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4A HART WAY - BUILDING INSPECTION
r • ' fG/ od . 6-cz) The Commonwealth of 11�lassachusetts i. Department of Public Safety \lassachusclls Sl.de �uilding Code(78t1 C'\IR) Building Permit Application for any Building other than a One-orTwo-Family Dwelling (Ibis Section For Official Use Only) Building Permit Number: Date Applied: __ Building Official: - SE11CFION 1: LOCATION(Plleaasee indicate Block #and Lot#fur locations fur which a street address is not available) No. and Street I Ci15' i fown /ip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition ut .\L\Stale Code used If New Construction check here❑or check all That apl+ly in the hvu nnvs below >islin}; Iuilding❑ Repair❑ Alteration ❑ A,idition❑ Demolition ❑ (Please till out and submit :\ ,pendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:. Are building plans and/or con.struclion doc'unnvtls being supplied as part oI this permit appgNN ? Yes ❑ No ❑ Is an Indepvndent Structural Englnceril Pee/Review w u rcdn�1 / Yes ❑ No ❑ i, Brief IJcscriylt'o"t of I'/n,p,ctied Work: l`d�' ` ✓JeC K.__ZK� T 1- JorS'rt�L QQ�j �___ lag - l°n.nIeSl�_�C iw[ (d.K /.lc�rnr e.,jI ,s�l, r�°ve2v' C'OT(__ SECTION 3:COMPLETE Tf1IS SECTION IF EXIS"rING BUILDING UNDERGOING R 'r1ON, ADDITION,Oil CHANGE IN USE OR OCCUPANCY Chcck here if an Existing Building Investigation and Evaluation is cuclowd (See 780 C\IR.`I4 Existing Use Group(s): Proposed Use Gruu ___ ..____SECrfON 4:BUILDING HEIGHT AND AREA ExiProposalNo.nt Flours/Stories(include basement levels)&Area Per Fluor(sq. ft.) Total Area(sq. ft.)and Total height(ft.) SECTION 5: USE GROUP(Check as a liable) A: Assembly A-I ❑ A-'_❑ Nightclub ❑ A-\ ❑ A4 ❑ .\-3❑ B: BusinessE: [iducational ❑10 facto F-I ❑ F'❑ Ili Ifi h flaz.wd f1-1 ❑ H-2❑ 11-�❑ 1.1-5❑1: Institutional I-1 ❑ 1-_2❑ 1.3❑ 1-4❑ \I: Mercantile❑ Rt Residential RR-2❑ R-3❑ R-a ❑U: Utility❑ Special Use❑and escribe below: - Special Use SECHON 6:CONS'I'RUCr1ON I-YI'F (Check as applicable) IAA IB ❑ IL\ ❑ IIB ❑ III,\ ❑ IIIB ❑ IV ❑ V:\ ❑ \'It ❑ SEC'IJON 7: SITE INFOR\L\TION(refer to 78B C\Fit Ill 0 fnr details on each item) Water Su I Flood Zone Information: Sewage Uieposal: french Perini Dcbris Reltloval: vP r Public ❑ Check it outside Ilood /_one❑ Indicate municipal ❑ A Ircnch will not bc• Li, hi+posal tiile❑ Prl\.Ile❑ I or indvnlily Lonr� _._. __— or on site ss stein ❑ nvpiin•d ❑or trench or sP' if v. . permit is me lose I ❑ Itailroad right-of-way: hazards to Air Nav igatiun: .. , „.,, blv❑ Is'Itnirtore t, dim uport AIII ,n h erra' Is their rev n•,r„nnplvlvd' nr C S�mant to Build,'n,I nsr,10 lrs❑ ��r.\o❑ 1v+❑ \'i� ❑ __--- SI IION 8: CONTENT OF Chat HFICA 1"1;OF UC(-L'1'.\N('Y I ,Iilum'.I (,,,le: ( ,v Urnupl.). twit (tc,up.ml 1 ,4ad p,•r l hnrt I. Itn+ Ihr lniildin};,rn Lini ,m �prinhhrIV tis slrm.` �prc i.d�I;puluhins SR.I ION 1 11(0111:111 Y OWNfRAU 111ORILA I ION \ unC Intl \tldnss of l'r(�(+rrl�'11r�nir } J- No. and Str•cl Ctly/Town _— Lip Name(Print) . Property Owner Contact Information: Ville telephone No. (business) Telephone No. (cull) c-mail address If applicable, the property owner hercbv authorizes Name Street Address ----- -City/Town --- State --._Zip ..— to act on the property owner's behalf, in all matters relative it,work authorized b • this building permit application. - SECTION 10:CONSTRUCTION CONTROL(please fill out Appendix 2) If buildin•is less than lS,UNI cu.ft.of enclosed s pace and or nut under Constntclion Control them check here❑:cod.skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control QPnb ( l fG� 9�gsZgs21 f� nl f I gq �(e -Registration Number Nance(Registrant) Telephone No. a-mail address Street Address City/Town state, Zip Discipline —L pi(atiun Date 10.2 General Contractor W�e BiCS Company Nance 00,4A44S C�1 eu1 fie. �r FG Cs y -- Name of Person Responsible for Construction License No. and Type if Applicable �� (1cd.as IZr Sfipe'f' etbec� ti_treat Address City/T wnn ^^ State Zip 2L 0--S3:6- 1/4 /S _ Pa De I de 21 tor( tj E- -- tele phone No. business) Telephone No. cell c-mail address SECI'1ON 11: to as,l l::,'.I_t A111 V,AI b0%"Lyl11 n:A.Nt b .tl i 11 I M.G.L.c. 152. 25C 6 A Workers'Compensation lnsurnnce Affidavit from the CIA Department of Industrial Accidents npust be completed anal ski bill itted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a sl pned Affidavit submitted with this application? Yes O No ❑ SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6) S_. I. Building b Building Permit Fee s Total Construction Cost x (Insert here '_. Electrical S appropriate municipal factor) S 1. Plumbing, 5 !. \IcchaniCal (hIV:\q S Note: \lininnnn (ee 5 (Contact i� mteipality) i. Mechanical Other S FnClose check payable a. folal Cost > SS'20 •0 Q (Contact nuutici palily)and write check number here SECTION 13:SIGNA PURE OF BUILDING PERMIT APPLICANT Itt entering m)' name tit-lots, I hcrcbv Itcet under the pains and pcnaltivs of perjury that all of cite information,ontail d in this ipplicaltou is lrruv nttl lCCkUnity to C be(tt of lov l,uo,t •tIg an understanding. p?�y v r. ' �. ° __ (J(Un(t°•2 f .6.5_ 2 Z l._ 19rase print nttl sign name . - I tile ___ frlt•pl n • : o. Pow �uert \d.l n•ss3/.. )-V�`PVICr sl'C'PC� '�AIhQGGGIII / ) Municipal Inspector to fill oul this section upon appliCatiun approval: _.... .__"___ �.__ _...•'. . [✓ �/ Name p,ue C11-Y OF NWS,kCHl:SE"ITS i. DtP. � 110 \'f/ASHL�IGTON STREET, i0 FLOUR \j�,ea.o��e TEL (978) 715.9595 - F.k-x(979) 110.9846 ±v.\f0i Rr Y DPISCOLL 'nimuSST.111EX" NLiYOA DIRECTOR OF PC9LtC PROPERTY/OI:R.DNC,CO\L%tlaSfUNEIt Workers' Compensation Insurance Affidavit: Builders/Contracture/Electricians/Plumbers koolicant Informatinn Vfcase Print Legibly NaineIIlmilxsUrg,tmratiun.lmlividual) NQe"e Bo_o "'' -aU Address: S(y pot a.1 / s2eeT City/State/Zip: Pei 1)lid )hung N: `tajg 53'Z 4S'Z 1 Are gnu an employer!Check the appropriate bolt 'type of prnject(required): 1.�] I am a employer with a. Q I am a general contractor and 1 6. ❑New construction ryempinyces(full and/or part-time).• have hired the subcontractors 2.t..r) t am a sole proprietor ur partner. listed on the auachcd.+heat t 7, ❑ Remodeling .hip and have no employees These sub-contractors have V. Q Demolition workingfor me in an capacity. workers'camp.insurance. 9. Y ❑ Building addition [No workers:comp.insurance 3. 0 We are a corporation and its required.] ofOcers have exercised their I 1 10.0Electrical repairs or additions 3.0 lam a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions myself.[Na workers'sump. c. 132, )1(4),and we have no 12.0 Roof repairs insurancerequired.11 umpluyecs. [No workers' 13.QOthar //JSAkce (JCCf�l comp. insurance required.; •nay applic:un dW aliwka bat rl must also rill sus rhv sactiuo bulaw showing theif nrmkm'campnudun punvy inllnmadan. 't Lvnauwr+v who whnnis this uflcbwil indicating ihcy am doing all wart[and than his uu4ide eanlmeMle onus niMnls a new atltdavil indieasing ruck :C,,mrwton that ch vk Nit bast muss anachad an.i"ifurW.hest.huwing the nwna of the rubwanlrKtuO and[hair workers'rumµ policy InWmudaa. I utn un runpluyer shut is pruv7JLrX rvorkar'cumpenradun Ltsrrunee[or my etnpluyrrs: Bduw/s the Polley and job site infurerurinn. In,umncc Company Name: _..-.-.-. llnlicy 4 or Selr-ins. Lic. to: Expiration Date: Ma Site Addruss: City/Statet2ip: Attach a copy of the workers'compensation policy declaration paKs(showing the policy number and expiration data). Kiiluru to wcury cuveriga as required under Section 35A of MGL e. 152 can lead to the imposition of criminal penalties of s rine up to 11,500.00 and/ur one-year iinprisnnmcnt, as well as civil penalties in the tarts of a STOP WORK ORDER and a line of up to S_'d0.170 a dry �gaing the viulamr. Ile advkcd that a cupy of this ntatemem may be furwarelcd to ilia Ofttcd of Ltrc,tig3riun.+oi the DIA I'or insurance cov,:mge veri licaliun. 1,10 hereby veal/y under rile point and prnulrle.r,tfperjury finis r/u ubuve it true•end corral 01/iciul rue,rely. O,r nor iwiu in doer Jr<u, ru Se cumpl�toJ by rAiy ur town Ar//kiu[ ..i Pcrmitil.lcense i—._. .. ..-- . . 1.,uin„\uthuritr (circla eau): I. llu:ird ul Ileallh I. I11jildlm-4 Vep.irimeut 1. lily;fawn Clerk J. Efcetrlcal In,tiecrtr i. DlnmDing, futpecnir 6. Other (''url.i,l I'cnnn: Vttnnu .r• CITY OF S,V-F,Nf, Aus,wfi(,'SETTS JLMDLVG DEP.1AT%unNT I '0 "VASHC4GTON STIM, 1'a FtOOL ILL 1973) 74S.9599 PAX(97S) 1149844 1C!J�tFJtLfiY O ItLSCO LL .tiUYOII rkoxw ST.pmus OtR TOLOPPLUICPROPlL7Y/eLMDLYGCOJfdI1SSIONE1< COn9trucdon Debris Disposal ' Affidavit (required for all demolition and renovation work) In accordance with the sixth edition orthe State Building Code, 1SO CMR section 111.5 Debris, and the provisions of MCL a 40, S 34; Building Permit N 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 ,&ICL a I 11. S 1 JOA. The /debris Jwill �be"transported by: (name orhauler) The debris will be disposed of inn: o 1 O Svl ( n/ - (name of hcday) =� — q 'm0 c I % -a3 IJdrefr ot'rnl,�y) tn�ruteuf�erm,t ipp6ant '„e DECK COLORS AND PROCEDURES NEW DECKS: 1. Pressure treated material should be allowed to dry per manufacturer's recommendations. All other types of woods should be lightly sanded in order to remove any potential mill glaze. 2. Apply one coat of oil based clear decking stain. As always, follow manufacture's instructions. EXISTING DECKS: 1. Scrape and/or sand any peeling or blistering paint. 2. Wash with a solution of 3 parts water to 1 part bleach to remove any potential mold. 3. Allow to dry and apply one coat solid latex deck stain. PRODUCTS: 1. California Products Corp. — Storm Stain clear deck finish and water proofing sealer #20040. 2. Cabot Stain Inc. —Clear decking stain#1400 series. 3. Performance Coatings—Penofin Cedar/Marine. Marine oil finish exterior. Locations of where to purchase the above listed products: I. Walls of Ddcor, 515 Lowell Street, Peabody, MA 2. Waters and Brown, 281 Derby Street, Salem, MA 3. Norman's Paint& Wallpaper, Vinnin Square 4. Winer Bros. Paint, 85 Lafayette Street, Salem, MA 5. Moynihan Lumber, Beverly, MA 6. Town Paint and Supply, 317 Cabot Street, Salem, MA If you install new pressure treated stairs to an existing deck that is already painted: Apply clear stain from the companies above. If you will be staining your existing deck, the following is a list of colors that were applied by address: Cabot Desert Sand Cabot Red Cedar Olympic Beechwood Halsey Nimitz Fillmore Spruance Marion Hart Russell Fletcher Griswold Arnold Dewey Stillwell Pickman If your street is listed under Cabot Desert Sand or Cabot Red Cedar, please stay with the Cabot product. If your street is listed under Olympic Beechwood, a discontinued color, retailers suggest matching the color with a California Paint Color. F-DATE CERTIFICATE OF LIABILITY INSURANCE 1 9/26/201Y1) 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:: Marian Cruz-Carrion Farquhar & Black Insurance Agency, Inc. PHONE Ext: (781)599-2200 �NC`o): (781)581-3990 85 Exchange Street - Suite 101 ADDRESS:Marian@FandBInsurance.com PRODUCER p0033177 _CUSTOMERJD#. Lynn MA 01901-1475 INSURERIS)AFFORDING COVERAGE NAICO INSURED INSURERA Travelers Cas & Sur of Illinoi 19046 INSURER B: CLARKE BROTHERS DENNIS CLARRKE INSURER C: 36 PULASKI STREET INSURER D: INSURER E PEABODY MA 01960 INSURER F: COVERAGES CERTIFICATE NUMBER:Insured 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�TR TYPE OF INSURANCE DDL SUER POLICY NUMBER MPOLICY EFF MPWDD UP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occunence) $ 300,000 A (CLAIMS-MADE OCCUR - 1680166M6465ACJ 0/7/2011 10/7/2012 MED Up(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP ASS $ 2,000,000 X POLICY I PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea awdent) $ BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTYAGE $ HIRED AUTOS (Per accidem)iderrt) NON-OWNED AUTOS $ $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ORYIN7LT EEL ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ (Mandatory In NH) E.L.DISEASE-FA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Adaeh ACORD 101,Additional Remarks Schedule,R more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Clarke Brothers ACCORDANCE WITH THE POLICY PROVISIONS. C/o Dennis Clarke 36 Pulaski Street AUTHORIZED REPRESENTATIVE Peabody, MA 01970 Harian Cruz ACORD 25(2009109) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(2009MI The ACORD name and logo are registered marks of ACORD :Massachusetts - Department of Public Satet) Board of, Buildin, n Re, ations and SCmdard Construction Supervisor Specialty License License: CS SL 99684 _ Restricted to: RF,WS,DM DENNIS CLARKE i 36 PULASKI STREET ttt PEABODY, MA 01960 off_ y� Expiration: 8/25/2013 ('nnmi+si„nrr Tr#: 20980 ✓Me '(Ja»vrnnruue�l��t _�:lGx,�,.�/ Office of Consumer Affairs&B smess Regulation 1 - HOME IMPROVEMENT CONTRACTOR Type. Registration 118936 DBA Expiration 57712013 IRKE BROTHERS i DENNIS CLARKE t �� 36 pULASKI ST. PEABODY,MA 01960 Undersecretary