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84 HIGHLAND AVE - BUILDING INSPECTION (8)
The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Famil wel ' " �N 0A/O .4VE Szf!'L'5 7 C7 70 v Ga No:and Street City/Town Zip Code Name of Building(if applicable) Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below A Existing Building Repair 01 Alteration Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as put of this permit application? Yes ❑ No, ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: - =z 12 A o f- .a Po.e T'io�v n/' 7-14 0`` ('i?OV,v B J L.®O/c' /t cSF'f O V)O j=L.n r7g TO C' o.✓ i/E Ff T .CjLS/ N.E c c c P T A C6' c.i.. 7- Lei /N_ ril7c9 ,�.•_ n A T 7'.4ZE F/.PST F[ oOiF - _� (/ C/.� O Fy fKz Q .c Co ,O C` r' r7 =Use ing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ : n - /3 e/-5/ A/E.S C ProposedUseGroup(s): ProExisting PosedNo.of Floors/Storie (include basement levels)&Area Per Floor.(sq.ft.) • : Total Area(sq.ft.)and Total Height(ft.) z/Z 7,9 yr 7 A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A 5❑ B: Business ®-� E: Educational ❑ M. F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2 R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: x „ IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA IIIB ❑ IV ❑ VA ❑ VB ❑ Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: A trench will of be Licensed Disposal Site Public fd� Check if outside Flood Zone Indicate municipal required trench or specify:TWOS74 A Private❑ or indentify Zone:_ or on site system❑ permit is enclosed❑ F Railroad right-of-way: Hazards to Air Navigation: 1AA Historic Conmtission Review Process: INot Applicable� Is Structure within airport appro area? Is their review complete ? or Consent to Build enclosed❑ Yes❑ or No Yes❑ - i Edi. n of Code: Use Group(s) Type of Construction:3 A Occupant Load per Floor 'Y3 - Does the building contain an Sprinkler System?:yE'S Special Stipulations: a �L9xna Y Name and Address of Property Owner G.. Ft3 D 6Q .ATLd/JT/C /t✓E JO.S7�oN /"1µ Zip Name(Print) 7-1&,fir-No.and Street City/Town Property Owner Contact Information: ,C x 7 G.iS TRt/STEE /R w13 C`' '0F/ GL- RILtC (3E/'✓O4-T_§0n4 617 e27- OfS 9.3 Ste.-5?-�- /H93 e-mail address Title Telephone No.(business) Telephone No. (cell) If applicable,the property owner hereby authorizes - PatlL La �'FRR/�R� 63 ,9TL,auT/G dv� /3osTo•u, r�/F �r��/a Name Ci Town State ZIP- Street Address tY/ to act on the x ex owns s behalf,in all matters relative to work authorized b this buildin ermit a lication. e e ry`r ,ekC///T.EGT(/IZAL TEdM - pRCF//x-EGT/i/PNGT�t) ^7 � R as ems- t) Telephone � Registration Numb Name(Registrant) .No. e-mail address - .c ) nor It7< I��P/ Gf/EG.SG`A _ o /S� ARGf1 {' State Zip Discipline Expiration Date Street Address City/Town Company Name 7 cs s4v 6f3� 9 ., o G, /J, S U(� anti e if Applicable ' Name of Person Responsible for Construction � License No. Typ PP 7z h'11977roKO P//lam A/ sC2,LL, E ozp Street Address City/Town - State Zip - 7 3f190 ho/ 2�rr 9/7_3 to s/l /Jy era ivf�/raic . co Tele honeNo. cell e-mail address Tele hone No. business A Workers'Compensation Insurance Affidavit from'me MA Department of Industrial Accidents must be completed and e of the building permit. submitted with this application. Failure to provide this affidavit will result in the denial ofs a i' No ❑ Is a si ed Affidavit submitted with this a lication7 f Estimated Costs:(Labor / / Item and Materials) " Total Construction Cost(from Item 6)_$ /O I O 00 1.Building $ O - Building Permit Fee=Total Construction Cost x LL@(Insert here 2.Electrical $ 8 " appropriate municipal factor)_$ 3.Plumbing $ Note:Minimum fee contact municipality) =$ 4.Mechanical (HVAC) $ 0 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ / //Q OGZ� °r (contact municipality)and write check number here 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 best of�ymy/kn/j/`'1/e/d.ge an derrlstanding. IaiGt1�EL 0° S /4UE C/ / ^' , // `/ C>E iT voL -�� a© Title Telephone No. ate Please print and sign name Rr „aC,9 City/Town State Zip Street Address 5 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 appticable No. Item Submitted Incomplete Not Re uired 1 Architectural1,7 - 2 Foundation _ 3 Structural N4FireSupprassion u ression larm ma re Ccalbin include local connectionsatural,Pro ane,Medical or other ed Sie Plan Utilities,Wetland,etc.ifications tural Peer Review 13 Structural Tests&Inspections Pro am 14 Fire Protection Narrative Report 15 Existing Building Survey/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 S ec' 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 A Gf//>1'G rU.Q E4 Ea 7 &F'®(3t= '�" y�=RR/_E2 G/7-689- L/S'o� py�`�✓/L�2@ co g , 779 Name(Registrant) Telephone No. e-mail address Registration Number 5o core/roNOd. /TS /ay G �c/SEQ �/� Oz/Sd 'JAGS 3/ /Z Street Address City/Town State Zip Discipline Expiration Date N E C'O/ \t/i L L r.dT 1 &<c xE L `/o/_ L. 70// JVi/✓ES//°��/E/Lr ro c/ Registration Number Name(Registrant) Telephone No. e-mail address � ^OZ GK,C E.vr//GG.�' /1YE -TO/1N CT6N 13—Z Z9� /30//J' Street Address City/Town State zip Discipline Expiration Date ;�,yG/�rEERr,vG.Go�9, 2OO�a8 TAMES STiIOK 9B/-3o3- /7OG /�zA X L° ZEX Registration Number Name(Registrant) Telephone No. e-mail address /L/ I .�/0O22 A'D /3A.a/hr 7/C EE �4 OL Di/-cG> Discipline Expiration Date Street Address City/Town State zip GE ADVZ3rA/- C,/7-37G-8&77 DUG+cr�6r/c2S � G A i2/J S T 9 u r xr C y, n T d. . p2 16 The Commonwealth of Massachusetts G-�rdllf,'1 Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NaIriO (Business/Organization/Individual): SUGRUE&ASSOC.,INC Address 72 HARTFORD PIKE City/State/Zip:N SCITUATE R.I. 02857 Phone#:401-647-3890 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I 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 listed on the attached sheet. 7. ❑✓ Remodeling 2.❑ I am a sole proprietor or partner- se subcontractors have ship and have no employees The 8. ❑ Demolition working for mein any capacity. ' employees and have workers' 9 ❑ Building addition o workers' com insurance comp. insurance.t re P• 10:0 Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other. employees. [No workers' comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the time of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:LIBERTY MUTUAL INSURANCE Policy#or Self-ins.Lic. #: WC1-31S-371929-021 Expiration Date:5/20/2012 Job Site Address: 84 HIGHLAND AVE. City/State/Zip:SALEM, MA 01970 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 hereb certi under the pains and ena s o er'u that the information provided above is true and correct. s / /17/2012 Si afore: Date: Phone#:401-647-3890 Official use only. Do not write in this area, to he 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.Electrical Inspector 5.Plumbing Inspector. 6. Other Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) of e. Limited Liability Companies LC or Limited Liability Partnerships (LLP)with no employees other than the insuranc tY ty P (L ) members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have an questions regarding the law or if you are required to obtai n a workers' Y Y compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2017 TeL #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 A`C ® DATE(MM/OD/YYYY) ems„ CERTIFICATE OF LIABILITY INSURANCE 4/17/2012 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 endorsement(s). PRODUCER CONMTACT NA E: Terri Williams Marketing Associates Insurance Agency, Inc. PHONE (617)964-5340 FAC o,(617)965-1843 150 Wells Avenue AOE-MAILDR .twilliams@telamonins.corn INSURE S AFFORDING COVERAGE NAIC 0 Newton MA 02459 - INSURER AArbella Protection 41360- INSURED - INSURERS: Sugrue & Associates, Inc. - INSURERC: 72 Hartford Pike INSURER D: - INSURER E: North Scituate RI 02857 INsuRER F: COVERAGES CERTIFICATE NUMBER,.CL1241708355 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 DDL R POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDDM/YY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES occurrence $ 300,000 A CLAIMS-MADE OCCUR 8500045977 /23/2012 /23/2013 MED EXP Any one person) $ 10,000 PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE .$ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PRO-'lFCTLOG - $ AUTOMOBILE UABIUTY Ea accidentED 51NGLE LIMIT ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per eccMent) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXC EBB UAB CLAIMS-MADE AGGREGATE $ DEC RETENTION $ WORKERS COMPENSATION - ill be issued under WCSTATU-AND EMPLOYERS'LIABILITY ANY PROPRIETOWPARrNERJEXECVTIVE Y� NIA seperate cove! within E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? 4 t0 48 hours. E.L.DISEASE-FA EMPLOYE $ (Mandatory In NH) H yyes.desedbe and r DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addltlonal Remalte Schedule,If more apace Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Salem 93 Washington Street - Salem, MA 01970 AUTHORIZED REPRESENTATIVE Michael Susco/AMYSEA