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24 HAWTHORNE - BUILDING INSPECTION
z g7. s �C\ The Commonwealth of Massachusetts Department of Public Safety * 161b JUL 18 A $ 11 Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (Mis Section For Official Use Only) Budding Permit Number: Date Applied: -Budding Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) ,9 .vtA- piqJ9 No.and Street City/Town Zip Code Name of Building(if applicable) I SECTION 2•PROPOSED WORK. (1 Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below I Existing Building Repair C9t Alteration ® 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 ❑ Is an Independent Structural Engineers eer Review r quired? Yes ❑ No Brief De ri tion of Proposed W rk: 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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ ft: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional 1-1❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA El 160 IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ 1 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: A trench will not be Licensed Disposal Site❑ Public ElCheck if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify: Private❑ or inden[ify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: ::\i\I h,t.n.'..Conuni,sion,tic.u , 1 'o r Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ I Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Gruup(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: M4Lt_ -M CbtJT '2 . mf4-11-E0 71 -1 / ?' SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner _ �f�rta�-� 0 iiw�S Z�1 (�2u1 ><vtP �P.w� ©i q7D N me(Print) S y� S��,No.and$lre t ,� ?v, ity/T,own�N ,11 A t� D14o /' Zip ro Owner Con kfnfonnntion: Title - Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name V Street Address j CitylToWV State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building50 is less than 300 cu.h:of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control &4,�d tU . fs gg &<<err g (S -0321�i"7 Name(Re tran cp ne No. a-r{� il adllrys,� ( � egistration Number / Street AddressCity/Town LJ State Zip Discipline Ex irntion Date 10.2 General Contractor L �/lr,1.t & (�< r,N Co rpany Name CZ (f l;7- D321q 441C /01743 Name of Person Responsible for Cons coon License No. and Type if Applicable Street Address p�� C" /Towns State Zii �„ r / 7 -tea ��e o �- 1�LJ-x9 e 1 P'�Seea rta.,ryr�r� 4 �Ce/l t/ !/ZfJ'•vra Tele hone No. business Tele hone No. cell t a-mail address SECTION 11:W0RKF.R9'CONIPI NSAI'[ON INSURANCE AFF'IDAVI'P 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? Yes O No ❑ SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE. Item Estimated Costs:(Labor and laterials) Total Construction Cost(from Item 6) 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=$ 3. Plumbing $ d. 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:§IGNATURE 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 1s true and accurate to the 4est of my e u ndin . 593 66 r3o Please prt�ry}..`y; ign n: ue _ Title nwelephon^ e ,N Date Street Address J C /Town State Zip Municipal hrspector to fill out this section upon application approval: Name Date 0 N N Li O CO (O ih F V O 5'-O" LO � O O C 7'-3 1/2"— m 22'.0" 1 Brian Burns Leland M.Hussey Contracting 24 Hawthorne Ave. 490 Washington St Lynn,MA 01901 Salem, MA 01970 Scale%"=1'-O" 781593 6630 Massachusetts Department of Public Safety %' Board of Building Regulations and Standards License: CS-032197 a3s „Onsvn—,,i n cur -jvis cr 2¢ LELAND HUSSEY t 3 _ 490-000 WASHINGTON ST -:i - LYNN MA 01901 -- r'l Expiration: Commissioner t0F16/2017 - 1e-of`Car4sueid�ffaQp&d"Bus�nYteQulnY�an ;i- - E1�1&iMPRt}YEMENT CONTRACTOR : ��.. � ag�54'at�on, ti077A3 T;�pe - - �,_ :' �Expvatrop S}297201fi � DBR I:El1i'ND-`M HUSSEY CONZ,RAGT9R Leland 490 ihaWASHINGTONST: IYNN{MA D19W - '�'[Tad ersecretay ® CERTIFICATE 4/ TE ®F LIABILITY INSURANCE DATE(MM2 / 4 25 16 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMAnVELY 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 endorsemen s- MAIM, CONTACT NAh1E PRODUCER : AMAZONia Insurance Agency Inc. PHONE _ (617) 625-1900 TAX No: (617) 666-0037 66 How Street Ea'AI` ADDRESS: Somcr 111e, MA 02143 INSURERS)AFFORDING COVERAGE NAICE INSURERA:COmmerce Insurance INSURED INSUREne:AIM Mutual Insurance CO CREATIVE HOME IMPROVEMENT INsuftFR c: EMERSON R DACRUZ NsuRe+D: 12 TIMOTHY AVE INSURER E: EVERETT, MA 02149 INSl1ftFR F: COVERAGES CERTIFICATE NUMBER 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, EXCLUOONS ANDCONDITIONS OFSUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. PoucY EFF P cY EXP UNdTS LTRR TYPEOFINSURINCE INS SU&= POu4Y NUMBER (Mmwffyrfl lw1DDfYYYYI A GENERALUABIUTY BDWDRT 2/20116 2/20/17 EACH OCCURRENCE S 1 ODD 000 DAMAGE TO REN'ED X1 COMMERCIALGENERALUABIUTY CLAIMSSAADEOCCUR 1 MED FXP More Pttsal S 5 000 PERSONAL&ADVINNRY S 1,000,000 GENERALAGGREGATE S 2.000.000 GEN'LAGGRECATE LIMIT APPLIES PER PRODUCTS-QJMPRJP AGG $ 2 DDD 000 -XI POLICY F LOG S AUTOMOBILE LIABILITY [E.accllNarm LNG ELIMn S BODILY INJURY(Per person) $ ANYAUTO ALLOWAED SCHEDULED BODILY INJURY(Per accident) S AVT0.5 AUTOS NO AWNED PROPERTYDAMAGE S HIREOAln05 _AUTOS eramdent S UMBRELLA LIAB OCCUR I EACH OCCURRENCE S EXCESS LIAB CLAIM$-AMDE AGGREGATE 5 DED RETENTIONS S B WORKERS COMPENSATION VWC10060184642016 4/5/16 4/5/17 X. WC STATLL OTH- ANDEMPLOYERTUABILJTY YIN ANYPROPRIE70RPARTNEIWXECUTi L NIA EL.EACHACOCEM 5 500,000 OFFICERNEMBER EXCLUDED? iMaralaroryin NH) EL DISEASE-EA EIAPUME0 S 500,000 Vice desuive under EL.DISEASE-POLICY LIMIT S 500,000 0 SCLRIPnONCFOPERATIONSNIIM DESCRIPTIONOFOPERATIONSILOCATIONSIVEWCLES (Adach AOORD1a1,AdddiomIRermr Schedule,If more eP3ce 5 required) LELAND HUSSEY CONTRACTING IS LISTED AS ADDITIONAL INSURED ON THE GENERAL LIABILITY POLICY Email : build@marblehead-org Husseycontracting@yahoo.com CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN LELAND HUSSEY CONTRACTING ACCORDANCE WITH THE POLICY PROVISIONS. 490 WASHINGTON ST LYNN, MA 01901 AUTHORIZED REPRESENTATIVE AMAZONIA INSURANCE AGENCY ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: A�R\ nATE(AderowrvrY) CERTIFICATE OF LIABILITY INSURANCE 5i18n6 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 poliey(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 onthis certificate does not confer rights to the certificate holder in lieu of such endorsemen s. CONTACT PRODUCER -NAM AME: Benevento Insurance Agency Inc PHONE (781) 599-3411 EAIL Nna. (781) 581-7200 497 Humphrey Street AD ESS: Swampscott, MA 01907 INSURE S AFFOROING COVERAGE NAIC# INSURERA:ColonV Ins CO INSURED INSURER B: Leland M Hussey INSURERC: Hussey Contracting INSURERD: 490 Washington St. INSt)KME: Lynn, MA 01901-1218 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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. INBR ADOL SUBR - - - POLICY EFF POLICY EXP LIMTS LT R TYPE OF INSURANCE POUCY NUMBER MND/Y MAIDCYYYYY A GENERALUABILIiY 103GLOO13037 3/2/16 3/2/17 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ SO OOO X COMMERCIALGENERALLIABIUTY cLAWSWADE OX OLCUR b DEJP(An,ompereon) $ 1 000 PERSONAL&ADVINJURY s 1,000,000 GENERAL AGGREGATE s 2,000,000 GEN'LAGGREGATELMTAPPUESPER PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY PRO- LOC $ COMBINED INGLELM AUTOMOBILE LIABILITY aaaident $ BODILY INJURY(Per person) $ ANYAUTD ALLOWFED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-OWNED er academ $ HIREDAUTOS _ AUTOS UWRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS- ADE AGGREGATE $ DED RETENTIONS $ WORKERS CONDENSATION WC STATU- OTH- ANDEMPLOYERVLIABILITY YIN ANYPROPRIPARTNERIExECUTME NIA EL.EACH ACtl DEM $ ETDR/ OFFICERIMEMBER EXCLUDED?_ (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yyes,describe under E.L.DISEASE-POLICYLIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPnONOFOPEMTIONSILOCATONS/VEDCLES (ADach ACORD 101,AddiBOMel Rermr SchedWa,N mom spew le mQUmd) General Contractor CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED M ACCORDANCE WITH THE POLICY PROVISIONS. AUTHOR®RE1PRESENTATVE Brvao, Benevento © 1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: , Y �s The Commonwealth of Massachusetts Department oflndustrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information L'-. Please Print Legibly Business/Organization Nature-:1 �IA N t l� S s ev Address: 410 GJe��WWIG(Te-� �Tt© ' City/State/Zip: l 1/ Y1/M t"1 "1®' Phone#: 7py ) S!j?j 6 G 3 O Are you an employer?Check the appropriate box: , Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail orpart-time).* 6. ❑Restaurant/Bar/EatingEstablishment 2.M I am a sole proprietor or partnership and have no 7. Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] S- Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing no employees. [No workers'comp.insurance required]** I I ❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensadon insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: 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 c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,u d p�yrs an enaaies ofperjury that the information provided ab vie its tr a and correct Si attire: v� 2 Date: —! 17 Phone#- 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.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia