14 HARRISON AVE - BUILDING INSPECTION UCEIVED
The Commonwealth of MassachuslWV(104 ;E SERVICES
UlfDepartment of Public Safety
Massachusetts State Building Code(780 CMR) 2015 JUL -2 P 1; 22
Building Permit Application for any Building other than a One-or Two-Family Dwelling
'\J (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SE ON 1:LOCATION(Please indi ate Block# d Lot#for locations for which a str t ddress is not available)
v. A —Q[lq O _
�- No.and Street City/Town Zip Code Name o)Buil ' (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
1
Existing Buildin Repair Alteration ❑ 1 Addition❑ 1 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 Review required? Yes ❑ No Z&
Brief Description of Proposed Work:
S y\
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): Proposed Use Group(s):
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❑ I B: Business ❑ E: Educational ❑
R Facto F-1❑ F2❑ H: Hiah Hazard H-1❑ H-2❑ H-3 ❑ H4❑ - H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ Ili❑ 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 Ill ❑ IIA ❑ TB ❑ IIIA ❑ HMO I IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water SuppI Flood Zone Information Sewage Disposal: Trench Permit. Debris Removal:
Public Check if outside Flood Zone❑ Indicate municipa A trench will not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ re permit
iT�r trench or specify:
perrmit is enclosed❑
Railroad right-of-wp: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable, Is Structure within airport ap roach area? Is their review comp ed?
or Consent to Build enclosed❑ Yes❑ or Nqq 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:
C4-Dv t_L� ; N I I, ', L tnn 0 Y -1 ) {v, A t
SECTION 9: PROPERTY OWNER AUTHORIZATION
N�aoe a Address Prop rty Owner
ILI ., Vt �--
Name(Print) No.and Street City/Town Zip
Property Owner ontad InformahgFt;1n m f
Title Telephone No.(business) Telephone No. (cell) e-mail address
If Doplica ,the r perty owner hemao r y a thorizes (/'
b P M�q �Jpj0[
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized bv this bddding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) J
If buildingis less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here d 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
ET
any 1Re � L✓of rson spon a for Construction icense No. and Type if Qpl6licable
&VAA
Street Addr ss City/Town State Zi
Telephone No. business Telephone No. cell e-mail addr —�
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? Ye No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 41. 6,06 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
i
Note:Minimum fee=$ (contact m lity)
4.Mechanical (I-IVAC) $
5.Mechanical (Other) $ i
dO Enclose check payable to
6.Total Cost $ L1, re)O — (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 tru1ep nd accurate to the best of my knowledge and understanding.
P se print and sign e Title Jp0 11tTelephone o. Date
II
Street Aldress City/TON t State Zip
Municipal Inspector to fill out this section upon application approval:
Name - Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location(Please indicate Block# and Lot#for locations for which a street address is not
available)
No.and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other(if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107.The
checklist below is a compilation of the documents that may be required for this.The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents"
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
"Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State Zip
`v�)e Massachusetts-Department of Public Safety
v Board of Building Regulations and Standards
License:CS-101400
EENNETH R DE6fARC0' ,c
2 SPRUCE RUN ; fC� '
BEVERLY MA:915
� e f� ,�^'�x - Expiration
Commissioner 05115@016
,Office of Consumer Affairs&Business Regulation
P ,.-F�fOME IMPROVEMENT CONTRACTOR
egistation: 170731 Type:
,Expiation: 12/9/2D15 Individual
KENNETH R.DEMARCO
KENNETH DEMARCO
2 SPRUCE RUN 4
BEVERLY,MA 01915
Undersecrom,
ANCHOR BUILDING CO. LLC
Rom Game to linuh
B�
Ken DeMarco
77— O mrr
kendemarco@coma,set
2 Spruce Ru,
Beverly,Ma 01915 Ph:617-549.1968
Fax:751.723-0362
BERKSHIRE HA-THAW" Worker's Compensation and Employer's Liability Policy
GUARD INSURANCE AmGUARD Insurance Company - A Stock Company
NCOMPANIES Policy Number R2WC510297
Renewal of NEW
NCCI No. [21873]
Policy Information Page (AR)
[1]Named Insured and Mailing Address Agency
ANCHOR BUILDING COMPANY LLC NORTHEAST INS AGENCY INC
2 SPRUCE RUN 567 Southbridge St.
BEVERLY, MA 01915 Auburn, MA 01501
Agency Code: MANORE12
Federal Employer's ID 47-1216017 Insured is Limited Liability Co. (LLC)
[2] Policy Period
From July 11, 2014 to July 11, 2015, 12:01 AM, standard time at the insured's mailing address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident- each accident $500,000
Bodily Injury by Disease - each employee $500,000
Bodily Injury by Disease- policy limit $500,000
C. Refer to Residual Market Limited Other States Insurance Endorsement-WC 00 03 26A
D. This policy Includes these endorsements and schedules:
See Extension of Information Page -Schedule of Forms
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change by
audit. (Continued on another page)
Total Estimated Policy Premium $ 3,624
Total Surcharges/Assessments $ 167.00
Total Estimated Cost $ 3,812.00
INTERNAL USE OH Page- 1 - Information Page
MGA :R2WC510297 WC 000001A
Date :0713CV2014
MANOTE
Issuing Office: P.O. Box A-H, 16 S. River Street,Wilkes-Barre,PA 18703-0020 •www.guard.com
BERKSHIRE HATHAWAY Worker's Compensation and Emoloyer's Liability Policy
INSURANCE AmGUARD Insurance Company - A Stock Company
NGUARDCOMPANIES Policy Number R2WC510297
Renewal of NEW
NCCI No. [21873]
Policy Information Page (AR)
Extension of Information Page
Schedule of Forms
WCOOOOOOB-STANDARD POLICY
WCOOOOOIA- INFORMATION PAGE
WCOOD414- NOTIFICATION OF CHANGE IN OWNERSHIP ENDT
WC200101 - MA TERR. RISK INS. PROG REAUTHORIZATION
WC200102-MA NOTICE OF PEND LAW CHANGE TO TRIPRA
WC200301 - MA LIMITS OF LIABILITY ENDORSEMENT
WC200302A - MA ASSESSMENT CHARGE
WC200303D - MA NOTICE TO POLICYHOLDER ENDORSEMENT
WC200306B- MA LIMITED OTHER STATES BENEFIT ENDT.
WC200307- MA ASSIGNED RISK POOL ELIGIBILITY ENDT.
WC200403 - MA CONSTRCTN CLASS PREM. ADJUSTMENT ENDT
WC200405 - MA PREMIUM DUE DATE ENDORSEMENT
WC200601A - MA CANCELLATION ENDORSEMENT
WC200604- MA POLICY DEFINITION ENDORSEMENT
INTERNAL USE OH Page - 2- Information Page
MGA : R2WC510297 WC 000001A
Date : 07/30/2014
MANOTE
issuing Office:P.O. Box A-H, 16 S. River Street, Wilkes-Barre,PA 18703-0020 •www.guard.com
BERKSHIRE HATHAWAY Worker's Compensation and Employer's Liability Policy
GUARD INSURANCE
COMPANIES AmGUARD Insurance Company - A Stock Company
Policy Number R2WC510297
Renewal of NEW
NCCI No. [21873]
Policy Information Page (AR)
[4) Premium (cont.)
Massachusetts
Classification Code Premium Basis: Rate per Estimated
Total Estimated $100 Annual
Annual Remuneration Premium
Remuneration
Effective: 07/11/2014-07111/2015
CARPENTRY NOC 5403 IF ANY 9.86 0
ROOFING NOC,YARO EMPLOYEES&DRIVER 5545 IF ANY 31.79 0
CARPENTRY-DETACHED 1/2 FAMILY DWGS 5645 IF ANY 8.06 0
CARPENTRY-THREE STORIES OR LESS 5651 40,000.00 8.06 3,224
Increased Limits Emp Liability 500000/500000/500000 9807 1.000% 32
Amt to Bal Inc Lim 9848 18
Tat Est Premium 07/11/2014-07/11/2015 3,274
Minimum Premium $500
Tot Est Standard Premium for Massachusetts 3,274
Polla Totals
Total Estimated Standard Premium for Massachusetts 3,274
Expense Constant 338
Total Terrorism MA 9740 0.03 40,000 12
Minimum Premium MA $500
Total Estimated Annual Premium 3,624
MA State Assessment 07/11/2014-07/11/2015 5.8000% 187
Total Estimated Cost for R2WC510297 3,811
INTERNAL USE. 011 Page- 3- Information Page
MGA :RZWC510297 WC 000001A
Date :07/30/2014
MANOTE
Issuing Office: P.O. Box A-R,16 S.River Street,Wilkes-Barre,PA 18703-0020 •www.guard.com
BERKSHIRE HATHAWAY Worker's Compensation and Employer's Liability Policy
GUARD INSURANCE
COMPANIES AmGUARD Insurance Company- A Stock Company
Policy Number R2WC510297
Renewal of NEW
NCCI No. [21873)
Policy Information Page(AR)
Policy Payment Terms
Payment Option: Direct Bill
Installment Plan
(prepared 07/30/2014)
Down Payment received 07/17/2014- $3,811.00
INTERNAL L75E OM Page -4-
MGA :R2WC510297
Date :07/30/2014
MANOTE
Issuing officac P.o. Box A-H, 10 S. River street,Wilkes-Barre,PA 18703-0020 0 www.guard.mm
CITY OF SiU1 ENl. NL-kSSACHUSETTS
• BUILDING DEPARTME+Z%T
130 WASHNGTON STREET, 3r FLOOR
rj TFL. (978) 745-9595
FA%(979) 740-9846
NIBEP RY DRISCOLL THo.%w ST.PIEM
MAYOR
DIRECTOR OF PUBLIC PROPERTY/HL'II.DLNG COSLMSSIO;•iER
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 :
SAA�W\- �-p q0�1 ��
n(name of facility)
MA
(address of facility)
si nature of permit applicant
2 �s�
date
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www ntass.govVi is
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Anwh7cautIn Print
Name (Business/OrganizAtion/Individual): �],/
Address: �^ �Ji7 D
City/State/Zip: tfV4 Phone k 00 I I W
Are you an employer?Check the appro late box: Type of project(required):
1. a employer with employees(full and/or part-time).' 7. �New construction
a sole proprietor or partnership and have no employees working for me in g. Remodeling
y capacity.[No workers'comp.insurance required.]
9. �Demolition
3. I am a homeowner doing all work myself[No workers'comp.insurance required.]t
10 Q Building addition
4.n I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation imumnce or are sole ]L❑Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5. 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These subcontractors have employees and have workers'comp.insurance.: 13.❑Roof repairs _
14.�f Other V9RIL1� D�u✓
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. �
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'AM applicant that cheeks 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
tCorrtractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities ban
anployees. If the sub-conuacmrs 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 under 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 hereby c der th and penadfes of perjury that the information provided ve true ryrd correct
i Date:
i )�
ne
Official use only. Do not write in this area,to be completed 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
Contact Person: Phone#:
6/2 s•/15
Proposal for 14 Harrison Ave.
I
Scope of work summary:
Demo and dispose of existing 2 floor deck and roof. Ice and water shield behind deck ledger at each floor. Re-Frame
deck both floors out of 2"x8"P.T. Lumber.All posts to be 4"x6" P.T.. Deck ledger to be 2"x8" P.T., capped with plastic
deck flashing, and bolted to house using 5" ledger locks @ 16"O.C.(2" up and down from leading edges of ledger board).
Front carrying beams to be triple 2"x10" P.T.. Roof framing to be 2"x8" K.D. @ 16" O.C.,with 2"x12" ridge beam. Roof
sheathing to be 11/16"Zip ply/taped @ the seams. Gable sheathing to be 7/16" zip ply/taped @ seams. Ceiling to be
2"x6" K.D. @ 16" O.C.. Simple roof trim to be 1"x8"azek with siding tuck, VxV soffit board on eaves, and 1"x3"shadow
board. Re-use existing siding on gable,and patches. Re-use vented soffit to tie in old trim to new. Re-roof using 30 year
arch,white aluminum drip edge, and brown coil stock @ valleys. All flush framing to be hung with 2"x8" Simpson zinc
coated hangers. Every other rafter to have Simpson hurricane ties tied to beam,fastened with galvanized hanger nails.
All Framing to be'fastened with 10d galvanized framing nails;in compliance with required gauges. Decking to be 5/4"x 6"
composite decking face screwed with stainless steel deck screws,or equal ( coated ext. deck screws). Railings to be
2"x4" P.T.Cap and nailers for square P.T. Balusters @ 5"O.C.With 3" support block @ mid-span. Re-use P.T. Ply @ first
floor to keep animals from under deck. Add 1 set of stairs,to right side of deck. Cut concrete pad flush with first floor
framing and close in with P.T. Ply.Azek risers. Daily clean up.
v
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