Loading...
29 HIGHLAND AVENUE B-15/32 BERTRAM FIELD LIGHT The Commonwealth of Massachusetts Department of Public Safety 1 Massachusetts State Building Code(780 CMR) \� Building Permit Application for any Building other than a One-or Two-Family Dwelling ` (This Section For Official Use Only) 1 , , Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) a9 lh'ah l/ar1 f lle MILO (3/9 40 —&r/m/ n 13jt/d No.and Street City /Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK UEdition of MA State Code used If New Construction check here❑ or check all that apply in the two rows below 1 Existing Building❑ Repair❑ I Alteration jr I Addition❑ 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 X No ❑ Is an Independent Structural Engineering Peer Review required? 7 tl Yes ❑ No ief Description of Proposed Work: r P 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 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ 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(Check as applicable) IA IB ❑ IIA ❑ - IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Debris Removal: - Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Disposal Site❑ Public El Check if outside Flood Zone El Indicate municipal❑ A trench will not be p Private❑ orindentify Zone: or on site system❑, required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: 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 Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 9( ) a bSh/U29bu3 � 1 am 019-y Name( int) No.and Street City/Town Zip Pro erty Owner Contact Information: Title 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 2roperty 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 building is less than 35,000 cu.ft.of enclosed s ace and/or not under Construction Control then check here❑and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control enal s �r ,� 9�8 - .y _ erg �2�I 545 N n e(Registrant) _�-- Te�e h��one No. e-mail d dress Registration Number cyalnn "_ 01976 Rrr H,-G Street Addres City/Town .State Zip Discipline Expiration Date 10.2 General Contractor 1�nC( Leo �9 &YC i jo r Company Name i SJar�ad (�nPil es 6gagy V� �.&Jos� Name of Person Responsible for Construction License No. and Type if Applicable (a A// �_a rje)Y M19i O Q5I0 Street Address City/Town State Zip xl r�.r�d 14psf44sl ms cam 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 si ned Affidavit submitted with this a lication? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ dull QG Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ zft aty,tinappropriate municipal factor)_$ . 3. Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ nn Enclose check payable to 6.Total Cost $ �d tNa QQ (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 ap i ation is rue:=accurabest of m knowledge and understanding. eas rint and cgn name Title Telephone No. Date Q10� \IL k Street Address City/Town late Zip Municipal Inspector to fill out this section upon application approval: Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block# and Lot# for locations for which a street address is not available) No. and Street City /Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No Cl Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existhn Buildin Surve /Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address - Ci /Town State Zi Discipline Expiration Date �1 ,� , � � � � � � �� ��� �u�> The Commonwealth of Massachusetts w Department of Public Safety Massachusetts State Building Code (780 CMR) ut a `O Building Permit Application to Construct,Repair, Renovate or Demolish any Building other than a One-or Two-Family Dwelling Code and Other Requirements for Building Permits The Department of Public Safety has issued these building permit application forms so that municipalities across the state can move toward use of a single permit form and consistent permit application process. The MA State Building Code specifies the requirements of building permits and the applicant is advised to review and be familiar with these requirements in order to avoid some of the common permit application problems. Likewise the applicant should be aware that some municipalities require that the owner confirm, even prior to acceptance of the building permit application, that no outstanding property taxes, water fees, etc. exist. Filing Instructions 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be reviewed if construction documents, specifications, fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a check for the Building Permit fee. The fee may be calculated using the information to be supplied in section 12 of the Building Permit Application. The check is to be made payable to the local city or town where the work will be done. Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 8th edition of the ' Massachusetts State Building Code, 780 CMR, Section 107 Project Title: xxxxxxxxxxxxx Date:12-9-2014 Property Address: BERTRAM FIELD Project: Check(x) one or both as applicable: New construction x Existing Construction Project description: NEW FIELD LIGHT POLE AND LIGHTING I Dennis J. Gray MA Registration Number: 5185 Expiration date: 08-20-15 ,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': x Architectural x Structural Mechanical Fire Protection x Electrical Other: for the above named project and that to the best of my knowledge, information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I(or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. Enter in the space to the right a"wet"or G\5`ERED AReyi +,\S n No.5185 �+ eosrow L` o r.ss Z electronic signature and seal:- Phone number: 978 745 4404 Email: dennisgray@verizoti.net Building Official Use Only Building Official Name: Permit No.: Date: Note I.Indicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If`other' is chosen, provide a description. Version 06 11 2013 qy Massachusetts [)QPa(i'110flt Of Public Safety BOcHd Of B"J'A"19 Regulations and Standard mn'1111'(iml ';ulpt ni"" -:C,CfIS" CS-108187 JARROD J ONE IL 4 FERN PATH - MEDWAY MA 02053 Cumrnissmner 07/06/2018 Unrestricted -Buildings of any Use group which contain less than 35,000 Cubic feet(99 1 M3 of enclosed Space. Failure to Possess a current edition of the Massachusetts State Building Code is cause for revocation Of this license. For DPS Licensing information visit: www.MaS5GOv/DPS A� CERTIFICATE OF LIABILITY INSURANCE F °ATE(MM014 i 12/29/2014 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 CONTNAME,ACT Kathleen Hatfield Eastern Insurance Group LLC R-,'.ak'h-;tfield@easterninsurance.com Fax o:C N 233 West Central St pooliE ;khatfield@easterninsurance.com INSURERS AFFORDING COVERAGE NAIC p Natick MA 01760 INSURERA:valle Fore Insurance Co 20508 INSURED INSURERBNational Fire Insurance Co. 20893 Island Lighting & Power Systems Inc INSURER C:Travel ere Prop & Casualty Amer 6 Hill Street INSURER D Liberty Surplus INSURER E: Norfolk MA 02056-1628 1 INSURER F: COVERAGES CERTIFICATE NUMBER Master 2014-2015 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. INSR 0 U LTR TYPE OF INSURANCE POLICY NUMBER MM/UUY� MM/DOY EXP /YYVV LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAG RENTED PREMISES Eaoccurrence $ 500,000 A CLAIMS-MADE OCCUR 5091052136 /28/2014 2/28/2015 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENL AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PIFCTRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaaccident 1 000 000 B X ANY AUTO BODI LY INJU RY(Per person) $ ALL OWNED SCHEDULED 5091052105 /28/2014 /28/2015 ( ) AUTOS AUTOS BODILY INJURY Per accident $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ Uninsured motorist Bl split limit $ 500.01 X UMBRELLA LABOCCUR EACH OCCURRENCE $ 5,000,000 C. EXCESS LIAB CLAIMS-MADE' AGGREGATE $ 5,000,000 DIED I X I RETENTION$ 10,0i ZOP15N2562714NF /28/2014 /28/2015 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOPJPARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) - E.L.DISEASE-EA EMPLOYEE 8 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Equipment Floater 5091052136 02/28/2014 02/28/2015 Lsd/Rented 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if mom space is required) A Workers Compensation Certificate will be sent directly by A.I.M. Mutual Ins. CO. Additional Insured status provided when required by written contract per GL Forma G-140331-C & G-300604-A. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 'EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 93 Washington St Salem, MA 01970 AUTHORIZED REPRESENTATIVE John Koegel/&HATFI ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 r?ntnns ni Th.ACrii in—and In-n vn rnnicfemd ni of Arnpin ,acoao® CERTIFICATE OF LIABILITY INSURANCE DATE �� 1z/3o/zB1a 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 WANED, 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 04331 -001 NONTACT Eastern Insurance Group LLC . c (800)333-7234 LU No: (508)653-8089 233 West Central Street Natick,MA 01760 ODF AE&1qILESS: eDocs@easterninsur�ce.com Nat 0 A.I.M.Mutual Insurance Company 33758 INSURED INSURER B Island Lighting & Power Systems Inc 6 Hill Street Norfolk, MA 02056 INSURER EINSURER 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 MAY HAVE BEEN REDUCED BY PAID CLAIMS. RN TYPE OF INSURANCE INSR 4VVD POLICY NUMBER kON& 906STRf, LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY GE TO RENTED PREMISESoccurrence) $ CLAIMS-MADE 7 OCCUR MED EXP(Any one Person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ OUCY ECG OC AUTOMOBILE LIABILITY COMBINED SINGLE OMIT $ rr amid en ANY AUTO BODILY INJURY(PeT Person) $ AULD ED SCHEDULED AUTOS AUTOS BODILY INJURY(Per acculerd) $ HIRED AUTOS NO, PROPERTY DAMAGE AUTOS Per amiden $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMSMADE AGGREGATE $ V,rpplD(EEpDg pMpERNETENTIIOJN $ S7 �l TI{ $ gANNyD pEgM�PpLgOC�Y�ERpsR'/lplpg l�rylE{RY/EX X TORY LIMITT OER A OFFICENIMEMBER EXCIUOED7 ECUTIVE Y� N 1A pWCd00-7025872-2014A 2/28I2014 212812015 E.L.EACH ACCIDENT $ 'I,QOB4O00,00 I(mandatory �Iyna pN�H�)e E.L.DISEASE.EA EMPLOYEE $ 1,000,000.00 Ditl (ON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 T F DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Addmonal Remarks Schedule,H more space Is required) CERTIFICATE HOLDER CANCELLATION City of Salem 93 Washington Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Salem,MA 01970 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE nn 911988.2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD t T , R � At It e, AWL 5 �. e 5 'R ;'_x �, 0 Ir • ,�, A ISM � v� ' r EDGE OF FOOTBALL FIELD 6 -- + RIDGELINE 6300 + 62.94� 6?_.79 6L.91 r} I o 62.59 62.45 63 62.76 --- FOGTBALO F:E_J ------- 63.55 63.6 63.4 63.30 DTBALL FIELD 6 J i _ 62.61 r 52.70 D64H #2 IPIJ IN: �A')j) 58. D- N`=,' IN: FyO A IDPE NVn,C % '58.20 B Sll -n 1. i AR OF --------------------- ---------------------- BA o o o E)USTING 2'BLEACHERS EXISTING JUNCTION 3. E CC BOX 4. zo ELECTRICAL 5. F °o CONNECTION FE CONCRETE LIGHT cc POST CC °EXISTING POLE TO PLAN SCALE: 1/4"=1'-0" A-1.0 BE CUT OFF AT BASE. FILL ANY AND ALL VOIDS AT BASE WITH 3000 PSI CONCRETE. REMOVE JUNCTION BOX AND CONDUIT. REMOUNT JUNCTION BOX ON NEW POLE. REFER TO ELECTRICAL CONCRETE LIGHT DRAWING FOR POST DETAILS AND ELECTRICAL ADDITIONAL NOTES. CONNECTION FINISH GRADE EXISTING LIGHTING STANDARD (ISTING SECONDARY SERVICE EXISTING POLE MOUNTED BOX TO BE REPLACED WITH BALLAST BOX NEW BALLAST BOX INSTALLED 10' UP POLE EXIST BY C DISC( TO POLE