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17 HAWTHORNE BLVD - BUILDING INSPECTION RECEIVED The Commonwealth of MassachdfMUf OVAL SERVICES Y Department of Public Safety O + y� Massachusetts State Building Code(780 ChIR), �pth C _3 q p; 40 Building Permit Application for any Building other than a One-c o-O amily Dwelling ,(This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: \� SECTION 1:LOCATION(Please indicate Block fl and Lot#for locations for which a street address is not available) Ntor4 s SflL�Wx MA ok9-)0 Zrr+ MACU1A �Cc^Ce(Df ntsf �zFcTary �\ No.and Street City/Town Zip Code Name of Building(if applicable) r/ 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 Existing Building I Repair❑ 1 Alteration ($ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No A Is an Independent Structural Engineering Peer Review required? Yes ❑ No P( Brief D�scription of Proposed Work: moclerf"" .e t EX.sC:Yx w Q rytH(2oo rr� , e�� Z rew C�A� Rcowxs. 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): I 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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ II: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ FI-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-t ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check asappiicable) 1A ❑ IB ❑ IL\ ❑ 110 ❑ IIIA ❑ 11111 ❑ IV ❑ VA ❑ VB O 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: Al trench will not be Licensed Disposal Site❑ Punic CI Check if outside flood Zone❑ Indicate Municipal❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: I Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ 1 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: ____ r- SECTION 9: PROPERTY OWNER AUTHORIZATION t :1 Name and Address of Property Owner i 'I—i;.. -, -,•, "So urvc4-4 sy ,A "n !Lin v9 O/970 Name(Print) ""' No.and Street City/Town Zip Property'Owner Contact Information: _ Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes bf//V PflfVTfl()fls V6) /C7(�r// 'Prig 8owy ✓V]4 01596,1 Name Street Address City/Town State Zip _. r to act on the property owner's behalf, in all matters relative to work authorized by this building permit application. i SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then.check here 0 and ski Section 10.1 10.1 Registered Professional Responsible for Construction Control 111 M 9A N7 ADA) 7205— JAn AvTW) HdT"Il CsL 3297 Name(Registrant) Y1`�elephone No. e-mail address Registration Number Wn7 1�t..e\I 11 PJA_a V'ii 09 01U11 (/ /6 /L/S- Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor - �i), Se 4 rxf7- 1 PAY Compvty Name PANT11-PAY 7yl y �Z Name of Person Responsible for Construction License No. and Type if Applicable Street Address�l City/Town I n/� State { Zip 9O- /L ]�O� �A1,n f'a rv1^..�dlS� /GTiw0.,ICc^'x Telephone No. business Telephone No. cell a-mail address SECTION 11:WORKHS'COMPENSA PION INSURANCE AFFIUAVI'I M.C.L.c.152.§25C fi A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed anal 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 E3 No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE' Item Estimated Costs: (Labor and Materials) dotal Construction Cost(from Item 6)_$ 1. Building $ 16,006 Building Permit Fee-Total Construction Cost x_(hisert here 2. Electrical $ 4,16 appropriate municipal factor)=$ 3. Plumbing 5 Y- d. Slcchanical (FIVAC) S Note:Minimum fee=$ (costa' t�nict `lily) ` 5. �lechanicnl Other $ ne Enclose check payable to U` o 6.Total Cost $ Q�t7 -� (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 est f my or. edge and understanding. _ N eoYT o it a_ 7,2,1 y Please print and sign name - Title Telephone No. Date c FCL PFA 0,(2&- Street Address City/Town State ip Municipal inspector to fill out this section upon application approval: Name Date I CERTIFICATE OF LIABILITY INSURANCE D 12/02/DDYY/20142/02 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(les)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 endorsements. PRODUCER coNrACT Brenda Cozzolino E A Kelley AIC No, (401 j 1 -8338 FA . (800)370-2924 450 Veterans Memorial Parkway ADDRESS brendac@eakelley.com Building 5 PRODUCER 216303 Fast Providence RI 02914 INSURED INSURERA: Atlantic Casualty Ins CO 42846 John Pantapas INSURER B: 407 Lowell Street INSURER C: INSURER D: Peabody MA 01960 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NUMBER: THIS IS TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO NhHCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEDHEREIN IS SUBJECT TOALLTHE TERMS, EXCLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLSUB POLICY NUMBER POLICYEFF POLICY EXPJaR. LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1000,000 x COMMERCIALGENERALLIABILITV HMN�AVM $ 50,000 CLAIMS-MADE FNIOCCUR MED EXP(My one person) $ 5,000 A L118001204 03262014 03262015 PERSONAL a ADV INd1RY $ 1000,000 GENERALAGGREGATE $ 2000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1000,000 X POLICY LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea axitlent) $ ANYAUTO P-LOYdd EDAUTOS BODILY INXRY(PerpoGon) $ SCHEDULEDAUTOS BODILY INXRY(Peracdden) $ PROPERTY DAMAGE HIREDAUTOS (Peracadent) $ NON-OV.NEDAUTOS 8 $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMSWADE AGGREGATE $ DEDUCTIBLE $ RETENTION WORKERS COMPENSATION ANDOTH- EMPLOYERS'LIABILT' YIN p�FIPFR.4E,�MQAF EXCLUDED? N N/A E.L.EACH ACCIDENT $ (man�atory In NH) E.L.DISEASE-ON EMPLOYEE $ d s tllp T 10e oN untlerP RATIONS E.L.DISEASE-POLICY LIMn $ D CRIP F DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Aaach ACORD 101,Add'dlonal Remarks Schedule,If more space is required) Carpentry Contractor CERTIFICATE HOLDER CANCELLATION Immaculate Conception Rectory SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE P ory THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN 30 Union Street ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Salem MA 01970 Katherine M. Kelley, AAI, CIC ©1988-2009ACORD CORPORATION.All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD t° CCI•Y OF S,,U_EM, 2*L-1SSACHUSETI'S BL'ILDL:IG DEPART\tEINT 3 3�1 120 1V.1SHIINGTON STREET, San FLOOR TEL (978) 745-9595 FAx(978) 740-9846 KI\IBERLFY DRISCOLL :�LjYOR THoMAs ST.Pimm DIRECTOR OF PUBLIC PROPERTY/BUQ.DING CO\LMISSIONER Workers' Compensation Insurance Af idavit: Builders/Contractors/Electricians/Plumbers Applicantlnformation Please Print Legibly V;11T1C(Rosiness,Organ/1ira�tium'Individual):�d0(''( N RJVT19 PaS Address: Y49 I�cl� C& City/State/Zip: P(_ v"* 015'6/ Phone#: Are you an employer:'Check the appropriate box: Type of project(required): 1.0 I am a employer with 4, 0 I am a general contractor and 1 6. ❑New construction cinployees(full and/or pan-time).• have hired the sub-contractors 2� I an a sole proprietor or panned- listed on the attached sheet. I 7. (�Remodeling ,hip and have no employees These sub-contractors have H. 0 Demolition working for me in any capacity. workers'comp. insurance. 9. 0 Building addition I No workers'camp. insurance � J. 0 We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3. 1 am a homeowner doing all work right of exemption per MOIL I I.0 Plumbing repairs or additions myself. (No workers'comp. C. 152, §1(4),and we have no 12.0 Roof repairs - insurance required.) t employees.IN'o workers' j).0 Other cutup. inwrance required.J -Any applic:utl dul chucks hod rl muse also fill nul the sectiun below showing their workers'mmpensadva pulicy infutmafon. 'I Inmauwners who submit this afildwit indicating Ihcy am doing all work and then hire"tsida contractors must submit a new amdavit indicating such $lmtrxrors that shack Ibis box mast anachd an addidumal Aml sowing the nwne of the suboantraetun and their workers'Bump.pulley infurmalion. I our un rnrpluyer that li providing workers'cumpensedun insurance jot my employees. lie/sew/s the po/fry surd fob rife iujarumt/nn. Insurance Company Name: Policy it or Self-ins. Liu. 0: Expiration Dale: Job Site Address: City/State/Zip: AStaub a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 2JA of,LIGL e. 152 can lead to the imposition aferiminal penalties ofa tint:up to SI,500.00 unl/or one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a line of up to Snow a day against the violator. Re advised that a copy of this statement may by furwarded to the Office of Invcviigatiuna oroic nfA for insurance coverage verification. I do frere6y eerdjy tan of fhe pub ad renalflrs ujperjury that the JnjurtaruNon provided above is true wad correct Si•:n ours' Uam: Z� Phone of a OVA"al use only. Du oaf write Jn Mir area, to be coutpleted by airy or awn offlaui City or Town: Issuing Authurily (circle one): I. Huard ul'llealih 2. I3uiIJ1ng I)epartuteut J.Cifyffuwu Clerk J. Electrical luspcctor 5. Plnnlbing hmpeetor I 6. Other � C4nlarl I'e non: Phnnc a: QT'Y OF SALEK MASSACHUSEM Eft ' BUILDING DEPARTMENT 120 WASHINGTON STREET,3' FLOOR TEL. (978)745-9595 KIMBERLEY DRISCOLL FAX(978)740-9846 MAYOR THom S ST.PIERRE DIRECTOR OF PUBLICPROPERTY/BUILDING OCAMSSIONER 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 c40, 5 54; Building Permit # is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: L!'>'IC, LLB (name of hauler) The debris will be disposed of in: O,FARx.O;i 7rfln�J-�e� s��ry (name of facility) 1G 4�,, sT 0- 015(,61 (address of facility) Signature of ap icant ate