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6 HIBERNIA LN - BUILDING INSPECTION (3) Cci�i, The Commonwealth of Massachusetts o Department of Public Safety ,=t Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (Tliii,SectonFor ffici' Use Only). Budding Permit Nugtbei: °J Qiue'Appli@d - ' Building Qffictal.tip SECTION 1:LOCATION(Please indicate Block#and Lot#for locations fof which aastreetadd s;ls not available) a✓ (0W1kern:.v Laiu IT42401 014 f1497', No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 1PROPOSED'4VORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 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 Er Is an Independent Structural Engineering Peer Review required? Yes ❑ No M� Brief Description of Proposed Work:-rlvp tog c.r_ Kr',keAe.n (oo innl's T Ip,� C�hiT'kaef-/`er7< /T a art Tnsa,� crt�, Ctbihefs i� B4SEr�renf/leam t o Yh♦ < — F/PriNien/ R1&tenb,'njc SECTION 3:COMPLETE THIS SECTION.IFEXISTING 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❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: Hi h Hazard H-1 ❑ H-2❑ H-3 CIH-4❑ H-5❑ 1: Institutional 1-1 O I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 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(Checkers applicable). IA CI IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 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: FLicensed ris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required ❑or trenchfy: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: nAA Historic CUmmi55iOr1 f eevww Pnress: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes ❑ or No❑ 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 S rinklerSystem?: Special Stipulations: nw SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner eoriie Fav,+ H ,'hernia kanp. <5a/ewt MA- OM7e Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Qeora2 Vart �--12 W -- gr�rh �1wr� h9 !IS Q�I 'Co m Ti e Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTIONIO:CONSTRUCTION CONTROL(Pleas'e fdl out Appendix 2) (f buildin is lessthan 35,000 cu:ft:of enclosed s ace and"or not under'.Cbns[ruction:Contr6lthen check hereE and skip Section 10.1j. 10:1 Re 'stered'Professional Reso 6nsible fo Construction Control%'. Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor, Company Name 'Name of Person Responsible for Construction License No. and Type if Applicable Q 0±i_'S IZIh 1�- IS drtl-ek--4 1/ /AC Street Address City/Town State Zip g 767 do- YJ Telephone No. business Telephone No. cell e-mail address 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? Yes 0 No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE .Item Estimated Costs: (Labor 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 nicipali 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality) and write check number here SECTION 1 :"SIGNATURE OF BUILDINGI PERMIT APPLICANT B entering m name below, I hereby attest under the pains and penalties of e y g y y p p perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Cn"Pj P_ Fa ,n,k qaZ- 5?%1,1SCfi -5- 13 Please print and sign name Title Telephone No. Date ( lG In er n'a Ile,nP. wlew. I t �(11Q �tqz o Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval:, Name" Date Pro07:Micheiie KOhr PaX11J:eJ''/8'/'/'19J94 Liate : 'z/O/'zo13 10 : 4'/ AM page: 2 of 3 SOUSMAI OP ID: MK a`o�Ro ATE(MMloDffYYY) TE CERTIFICATE OF LIABILITY INSURANCE 70210512013 21051201 3 02105/23 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 Phone: 978-777-9394 CONTACT Steve Rich Dan Hurley Insurance Agency Fax: 978-777-3306 PHONE EAx Chestnut Green,Suite 24 Alc No EYt:y 78-777-9394 Alc No: 978-777-3306 Seven Federal Street ENAIIESS:srich@hurleyinsurance.com Danvers,MA 01923-3620 Daniel J Hurley INSURERS)AFFORDING COVERAGE NAIC If INSURER A:Preferred Mutual 15024 INSURED Manuel Sousa INSURER B:Atlantic Charter 9 Otis Road - Unit 15 Beverly, MA 01915 INSURER C INSURER D INSURER E 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 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADDL TYPE OF INSURANCE LTR INSR WVD POLICY NUMBER MOLICYYVY MMIDDIVYVY LIMBS GENERALUABILITY EACH OCCURRENCE $ 1,000,000 A x COMMERCIAL GENERAL LIABILITY CPP0110604459 09/07/2012 09/07/2013 PREMISES TTITrrrence $ 100,000 CLAIMS-MADE I OCCUR MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP'AGG S 2,000,000 POLICY PRO JECT LOC R AUTOMOBILE LIABILITY EOMaBIINoEeD SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Pdt AUTOS AUTOS ( ) NON OWNEDPROPERTY DAMAGE $ HIRED AUTOS (Per accident) AUTOS Per accident 6 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIM,MACE AGGREGATE $ RED RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN T R B OFFICERMEMSER EXCLUDED?EcurlvE NIA WCV00990500 02/23/2012 02123/2013 E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) SEE NOTES EL.DISEASE EAEMPLOYEE $ 100,000 Ifyes descnbeunder DESCRIPTION OF OPERATIONS below EL.DI ABASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) s per policies. CERTIFICATE HOLDER CANCELLATION CITYOFS IRC CAIIRM IIV IY VXIL IRLRCV.. IYVIR.. Intri LC VCLItlCRLU IIY City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington Street II. Salem, MA 01970 AUTHORIZED REPRESENTATIVE p G .� . fz-allz� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD hrom:Michelle Kohr hax1ll: U/811'1U3U4 Uate: 2/b/'L013 10 : 47 AM Page: 3 of 3 SOUSMAI PAGE 2 NOTEPAD INSURED'S NAME Manuel Sousa OP ID: MK DATE 02/05/13 s required by Massachusetts Workers Compensation Rating and Inspection Bureau: All requests for (workers' compensation) Certificates of Insurance must be submitted to the servicing carrier or voluntary direct assignment carrier. A request has been faxed to Insurer Bnamed on page 1. i CITY OF Siu.Em) ANSSACHUSETTS BUILDING DEPARTJIEINT 120 VVASHLNGTON STREET, 3'a FLOOR TEL (978)745-9595 FA.1c(978) 740-9946 ICI\BERLEY DRISCOLL MAYOR •I�tORtAs ST.P>F-RR8 DIRECTOR OF PUBLIC PROPERTY/BuILOLNG CO\aussIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A a sllcant Information Please Print Legibly Name(nusiix s Orgtnimtiorvindividual): Address: City/StatcyZip. Z -cins., Phone hl: Are you an employer?Check the appropriate box: Type of project(required): 1)4 1 am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time),* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached.sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers'camp. Insurance. 9• Building addition (No workers'comp. insurance 5. ❑ We are a corporation and its required.) ot7lcers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work tight of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workers'comp. C. 152,§1(4),and we have no 12.❑ Raof repairs insurance required.)t employees.LNo workers' comp.insurance rcquircd.) 13.❑Other Any applicants that cheeks ban r I mutt alws fill uut the seelieo below showing their wavi ms'camptsnsadun po&y infurmatlon. r I6vneuwners who sulmsit this affidavit indicating they am doing all work and then him"1 ide conincton musl submit a new amdavil indledng such. :Cunlmetors char check this box mast anached an addiliunul sheet showing the name of the subs anusctom and their wurkers'camp.pulley inseemanon. lain an eatplayei thatis provfdlnA workers'eampensadan fnsnrance for employees Below Is die policy and Job site information. Insurance Company Namc&- /L41 eigzo 01LC policy 4 or SelGins.. Lic, d: Expiration Date: lob Site Address: I,( 106l� ��i y t`-� City/Statr/Zip: Attach a copy of the workers'compensation policy declaral on 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 S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Investiguduns of that DIA for insurance coverage veriticaliun - l da hereby certify nader the pulps atd penairles of perjury thus the Grfuratatlon provided above is true and correct J(�n;tlllfe: Date' PFnne i• t Qjftlal use atdy. Do nor virile in Ih/j are,4 to be completed by city at town n/Jlehal I I city Issuing Aulhorily(circle one): 1. Board of llculth 2.Building, Deparlumall 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6,lather ...... Cunlacl Person: Phone tI: Office of Consumer Affairs and Ifusiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Con actor Registration Registration: 155795 Type: Individual T 274411 ( Expiration; 5/9/2013 MANUEL SOUSA MANUEL SOUSA !a� 9 OTIS ROAD UNIT 15 A BEVERLY, MA 01915 �� 0W Update Address and return card.Mark reason for change. Address I] Renewal Employment ❑-Lost Card ♦. nPSCA1 Ca 50M-04/06 G101216 - _ �T��nn �is fcgu License or registration valid for individu use only 1 Office ofcoa er arrs mess ego a oo before the expiration date. If found return to: - - HOME IMPROVEMENT CONTRACTOR Type. Office of Consumer Affairs and Business Regulation Registration ;155795 10 Park Plaza-Suite 5170 Expiration 5/9/2013 Individual Boston,MA 02116 - - MEL SOUSA MANUEL SOUSA31 �// 9 OTIS ROAD UNIT 15 / (, Not valid without st nature BEVERLY,MA 07915 Undersecretary t Massachusetts -Department of public Safety Board of Building Regulations and Standards Construction SuPen'isnr License: CS-073301 4. rr MANUEL M SUTS MA � 9 0775 RD wM 915 BEVERLY Expiration 11/2512014 ,1 Commissioner _� y( -; CITY OF S�1LE\t2 %LkSSACHUSETIS { ' BUtLD4\G DEP.{R"IILENT l3is o ' 120 WASHCYGTON STREET, 3" FLOOR TFL (978) 745-9595 KIMtBERI EY DRISCOLL FAX(978) 740-9846 MAYOR T ko\us ST.PtERAE DLRECTOR OF PUBLIC PROPERTY/BUILD41tG CO\L%IISSIONER 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 1 l 1.5 Debris, and the provisions of(vfGL c 40, S 54; Building Permit fk is issued with the condition this work shall be disposed of in a properly licensed waste dis os that the debris resulting from p al facili ( asd�11, S (SOA. tY cfined b y biGL c The debris will be transported by: l-r-i e,6 r!G P Ea h t (name of hauler) The debris will be disposed of in (name of racility) (address of t'acility)�— . Signature of permit applicant date dcbii+d i'f d.w