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128 HIGHLAND AVE - BUILDING INSPECTION - - -- -4-- _ ----------- "The CoinmohW' 611h of Massachusetts'' � I� Department of I'ubhc Safety r :\1.1ssac h it+clt+St.Jv Bu i hl t lilt Code(780 C\I R) .. }':, ;,w Iiuil„dingo' r•'mit Application for any Building other tlian-q One-or'1'wo Family L eI "n ('I"his Svction For Official Use Unto) Building Permif Number: D,de Applied: ._—__.-_______- Building Olficiah'. SECTION I: LOCATION(Please Indicate'llfock#'and Lot p for locations file which-a street address is of aVaildlilc)' No. mid Street City /town /ip Code Name of Building(it ap pl ica tile) -- SECTION 2:PROPOSED WORK i- Fditiun of \I:\SL»c Code rued If New Construction,heck here❑orcheck all Ihat apply in the two rotes below "-- F.+islinl; Buildinf;3' Repair❑ Altennion ❑ Addition Demolition O (Please till Out.1111f'0ubtidt Appendix 1) Choutl;c of Use ❑ Change Of Oceupanry ❑ Other ❑ Specify: Are building plans lend/or construction documents being supplied,ts part of this permit application? Yes ❑ No M--- --_- Is in Independent Structural Engineering Peer Review required? Yew ❑ No H Brief Doscripfion of Proposed Work:"_,__'' �.,.� �. a �- ----------- SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UND�., „ ERG G RENOVA"rION,ADDITION,OR CHANGE IN USE OR'OCCUPANCY - Check here it en Existing Building Investigation and Evaluation is enclosed (See 78B C\IR.1.1)_13 _ Existing Use CreruP(s)'' — 1. .11 1Proposed UseGruup(s):___— ..__._._ SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed Nu.of Floors/Stories(include bascnteut levels)&Area Per Fluor(sq. ft.) Told :\n•a(sq. ft.)end Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) mbly Gl 0:-A-2❑ Nightclub ❑ AJ ❑ :\-a ❑ A-i❑ 1 B: Business ❑ r•.: Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: Ili h Flazard H-1 ❑ H-2❑ - 11-3 ❑ fl-a Cl 11-5❑ I: institutional 1-1 ❑ 1.2❑ 1-t❑ 1-4❑ ,\I: Mercantile❑ 11: Residential.-R-.1❑ R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: U'tility,❑ Special-Use❑,ind please describe below: Special Use w• SF.Cr10N 6:CONS I"RUC rION TYPE(Check as applicable) IA ❑ 1B Cl IL\ ❑ IIB ❑ IIIA ❑ BIB o " - IV ❑ VA ❑ %'It ❑ SECTION 7:SI"I"E INFORMATION(refer to 78u CMIt IILB fur details on each item) Water Supply: Flood Zone Infornation: Sewage Disposal: french I'ennit Debris Remm al: Public`- Chuck it Outside I lood Zone Indie.nc❑unticipAIR trench will not be Liccnsrd Di+pos.d tiite§Z I'ricah•❑ or mdvlltd' /nnr> -or on situ st stem ❑ foquirvJ0 nr trench or vpri ify. IF If.0 ln:tJ right II yards to \ir Vav igarun: I kr \ C \phhr,d h ❑ - 1 , Is titnir hum o nbin.ur(r rt appmat h aroa.' Is fhcrr rren r, r omplOvd, or Conant to llo JJrmlos.'d ❑ - lcs ❑ �r No❑ I lr+❑ Xo ❑ t s6crR1N 8:C'UN,I I N l',OF.C1[It lll9('Alli OF OC'( UVANCYs. r i -- I Jilu n e Code l,r Gr miptd. I\pv I C' ndnit teen' t'rr ul+,wl LaJ prr llnnr. LItnr. Iho buildin);r, ntain.m�prinUrr tit.trm.' �(�rri,J�iipulation+. . ii Rd - ti1Cl'ION 1 IRO111!It IY OWNLRAU 1110141Z LION_ -- -------- --- \little and Address of Props rlY Ucv nc r N,unr (Print) No. and Strvot City/Town f 1'r,perty Owncr Canta/i t In(ormatiun: � / ltr. 7.�eS, l/1_ ¢----- c-mail address Title r,,iephone No. (business) Telephone No. (cell) If,1`pliiable, the property owner hereby authuriics Name Street Address Oily/Town State Zip to at t Ina thi• +moped `wncis behalf-iitaill matters relative th work au lho nzed'livih this buildin Phermita++lieatiun SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If buildin•is less than 15,00t)Co.ft. ,I inclosed s,nie and ur not under Construction COntrol Then check here O mad ski+Section Ill I 1(l.1 Registered Profe�sssioonall/Res onsible for Construction Control Mime(Registrant) I'clephone No. e-mail address Registnttion Noinber tired Address • City/Town Stale Zip Discipline Expiration Dote 10.2 General Contractor Company,N.unq,. ..,.; .... c �.. . . c?.•,;.•.::..: Name of person Responsible for Construction.,:r `.,`, P< ,. .,,.License No. and:Type it Applicable O/ Street Address Ci /Town State Zip 2&-Z�L/3ra A/--3d'9 9-2YJ /._K � ca.,��r„ . ca. — Tcic+hone No. business Tele phony. No. cell e-mail address , SECTION11:aatv �ll: !rt }nt_ :.�IIt,� I , lil'.)�tT ,tl �u�:a_11 M.G.L.c.152. 25C6 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❑ No O SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor D _ Item and Materials) Total Constrtc m(+ ion Cost((rum Ite ) =S__ I. Building 5Zz jcc Building Permit Fee s Total Construction Cost It_(Insert here 2. Electrical S Lip — appropriate municipal factor) -S 1. Plumbing $ .ZGl7 -- Note: \lininuun fee=S__(mntait inuniiipalit}') 1. Mechanical (IIVAQ S uqe— i. \lei hanii al Other 5 •nr ! ncltese iltvck parable to (,. total Cost 22 Gao — (ct)lttact numicipalily)and write i heck number here ---- SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Hr outrring Illy mate below, I herebv.attest under the pains,utd penalties of perjury that all M the in(unnalion inntainrd in this .,1,ph,,Own is true,and accurate to the hest of n1} kiln,Iedge-,uad understanding. . I'Irasr print and .i1;u mate Ilife rrlcl,honc Nu. Uete <Irrrt Wdress / Cav, hnacit r /ip 0mu7 i \tunic ipal Inspector to fill out this.ediun upon appliettiun appnn•al: Nano• I,ata ,.per- —'- -`✓/ie -Pomnwnurealr/>. �./�aoaae�iueet!' Office of Consumer Affairs&B siness Regulation _ HOME IMPROVEMENT CONTRACTOR_ ' - Registration:�,103634 Type: Expiration: �.7/9120.12 Individual f i ` BR`CE•E. PARADISE t-- Bruce Paradise 21 ELM PL. p -!1c Swam scoff VA:P 1907,„ Undersecretary M:assachuscUs-'Department of Public Safetc Board of Building Regulations and Standards G-Construction Supervisor License License: CS 40208 �✓• %f M 1 0 `^ - Y- c wBRUCE E PA_RADISE r21 ELM' PLACE #j r �SWAMFSCOTT MA 01407 Expiration: 10/31/2012 f.'omniis5iuricr°il'u Tr#: 6151 t 't CITY OF 5. .�t, %Ws.kcHusErrs BLILDING DEPAREMENT 120 WAiHL`1GTON STREET, 3o" FLOOR TEL [978) 745-9595 RIIA(97,-1) 710.9844 :,. l.%IDEU-FY DRISCOLL �L�YO:i I�i01L\3$T.PiE.axx DIAECTUROF PULIC PROPERTY/ELILOrNG COSL%IIESIONER Workers' Campensatlon insurance AMdavit: (3uiltten/ContractorvlElectr[clan.dPlumbers 4pnileant Infnrmatlnn Pt • e Print L gihly Vlltncln0/11eb17r�ang111J41ntl1V11111.11): �� d/ L ( p rlyj.afy zLC Address: CilylStatcyZip: L:32c-„nip. 7 �Q O/fy Phone N 7f/— T9=/1G0 '%re you an cmplayer'! Check the approprlate boas I.(� I am a ampfoycr with 4. 31 am a goncral contractor and I type of project(resulted): antployees(full and/or part-lime)." have hired the subcomnctars S. ❑Now,construction 2.❑ I Mn a sole propdcror ur partner- listed an the attached ahcct t 1• t2 Remodeling .hip and have no employees These subconlmetors hove 9. (]Demolition working for me in any capacity. Workers'camp, inaltrsnce, (No workers',camp, insurance 5. ❑ We are a corporstion and its /' ❑Building addition required.) oit7cers have exercised their 10.0 Electrical rapsirs or additions 1.❑ 131111 a homeowner doing all work right of exemption per MGL 11.0 Plumbing rcpoirl or additions myself.(No workers'camp. c. 132, 11(4),and we have na 12.Q Roof ropaira insurance required.) t umpiuyees.[No workers' comp.insurance rryuireJ.) 15•❑Other •.\ny spplluun aW ah.eb boa/I mwr aloe rill uul the wefiuq below shewine their awr4en'cum pa Ilan pulley mtllmr"i" : ,,.hits ih who rubmis Ihir mraaj it chae a., ihry+m define all twra and than him uuIliJe conlrelerq mrul whmh r new Lttaaril indiaine.uch. C,�mrwwn thus chsk his boa meal anaahud+n.t"hu"ad.heat,hawing tti nwne of the mbauntmrtore anJ Ihalt wnrYm'comp.paltry In(wmadaq. /urn inj'ornt"rfnrn•ampluyer that/a pruvldlnK workers'rumpnuadun lesarunce/or my emp/uysr>< Below Is fire polcy and job slre w /J In.urmce Company Nmne: �Go� Policy a or Selr-itn. La. d:_ O- � Eaptmtian Date: �/ JubSiteAddress: /�O 00z r !/� e i _ CilyiState/2ip: J4r,�+ 14q Q/yJU .uravk.copy of the Workers'compenradoo Palley deciaratlon 9490(showing the policy number and expiration dato). F'.tiluru to xeury cuverage is required under.Section 2JA of MGL c. 152 can lead to the imposilian of criminal penalties of A t�nc up ro'"Co do und/ur mle•ytar imprkrfnmcn4 ar Well as civil penalties in tho tarn of a STOP WORK URGER and a tine ai up to 52 M.00 s Jay rgainst file viohtrnr. Ile advi.;ed that a copy of this filvmcnt may be, turwirdcd to file Olt%e,or Ltvr,tiyatiun.t ofdw 01A tar insurance covsagc vurilic.rliun. /du/rrrrby t-erri/y�r/ot Jar tilt puinl mt/JJpt/�nulrlrr,r�purjury thus the rrrj'unnwhur pro viJaJ above i t rrae.urJ i urrrK I7ara: Z write ill this urr�r, to�e cwuplttej by city ur ruwn ,ill,ial City nr i'crmiUl.ln'nre Muin�.\ollnrfity (circlo nnc); _.—._. - . .._ 1. :6tord of Ilculfh !. Ilu ildhw pcp.t rlincnl 1, i ;lyi I'onn Ct¢rk J. fi lre rrit.tl fin teem i,I r Pln�nbirh; Lnpecfor L„tLnl i',rt... OP ID: NO ,4�oRo. CERTIFICATE OF LIABILITY INSURANCE DAM 0MMODI 6128111'YYY) 06/28/12 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 endorsements. PRODUCER 781-914-1000 CONTACT TGA Cross Insurance,Inc. NAME' FAX 401 Edgewater Place,Suite 220 PH Ed: INC,No): Wakefield,MA 01880 EMAIL Chris Hawthorne ADDRESS: PRODUCER pARAD-1 CU TOMER,, INSURERS)AFFORDING COVERAGE NAIC If INSUREd Paradise Construction, LLC INSURER A:Continental Western Ins Co 10804 21 Elm Place Realty Trust, Bruce Paradise,Trustee INsuRERB:Acadia Insurance 21 Elm Place INSURER C: Swampscott, MA 01907 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR sDOL SUER POLICY EFF TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYV MMIDDY EXP LTR /YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 13000,000 A X COMMERCIAL GENERAL LIABILITY CPP0202885-15 02115112 02115/13 PREMISES Eaoccurrence $ 300,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 15,000 PERSONAL S ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 2,0003000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,006 POLICY X PRO- LOC Emp Ben. $ 1M12 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) B ANY AUTO MAA0206214-15 02/15112 02115113 BODILY INJURY(Per person) $ ALL OWMED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIREDAUTOS (Per accident) $ X NON-0WNED AUTOS $ X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $ 5,000,000 B CUA0206216-15 02J15112 02/15113 DEDUCTIBLE $ X RETENTION $ NIL $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETORIPARTNERIEXECUTIVE YIN WCA0206216-15 02115112 02/15/13 E.L.EACH ACCIDENT S 600,000 OFFICERIMEMBER EXCLUDED? ❑N N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 II yes,describe under DE SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (AUach ACORD 101,Additional Remarks Schedule,V more space is required) CERTIFICATE HOLDER CANCELLATION VTALEB1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Viktoria Talebian 128 Highland Avenue AUTHORIZED REPRESENTATIVE Salem, MA 01970 Chris Hawthorne ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD CITY of S.u.Eac, Aus,kCHL:SE-rrs f3Ctmm DEP.IATIE.\T 110 W-kJJ4LVGTON STREET, J'O Rccit ILL (973) 743-9599 K113EJlLBY DUXOLL P.tiX(97t)) l id 984d N(AYOR !}io.%w Sir.Pru" DIRECT0S OF PL 811c PROPERTY/11C MDLNG CO1L%i1s310V ER Construction Debris Disposal At'tidavit (required lot•all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 190 CMR section 111.J Debris, and the provisions of MGL a 40, S 54; Building Permit a is issued with the condition that the debris resulting from this work shell be disposed of in it property licensed waste disposal racility as defined by 41�1GL c I1I, S1JOA. The debris will(name oy be transported by: rh,ular) The debris will be/disposed of in /Vo r 1 lieu. t�� --(name or ranlily) f S/-, 114 01?z7v (JJdrC7,Or rlcll (y) u�nJnuaufpermtrpphunr — J(C