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6 HAWTHORNE BLVD - BUILDING INSPECTION (2)
Th'eCommonivealth,oftN4iis,,sa'husetts Department of Public Safety e \Ia-dchusett,State Building.Cocle(780 CMR)Ciexenth Edition I ion oCity of Salem'. Building Permit Aeplication for any Building other than a I- or 2-Family Dwellin (This Section For Official Use Onlv) t tS I'" n 2-Fam 11 wel it n Building Permit Number: Date Applied: !E-!�-LU�udding Building SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available) r. H t, Au Chwt a 70 No. and 'Street Citv /T,)%%n Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK If New Construction check here 0 or check all that apply in the two rows below Existing Building 0 Repair'14 AlterationDemolition 13 (Please fill Out and submit Appendix 1) Change of Use 0 Change of Occupancy 0 Other 13 Specify: Are building P'ans�',nd/ur construction documents being supplied as part of this permit application? Yes 0 No 0 Nan Independent ructural Engineering Peer Review required? Yes 0 No 0 Brief Description: �f Proposed Work: 9"Wyo— AAA by& ki Jet&J-4, Magna/ +4 a Aag-&e 1, �Qk-1� 4, 4061#e 4LQ&,�,j SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING tJNL)tK(,;oING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check'here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) 0 Existing Use Croup(s): Proposed Use Group( ): Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: 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 0 A-2r 0 A-2nc 0 A-3 0 A-4 0 A-5 0 1 B: Business 13 E: Educational 13 I F: Factory F-1 0 F2[3 H-�Hi h Hazard H-1 U H-2 El H-3 0 H-4 03 H-5 0 1: Institutional I-1 0 1-2 0 1-10 1-4 0 M: Mercantile I _ -413 e 0 -FR.'Residential R-10 R-2 0 R-3 0 R-4 0 ow SpecialS StorLge 5-1 11 S-20 U; Utility 0 Special Use 0 and please describe below: Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA 0 IB 0 IIA [3 IIB 13 IRA 0 111 0 IV 0 VA 0 VB [3 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 0 Check if outsideFlood Zone 0 Indicate municipal ❑ A trench will not be Licensed Dj,,posol Site 0 P[I c,l le 0 or nduntif.% Zone or on site s%,tem Ej rellLored 0 or trench ur 1pUcl1%;- - permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: I.`trl]C[Ll I e to thin airporto ppn).ich area' " "'ell B1.11J11 vnclo,ed C3 Yea 0 or No 0 Ye, 0 \o 0 L SECTION 8:CONTENT OF CERTIFICA FE OF OCCUPANCY I diti"11 .4 Code L,e rc pt "i G11110LIC61111. _ per l lour: D""' thl'ILl Ild Mg 0 on Id I 11A 11 Spri nk ler S% tvin? Special Stipulation.,: -r-0 Cj I rl- w4ki wd ecll MA SECTION 9: PROPERTY OWNER AUTHORIZATION f Name and Address of Property Owner 4 - _ - p�. L,�-, pMd/n4 p!rt Q183� Cl+tw 4w q gpop- tires► �I�f—ul— �1MGf8+t U �"__Tf9T1 o.and Strce`{ t City/Town - Zip Name (Print) '9 Property w Oner-Contact Information: �d 9i 66 - �_ _� _— Title Telephone No. (business) Telephone No. (cell) a-mad address If applicable, the property owner hereby authorizes Name - - Street Address' City/Town Stale Zip to act on the pro pert% otyner's behalf, in all matters relative to work authorized by this building Eermit a E Elication. r SECTION 10:CONSTRUCTION CONTROL (Please,fill out Appendix-2),' - ':':';.- -".t + . (It building isles than 35,1M0 iu. ft. it enclosed s Yacc and/or not under Construction Control then check here❑and skip Section Ill.l) 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number � ici� Street Address City/Town S Discipline Expiration Date P',late Zip p 10.2 General Contractor - .rT �1} u.l it...� . +. ( . . .Y •n + r- r. "3Y4. •.� Company Name —T!2M am of Person sponsrble h Constriction License No and Type if Applicable L�IoRc��s�cln'3.__ Street Address VCity/Town State Zip Telephone No. (business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION OVSURANCE AFFIDAVIT(M.G.L.c.152.§ 2506)) 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? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor Item 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 m�icily) 5. Mechanical (Other) $ Enclose check payable to t �7`) 6. Total Cost $ D� (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest tinder the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Pleasv print and >igji name Title Telephone No. Dale >treet :Wdress City/Town . late Lip r G yunicipal Inspector to till out this section upon application approval: I Name Date 4 � C z CITY OF S.1L.EN[, .LASSACHCSETTS • BUILDING DEPARTMENT 120 WASHINGTON STREET, 3w FLOOR TBL (971) 745-9595 FAX(978) 740.91M KJ.IgFRi FY DRISCOLL MAYOR THONL%s ST.PIERAA DIRECTOR OF PUBLIC PROPERTY/BUILDING CO?L%BSSIONEll Workers' Compensation Insurance AITldavit: builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Susinev Orgaairatiomindtvidual): T. FF _ (terns Few f sf9� rn . Address: 11 Rol . City/State/Zip: bt/r01665 Phone#: ak(/ Are you as employer?Cheek the appropriate box: Type of project(required): I.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 employees(full and/or part-time)." have hired the sub.-contractors-contractorscorueto 6. ❑New construction 2.YY 1 am a sole proprietor or partner- listed on the attached sheet : ?• ❑ Remodeling ,hip and have no employees These sub-contractors have S. ❑ Mmolition working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition [No workers*comp. insurance S. ❑ We are a Corporation and its 10.❑ Electrical repairs or additions required.) officers have exercised their 3.❑ i am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. C. 152,q 1(4),and we have no 12.❑ Roof repairs insurance required.)t employees. [No workers' (;.❑Other comp. insurance required.) 'Any applicant that chocks boa Of must also rill uto the section below showing their workers'comprnsarwn policy i tten,s Boo, 'I I,aneuwrwra who sutsnil this affidavit indicating they ani doing all wont and then hire outside coormcton must suhmit a now anMdavit indicating suck r. tr -uoz dssl check this box must anxhod an additional ahett showing the tome of tM Nb-19nl/aetdra and the4 wwkars'comp,policy infanna t". nssall l unit an employer that Is providing workers'compensaton Insurance for my employees, Beluw/s the podry and job rinr informmion. Insurance Company Name: Policy #or Self-its. Lic, #: Expiration Date: Job Site Address: City/State/Zip: ,%ttacb 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 tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S230.00 a day against the violator. Ile advived that a copy of this statement maybe rorwurded to the Office of Investtgalions of the:DIA for insurance coverage verification. l do hereby certify under rho pains mad penaldes of perjury that the iorformralon provided above is true and carrect. ,;icratarc Date: Phone ,i: Offlic•ial use duly. Do nor write in this area,to be cumpleted by city or town ajficigi City or fuwn: _-_ __ Pcrmit/Llccmt# Nsuing Aulhurity (circle one): I. Board of health 2. Building Department 3. City/town Clerk 4. Electrical htspector 5. Plumbing Inspector 6. Other _ Gu lact Person: .. _ __, ___ Phone#: °ATE,MM°DmrY, CERTIFICATE OF LIABILITY INSURANCE 09/08/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Moynihan Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE YHOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 25 Burncoat Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. _Worcester MA 01605 INSURERS AFFORDING COVERAGE NAIC# INSURED Tom H Thanh INSURER A: Preferred Mutual Ins. Co. _ TH Construction Co. Inc. INSURER B: 11 Wawecus Road INSURER C: Worcester MA 01605 INSURER D: INSURER E' COVERAGES THE POLICI ESOF I NSURANCELISTED BELOW HAVEBEEN ISSUEDTOTHE INSUREDNAMEDABOVE FORTHEPOLICYPERIOD 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 SUBJECTTOALLTHE TERMS,EXCLUSIONSANDCONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $300,000 TO A x COMMERCIAL GENERAL LIABILITY CPP0100597700 05/11/2009 05/11/2010 DAMAGESiEaa,ED $ 100,000 CLAIMS MADE a OCCUR MED EXP An aneperson) $5,000 PERSONAL S ADV INJURY $300,000 GENERAL AGGREGATE $600,000 1 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $600,000 POLICY 71PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea acrident) 9 ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Par airdenl) f PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE f OCCUR CLAIMS MADE AGGREGATE f f DEDUCTIBLE $ RETENTION S S WORKERS COMPENSATION WC STATU- SE AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIV9--] E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? II (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ K yes,describe untler SPECIAL PROVISIONS below 7 E.L.DISEASE-POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION City Of Worcester DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 25 Meade Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABI OF ANY HIND UPON THE INSURER,ITS AGENTS OR Worcester, MA 01610 REPRESENTATIVE Phone: AUTHORIZED REP SEN Fax: ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD J.PREFERRED USUAL POLICY ISSUED ON THE CO-OPER IVE PLAN SURAP E COMPANY NEW BUSINESS F . COMMERCIAL LINES POLICY DIRECT BILL COMMON POLICY DECLARATIONS Policy Number: CPP 0100 59 77 00 Named Insured and Mailing Address(No., Street.Town or City, County,State, zip Code) TOM H THANH DBA TH CONSTRUCTION 11 WAWECUS RD WORCESTER MA 01605 Replacement or Renewal Number of Policy Period: From 05/11/2009 to 05/11/2010 12:01 A.M. standard time at the mailing address of the named insured as stated herein. IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM Commercial Property Coverage Part $ Commercial General Liability Coverage Part $ 984.00 Commercial Crime Coverage Part $ Commercial Inland Marine Coverage Part $ 4.00 Owners & Contractors Protective Liability Coverage Part $ Commercial Auto Coverage Part(Not Applicable In Massachusetts) $ TOTAL $ 988.00 Countersigned: 05/13/2009 By Authorized Representative 20-03900 MOYNIHAN INSURANCE AGENCY INC FOR AGENTS USE: 25 BURNCOAT STREET 182597700 WORCESTER MA 01605 (508)853-8080 THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART COVER- AGE FORMS(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. CD-1 (01-03) Ilenpcludes 'ghted material of Insurance Services Office, Inc.,with permission. Copyright, Insurance Services Office, Inc., 1983, 1984, j: MAY 18 2009 AGENT COPY CITY OF SALEM SL PUBLIC PROPRERTY DEPARTMENT KI P.1 I'K n,.I'i I. \i ,i etc 130 WA.+1 ING lONSCRUT • SAT I:M. MAtSM I❑ .r.I 'frfa 978.74i-9i95 ♦ V%X:978-740-9846 Construction Debris Disposal. Affidavit (required 1'or 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 disposcd of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. XThcde -is will be transported by: (name of hauler) The debris will be disposed of in name of'ract ity) (address of facility) i signature of permit ap i.icant date Jrbnafl dot e IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2009101) and Of Sul Regulatloo y0a si;Q;,`.�.Conslnic8�SuPON18W Licanaa; Licanaa: Ca',965 92 BGlhtlaM:.5/30/7982 . RaW►Hlorl 5/30%2010 TrN 98b ` i , ,�, I trkdon• ��:: TOM HOANG 1 11A KIRBY .., . WORCESTER MAOt810" ' �X co I !loard of Building Regulations and Standards, y Construction Supervisor License License: CS 96592 ,L•: j ,�� Birthdate: 5/30/1962 ' ' '.' . •f2- Expiration: 5/30/2010 Tr# 96592 Restriction: 00 TOM HOANG _ 11A KIRBY STREET WORCESTER, MA 01610 Commissioner' �ru tttttt q," 4 3 00 5,000 cf en,fjr a N§dace 1A-Wsaonry of ly �, LG-1 2 Famfly Homeq - y 1Peiluie to posses' a ourt`ent edition oK thy: � � Mae,$'ac6U1f`eCtfs State BuildfelgyCode � _ 1.c� visoeiise ffir�repocahon of this lioene'e., 41 A,f� l ` i -1.r