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205 HIGHLAND AVE - BUILDING INSPECTION (7) I � The Commonwealth of Massachusetts Department of Public Safe Massachusetts State Building Co 780 CM ) Building Permit Application for any Building other an a One or T Fa voRm (This Section For Official Use Onh ) Building Permit Number: Date Applied: ' I Brp cling ffici ` SECTION 1:LOCATION(Please indicate Block#and Lot#for location for ,MX4street address able) ZoS t*1G4 t-� A%4- SA t=�M ©l 5'?D No.and Street' City/Town Zip Code 3001 Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here El or check all that apply in the two rows below Existing Building❑ Repair e 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 Is an Independent Structural Engineering Peer Review required? Yes ❑ No N-� v Brief Description of Proposed Work: a—t y,--•v— tint 5 e- . [)^VLA-OF - CA c S$ _D Y t4 c S7,1-0af 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❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑ 1: Institutional I-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-111 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 ❑ VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public Check if outside Flood Zone Indicate municipal A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required ❑or trench or specify:� permit is enclosed ❑ N (A Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable t9' Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No V 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 M1REF Na4-A�wrne l_LGI Mo-,N& Aye, Satp_s•. HA Ota-7o Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Hp`i,,�{ or�e-cOmrnonS Nlegha� Nebern.a w IN _8Zv-p03'D `t79_7Y4- g�� r"19r@I;�calnag+, com Title — ` Telephone No. (business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes L� coln Apar�mrltt Marlace Alt Umi ParinafskiP 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. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.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 MAXLAum-7TrE g7$_yb5. 030� rneJ,r; vlar;na�iorrtc CS—t�85 �Z5 Name(Registrant) Telephone No. e-mail address yt of Registration Number Po t�o��{ Ko rk !�A` DIQS(� Co .at.S�a. It tl� ly Street Address City/To State Zip Discipline Expiration Date 10.2 General Contractor 1SLAK)b LLC_ Company Name f Name of Person Responsible for Construction License No. and Type if Applicable po &DX lygo I"r•+ W 01`t50 Street Address City/TeVn State Zip q6S 0307 q79-27p_y$34 me� •� ;ma �;na�c� n�rc5t , net Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of issuance of the building permit. Is a signed Affidavit submitted with this a lication? Yes No [] SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)=$ k .000 O O 1.Building $ G 00 . - Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor) 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to C l-Tq OP SA L EIn 6.Total Cost $ 1 (contact municipality)and write check number here 2352 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 application is true and accura�tee toAhee best of my knowledge and understanding. 6�k 'V MEMPiEK1 v21r-N�s ISW,uD 919-445_ 030-7 Lt L9 Please print and sign name (`MARK AvDtT� Title Telephone No. Date Pro 220x 1 L$O 1JEW g JR�O fLT t6' 0\C Sa Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date Je -dam Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massacsetts 02116 Home Improvement �44,setts Registration Registration: 155890 'fir I Type: Individual Expiration: 5/15/2013 Tr# 212468 MARK AUDETTE MARK AUDETTE ------_-- P.O. BOX 1480 -- NEWBURYPORT MA 01950 Update Address and return card.Mark reason for change. .. -- L] Address Renewal (—j Employment Lost Card iPS-CA1 O 60M-04104A701216 .. .__..._. _._ ._�._...._ .... ._ _ .. _ ........ ......_...__. _._..___ .._. ... . _ .. ..__.._. _..._.._._ ............. .__. Nos nsumer`O's�& o mess u4er7a License or registration valid for individul use only 0f0«o!consumer Affoin&B mess Regulation B Y HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Registration Aa Sego Type: Office of Consumer Affairs and Business Regulation Expiration 6f16t2p13 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 V DETTE; f .F]� - MARK AUDETTE 16 FIRST STREET SAUSBURY,MA 01952 a Undersecretary Not valid without signature Massachusetts Department of PUb![C Safety Board of Bui)dinq Regulations trnd Standards Construction Supers isor c..e n s e CS-085725 MARK L AUDETTE + 'tgror PO BOX 1480 ^=1 yr NEWBURYPORTMpit fh 1 pirgiLUn I Coirmis',aiona 11/16/2014� The Commonwealth of Massachusetts rK � _• Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Pease Print Legibly Name (Business/Organization/Individual):RING'S ISLAND,LCC Address:PO BOX 1480 City/State/Zip:NEWBURYPORT, MA 01950 Phone #:978-465-0307 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 5 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8, ❑ Demolition workingfor me in an capacity. employees and have workers' y P h'• 9. ❑ Building addition [No workers' comp. insurance comp. insurance? required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 I.❑ 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 employees. [No workers' 13.[v]'Other ElViv-& IILZ+7MvS 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 a new affidavit indicating such, tContractors that check this box must attached an additional sheet showing the name 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 CO. Policy#or Self-ins. Lia #:WC2-31S-384470-022 Expiration Date.. Job Site Address: t�f,wig orne CoM non s, l3 gh�a„d A » City/State/Zip: 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 cert v under the pains a d enalties ofperju2 that the in ormation provided above is true and correct. Sienature• . .--- Date It 2- t 12__ 1 G, Phone#:978-465-0307 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. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: 1 a ® CERTIFICATE OF LIABILITY INSURANCE DATE'MAV°D YYN) ACORO 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 certifleate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. It 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 HUB INTERNATIONAL NEW ENGLAND INC _ CONTACT 299 BALLARDVALE STREET HONE(A&,N* P W ILMINGTON, MA 01887 - _—�ealLtA!5"o: 8�g989Q3k ___ INSURER) I AFFORDit G.COVERAGE NAIC r INSURER A LL�12011yUtLLaj.jRS.ULaDGE ._..__— — _ NRINGS ISLAND MARINA LLC RINGS ISLAND LLC INSURER B___,___ IDEA CAMPOSCLEANING INSURERC: — PO BOX 1480 INSURER NEWBURYPORTMA 01950 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 13456049 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 TYPE OF INSURANCE SR POLICY NUMBER MINDDY/YYYY MMIDDY EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE It _ COMMERCIALS GENERAL LIABILITY _PREMISES EdEocc�nDenc) $_ _. CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL S ADV INJURY_ S GENERAL-AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OPAGG $ POLICY P JE RO- LOC $ AUTOMOBILE LIABILITY Ee eac Dent ED IN L MI $ -- — ANY AUTO BODILY INJURY(Per person) $ ALL OWNED l SCHEDULED BODILY INJURY(Per acGdenl) S AUTOS ILJ—'AUTOS NON OW PROPERTY AMAGE HIRED AUTOS AUTOS _jPerac RT.y $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $____ EXCESS LIAB _ GIAIME-MADE AGGREGATE $ DED RETENTIONS _ It _ E S _ WORN ERE COMPENSATION WC$TATU- A WC2-31S-384470-022 1117/2012 1/17/2013 T RY LI rt Mgt AND EMPLOYERS'UASIUTY ANY PROPRIETOWPARTNERIEXECUTIVE YIN NIA E.L.EACM ACCIDENT S 500000 OFFICER!MEEMEER EXCLUDED? a (Mendetory In NR(' 'E.L.DISEASE-E.AEMPLOYEE S _i59M00 If yea,descdhe ender DESCRIPTION OF OF below E.L.DISEASE-POLICY LIMIT E 500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Anach ACORD 101,Additional Remarks Schedule,If more space Is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state MA. CERTIFICATE HOLDER CANCELLATION ` m SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORRED REPRESENTATIVE UcLLJ Jeff Eldridge ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD COAT Tbie Ne Clflca Cee cancel.Lard CODE pe[aedeneALL peevl oue 11 ieaVadre2d[if.lca[ea6 AM Page 1 of 1