: - Building Official"" - c ` Y €" SECTION 1;'LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) - LA) Z n�r7n <-:-- �off No.and Street City/Town Zip Code Name of Building(if applicable) - '" iSECTION 2:PROPOSED WORK w °` '}'A Edition of MA State Code used J If New Construction check here❑ or check all that apply in 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 J i� Is an Independent Structural Engineering Peer Review required? Yes ❑ No. pa 45( Brief Description of Proposed Work: -1 u _ SECTION 3:COMPLETE THIS SECTION,IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR - *."- CHANGEINUSEARpCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): r` 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❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Haz- H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercan 1,❑ 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 ❑ II1130 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION:(refer to 780 CMR 111.0 for details on each item) Water Supply: - Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required 0 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: ,,SEcriON9: PROPERTY OWNER AUTHORIZATION . - s s Name and Address of Property Owner - 1 oo, WA e(Print) o.and Street City/Town Zip Property Owner Contact Infonnation: Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes (� it � �fa�clon\rr� on _�(klom5l��zc `,ati1w r \ p� I�Aune - Street Address City/To State Zip to act on the property owner's behalf,in all matters relative to work authoi permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix:2" i. ." building is less:than 35,000 cm ft.of enclosed space and/or not"under Construction Control then check hae❑and skr Section 10.1 10.1 Registered Professional Responsible for Construction Control LQn Name(Regisl; t) Telephone No. e-mail address Registration Number a 2)AQ ,�,cx, cp�) O \ a\ Street Address City/To vn State Zip Discipline Expiration Date '1`0.2\General Contractor 1-1UV(RYI�II\�Q0.�Y\>Z7�y,Ca,\l:.v� (C(�mpany Named C �� Ir, n moxr� l�t� C� �� cn�5 Name of Person Responsible for Construction 1n\ License No. and Type if Applicable t\ ) Street Address City/Town State Zip Telephone No.(business) Telephone No. cell a-mail ad ess 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' ance of the building permit Is a signed Affidavit submitted with this application? Yeses' No ❑ 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 $ C4 appropriate municipal factor)=$ - . 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (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 hereby attest under the pains and penalties of perjury that all of the information contained in this application is-true and accurate to the best ot my knowledge and understanding. 9A 9 Pleas ��rint and sign n e Title v�,,�Tele one Date - lY� "nI i,\ t ��n. d Street Address City/ wn State rp L1 Municipal Inspector to fill uutthis section upon application approval: Name Date" i CITY OF S.UENI, TNL SSACHUSETTS BuILDNG DEPART' \ 120 WASHNGTON STREET,3m FLOOR TEL- (978) 745-9595 FAX(978) 740-9846 KI1fBERL-Y DRISCOLL MAYOR :Tmmm ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BUMDNG CONLNIISSIONER 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 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of facility) sig hire of p� it applicant _ date dcbriwfT,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 II Site Name: Or��, L GEC bv1 `J n 0 �� I"P Street,City/Town, Zip: b S�YPt kAA Contact Name&'Phone at Site: —C I C O� ��lrl CL — �y S �S U g Signature: Printed Name: `( s k� Title: Organization: NOCA\ Sftim Date: R" 2+' I I Acknowledeed by ABCD's representative: ,�UYr 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 179 Tremont St Boston,MA 02111 fax: 617-357-4661 oark@bostonabcd.ore Two Adams Place ADVANTAGESuite 100 ®0,h`:, 0R OR Al 111) Quincy, MA 02169 -'6 - Date7/28/2011 AGENCY: Action for Boston Community Development, Inc. ABCD 178 Tremont St. Boston, MA 02111 HOMEOWNER: TOTAL Salem Street Properties WORK ORDER 64 & 64 1 2 Harbor St. Salem MA $22,916 Date"of walk through`s 4/20/11 k Job COst , 14037 r r - r AxzSAQ DESCRIPTION CITY. UNIT UNIT PRICE TOTAL PRICE DOORS Weatherstrip w/Q-Ion or equal 13 ea $43.00 $559 Automatic Sweep 13 ea $22.00 1 $286 MISC. MEASURES Basement air sealing 26 man/hr $75.00 $1,950 Building Permit 1 LS $422 1 $422 BASEMENT INSULATION Basement overhead insulation (Dense pack-9.5" - R32) 5,208 sq.ft. $3.75 1 $19,530 Strapping/ Sheet Rock, taped &coat -for holes in ceiling 32 32 $5.28 1 $169 Page 1 of 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office ofluvestigations 600 Washington Street Boston,MA 02111 wwwanass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Li lectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organintiowlndividual): Address: City/State/Zip: C \ Phone.#: l a-Y) Are you an employer?Check the appropriate box: I am a general contractor and I Type of protect(required):. 4. 1.[�,I am a employer with 10 ❑ g 6 employees(full and/or part-time).*- 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 workingfor me in an capacity. -employees and have workers'._._ Y '" 9:-❑Building addition [No workers'comp.insurance comp,msurance.t 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 1 LE]Plumbing repairs or additions . self. [No workers myself. co right 6f exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 Other i comp.insurance required:] *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 then hire outside contractors must submit a new affidavit indicating such. 1Contructurs that check this box must attached a additional sheet showing the name of the subcofirotors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp,policy number. I ant an employer that isproyiding workers'compensation insurance for my employees. Below is the policy and Job site information. \ / Insurance Company Name: 0) Policy#or Self-ins.Lic.#: QL. _o t•}���la`�,' Expiration Date: �. ZD aC, _ II ^1 \ Job Site Address: W� U\� IZ �p�j � . City/State/Zip: �m 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 e, 152 can lead to the imposition of criminal penalties of a fine rip 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 bIA for insurance coverage verification. I do hereby certify under the pains and penalties of erj that the inforrttaliat provided above is true an correct. Si atone: Date: Phone Official use only. Do not write in thrmsajea, tb be completed by city or town official. i i 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#: A� ® DATE(MMIOOIWri) ,�. CERTIFICATE OF LIABILITY INSURANCE 06/20/2011 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 15 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 Diane Shaw Fred C.Church,Inc. NAME: 41 Wellman Street H ON No EN: 9]8322]2R aC No, (9]8)454-1865 Lowell,MA 01851 EMAIL dshawQfredcchurch.mm - (800)225-1865 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL# INSURER A: Citation Insurance Company 40274 INSURED INSURER B: National Union Fire Insurance Company of Pittsburgh,PA 19445 Advantage Weatheraaticn,Inc. 42307 INSURER C: Navigators Insurance Company Two Adams Place,Suite 100 Gemini Insurance Company 10833 Quincy,MA 02169 INSURER D: Starr Indemnity SLiabllity Company 38318 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 8541 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 ADDLTYPE OF INSURANCE INSR SUER POLICY NUMBER MM DDY/YYYY MMIDDIEFF POLICY EXP TR LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1C 0,000 X DA AG TO 100,000 COMMERCIAL GENERAL LIABILITY PREMISES IF. occunence $ CLAIMS-MADErx] OCCUR MED EXP(Any one person) $ 5,000 D VUMA0000890 402011 4/2/2012 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGE $ 2,000,000 POLICY JIE OT LOG $ POMOBILELIABILITY COMBINED SING LE LIMIT 8 1,000,000 Ea acntlent ALL ANVAUTO BODILY INJURY(Per person) $ X SCHEDULED BBNT98 412/2011 41212012 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OHIRED AUTOS X AU70SWNED (Par..�RdPOPe DAMAGE $ $ X UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 5,000,000 E EXCESS LIAR CLAIMS-MADE BINDER 6120/2011 61202012 AGGREGATE $ 5,000,000 DED X I RETENTION$4 $ WORKERS COMPENSATION X WE STATU- DIP- AND EMPLOYERS'LIABILITY YIN TORV LIMIT ER ANY PROPRIETORIPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1.000,000 B OFFICERIMEMBER EXCLUDED] N/A OOfi430048 fi/20I2011 6/20I2012 (Myyandator,in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 ❑EasIce under SCdescr RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 $18,o9g989 x or as.9a9,a99 C Umbrella NYIIEXC7111931V 6/2012011 6/20/2012 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If moms pace is required) As required by Contract,Action,Inc.Keyspan Energy Deliveries and it's subsidlades,National Grid USA and it's subsidiaries and NSTAR are Included as Additional Insureds with respect M general liability only. Weath....bar Projects. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE }j+y Clientu 3141HMat# 1 bb4l Cert Holder# ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Almlls.,:uhn +.tN- UfpadmrRr iif Pnhhc + c�t,i ; Bnav!.d o Bufldim-, Ri ulatlans tad St.m latrfl— . LY1.ns.tlCt U^!t.fi.l p„e�;SrJY l., f'15N . I.teeRSe" 'r$ 102979 Rsstrtoed to: 00 BRIAN MACHADO .47 MALBONE,ROAD i ASSONET,iMA 02762 TM: 102978.. I i, L . ��l�JdnYp(fyleUJP2l,UE O�a/[Lr14JaC�661Y6 _ _''''ssss7777:::: Office of Consumer Affairs&Business Regulation License or registration valid for individul use only „ j$iOME IMPROVEMENT CONTRACTOR - before the expiration date. If found return to: c Office of Consumer Affairs and Business Regulation Registration 1611075 Type: 10 Park Plaza-Suite 5170 Expira4lan -0t212t112 Supplement Card Boston,MA 02116 ADVANTAGE N/E157tiER'72AYI6N{INC. - BRIAN MACHADO TWO ADAMS PLACE SUITE"1,00 ��-�- QUINCY, MA 02t69 - - Undersecretary ®®®® Not valid without signature i I I i