300 HIGHLAND AVE - BUILDING INSPECTION (2) A� Tile Commonwealth of Massachusetts
Department of Public Safety
}: ,I; \hts..trhtuclts tildtc Build ing Cudc(781)C%I R)
BuiIdingPermitAppIicationforanyBuiIdingotherthinaOne-orTwo-FantiIyDweIIing
('Phis Section For Official Use Only)
,)luildiuf;l'cnnitNumbce Date Applied: BuildingOffirial:
SECTION l: LOCATION please indicate Block B and Lot N for locations for which a street address is not available)
SO_ Ale__5�__ 011110 d
No. and Street City Town Zip Code Name of Building(if applicable)
SFCFION 2:PROPOSED WORK
Edition of NIA SLtle Code used_ If New Construction check here❑or dunk all that apply in the two rov,s below
Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ 1 Demolition O (Please fill out and submit Al+pendtx I)
Change of Use ❑ Change of Occupancy Cl Other ❑ Specify:—-- _
Are building plans and/or ctuhstntCtion ClOCIIt11en1S being supplied as part of this pernhit application? Yes ❑ No ❑ ----_—
Is an Independent Structural Engineerin, Peer Review naluircd? Yes ❑ No ❑
Brief De'Criptlon of Prnpused N
2,
SECTION 3:CONIPLETE'rms 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 7N)CN1R 34) ❑
Existing Use Group(s): Proposed Use Gruup(s):
SECTION 4: BUILDING MIGHT AND AREA
Existing Proposed -
No.of Floot:s/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-1❑ A-5❑ 1 B: Business 9I' I E: Educational ❑
F: Facto F-1 ❑ F2❑ 11: lli h Haxard H-1 ❑ H-2❑ H-3 ❑ FI-a❑ li-i❑
I: Institutional 1.1 ❑ 1-2❑ 1.3 CI14❑ NI: Nlercantile❑ R; Residential R-10 R-2❑ R-3❑ R4❑
S: Storage 5-1 O S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCriON 7-YPE(Check as applicable)
IA ❑ IB ❑ [IA Cl RB ❑ IIIA Cl IIIII O IV ❑ VA ❑ It,[I ❑
SECTION 7:STIT INFORNIA'FION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Pimhd Zone Information: Sewage Disposal:
'Trench Permit Debris Removal:
Public A trench will not be I.icvnsod Disposal Site❑
C3� Check if outside Hood Zune❑ Indicate municipal ❑
required ❑or trench or specify:".
Priyale❑ or indrnlily lone: ar�m site system❑
per III is encased❑
Railroad right-of-way: Hazards to Air Navigation: Ili , .':J, 1 .. .
Not Applicable❑ Is titrurture n'ithm a irpmt,lppro,ich an•d? Is their n•v iv%, rumplcleJ'
or C onwnl to Budd vnrlo%ed Cl 1 es❑ or.No❑ S'es❑ .\'o ❑
SI:C l[ON 8:CON I ENT OF CFR HFICA I F OF OCCUPANCY
Ifduiint nl Code: _.. ".. L'w Group(s): - _ i\IT al 6111strudwo: 1ptupmmt Ladd per l lom _
ILrs the buildin(;i owain an Sprinkler 1;% Ivio' 4per idl Stipulations:
SECTION 9: 111(OPI:I(I'Y OWNI:I(AU[IIOI(IZATION
--- ----- --
nuc,unl Addressut Property Owner
N,mie(1 rint) No.and Street Citv/ruwn Zip
Property Otener Contact Information:
.Title — ---- Telephone No. (business) -.relephone No. (cull) e-mail address
It opplicable, the property owner hereby authorizes
Nan e Street Address tty/Town State Zip
to art on the proper(proper(y owner's behalf, in all matters relative to work authorized by this bu ild illg termit a ,pl ica Lion.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
1f t+uilJin,is lass than 35,0W cu.ft.of enclosed space and/or not under Construction Control then check here O and ski Section HU
10.1 Re istered Professional Responsible for Construction Control
Nance(Reg sin it) Telephone No. e-mail address eg1sR str,tiun Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
(14) r—
C upany -tine
/ � 103Y L
Name t Person Resp slefoti —
License No. and Type if Applicable
5� gel-- 141*1 �2 � mh— o/ vim.
Street Address City/Town State Zip
A-k,2? --
Tcie,hone No. business Telephone No (cell e-mail address
SECTION11:t�.u,iai_I'ti i_�:wr.�:_:\11 ?\ i` u1\'ANy.'i 11,11 ,\\'II M.G.L.c.152.9 25C6
A Workers'Compensation Insurance Affidavit from the N A 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 a lication? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
,utd \laterials) Total Construction Cost(from Item 6)=S—
I. Building S Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=S
3, Plumbing 5
4. .%lochanical (HVAQ S Note: \lininmm fee=S (Contact municipality)
i. :\IcChaniCal Other $ � Enclose Idieck_ payable to -- _------
h.Total Cost S / `y
/ (Contact ill uniCip,tliti')and write Check number bore Z---_.-"--__
SECTION 13:SIGN,\"rURE OF BUILDING PERMIT APPLICANT
14v en4ving nav n.une below, I hrrebv attest ender the pains and penalties of perjury that all of the inh,nnati a Contained in this
al,l,liratio is true and acnvate to the best of my knonr ledge and understanding.
t
Please print xl si);n ntu title ..Iephone No. [),lieIV -- - _. _ Oc f
Clk—
tiIwel .Address / City,Ilncn sate /i )
Municipal Inspector to fill out this section upon application apprm
C(TY OF S.1LE,N(, AkSSACHUSETI'S
JLILDLNG 0EP.1AT%L,VT
120 VVASj4LVGT0N STUarI Jw FtcoIt
rM (978) 741.959S
KIMBERI RY 0X=OLL FkX(978) 74&9W
MAYOIt THO.-AU ST.PtF.ttttg
E)"ECT040PPLSLIC PROPHATY/KMDLNG CO.AallsslOVEx
Construction Debrij Disposal Attidavit
(required for all demOliUO4 and renovation work)
In accordance with the sixth
ri
Debs, and edition of the State Building Code, 780 CMR section I I I.3
the provisions of MOL c 40, S 54;
Building Permit M This work shall be is issued with the condition that the debris resulting from
disposed Orin a properly licensed waste disposal racility as defined by MOL c
111, S IJOA.
The debris will be transported by:
r /C
(name of hauler)
The debris will be disposed of in :
(name of nudity)
l�ddreu or r�cdry)
Brut fill of rmrt JPPlr' nt
'!ue
a y OF S:liLEms jNL1SS.ICffUSEYrS
+. BUILDING DEPA&TNiE.\T
120 WASHINGTON STREET, 3-FLOOR
TEL. (978) 745-9595
F.kx(978) 740-9846
KIMB Rf RY DRISCOLL
NVL.%YO.q Tkos1AS STTTIERRB
• DIRECTOR OF PUBLIC PROPERTY/BUMDING COJL\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlcians/Plumbers
Applicant information Pleatie Print Leclihiv
V;IInC Inmitx,.oUrgtniratiunindividual): I
Address: �i� 1?rl c y i
City/StateelZip: L Phone All: Lie
�� 8S� L_
Are you an employer?Cheek the appropriate box; Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑Now 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 subcontractors have R. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ &ilding addition
(No workers:comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
J.❑ 1 am a homeowner doing ail work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.(\o workers'comp, c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) e employees. LNce workers' IJ. ther lK„
comp.insurance required.)
•Any upplicmt dw chocks box at must also rill out the wcliuo below showing their waken'campenution pulit. inriumution.
'1 hvnemstan+who mhnsll This attlrlavil indicating they am doing utl work and then him outride cueencton metal suhmir arm 3171davit indicating such
K1m,m tan that chuck this box must allachud in additiunol Awl showing the mane of the subaonuacten and Ihelr workers'wmp,policy infoneudon.
I one an employer that is pruviding workers'cumpeersatlon insurance for my employees: Below Is there policy and Job slit ass
i ildrenution.
Insurance Company Name: _._.._.
Policy 4 or Self-his. Lic. 4: Expiration Date:
Job Site Address: City/StatetZip:
\Hach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
F'ailurel to secure coverage as required under Section 25A ofblGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,5C0.00 and/or one-year imprisonmcn4 as well as civil penalties in the form of o STOP WORK ORDER and a line
of up to 52io.00 J day against the violator. Ile advised that a CtlPy of this statement may be forwarded to the Gftiea of
Invrsligwiuus ul that DIA for insurance coverage veriliealiun.
/do hereby certify depth rahlyand en uhles ujperjury/but the inj'unnullon provide)ab ve iv tr1`o-at`died cornet.
ell /I
Of icial age anly. no not write be this area,to be completed by city ur town of/icio2 I
Cit tar fliwn;
Y Pcrmia7.lccnse 4
! hewing,\unwrily(circle one):
--
! 1. hoard of Ileallh 2. Iluildin-, ❑eparimem .1. Cltylfawn Clerk 4. Electrical hlwpcctur 5. Phtmbing Inspector !
i Contact l'crvun: _ _ I'hnna
i
Information and Instructions
.\tassachuseus General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an eerployee 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,corporatioa or other legal entity,or any two or more
of the foregoing engaged in ajoint 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
g owner of a dwellinghouse 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, 325C(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 orcompllance with the Insurance coverage required."
Additionally, MGL chapter 152, 325C(7)states"Neither the commonwealth not 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)nume(s),address(es)and phone numbers)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. Iran 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
he 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 any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter thew
self-insurance license number an the appropriate line.
City ar 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 till in the permittlicense number which will be used as a reference number, In addition,an applicant
that must submit multiple permitilicense 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 now affidavit must be fulled 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 bum 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.
l'he Department's address, telephone and fax number:
The Commionwealth of Massachusetts
Department of Industrial Accidents
Oltice of Investigations
600 Washington Street
Boston, MA 021 I 1
Tel. A 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 9 617-727-7749
Acviscd 5-26-05
www.mtss.gov/din
CERTIFICATE OF LIABILITY INSURANCE °AT01/2012
O
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.
2
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 policles:may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsements.
PRODUCER 978-774-43.3a CONTACT
Phil Richard Insurance,Inc NAME;
27 Garden Street Unit 18 978-774-1318 PHONaEe FAX
Danvers MA 01923 EMAIL
Philip W.Richard ADDRESS:
• UCER
CUSTDOMER ID p:YOUNG-2
INSURED Doug Young D/B/A Young Constru INEURERS AFFORDING COVERAGE NAIL#
53 Briar Hill Drive INSURER Mutual 10017
Lynn, MA 01902 INSURER B:
INSURER C:
INSURER D:
INSURER E:
COVERAGES INSURER F
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.
INSR
LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF MM/0DT LIMITS
EXYY
GENERAL LIABILITY
A X COMMERCIAL GENERAL LIABILITY X TBI CLAIMS MADE ❑X OCCUR EACH OCCURRENCE $ 1,000,00
�
01/19/12 O1/19113 P EMISES Eacccurrence $ 300,000 X Business Owners MED EXP(Arty one person) $ 5,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMB APPLIES PER: GENERAL AGGREGATE S 2,000,000
PRO- PRODUCTS-COMP/OP AGG $ 2,000,000
X POLICY LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY(Per person) $
SCHEDULED AUTOS BODILY INJURY(Per accident) $
HIRED AUTOS PROPERTY DAMAGE $
(Per accident)
NON-OWNEDAUTOS
UMBRELLA LIAB OCCUR
EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE $
DEDUCTIBLE AGGREGATE $
RETENTION $
$
WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY X VICE OTH-
ANY PROPRIETORIPARTNERIEXECUTIVE YIN ER
OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $
(Mandatory In NH)
If yes,de scribe under E.L.DISEASE-EA EMPLOYEE $
DESCRIPTION OF OPERATIONS below
E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101.Additional RemarksRTMENTS PA Schedule,It more apace is required)
YNNE
RESIDENT COUNCIL INC.,CME. J MANAGEMENT INC.,&CORCORAN MULL NS JENN SON INC.
ARE INCLUDED AS ADDITIONAL INSURED.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CMJ Management Co., ACCORDANCE WITH THE POLICY PROVISIONS.
KING'S LYNNE APARTMENTS
ATTN: JEANMARIE AUTHORIZED REPRESENTATIVE
115 O'CALLAGHAN WAY � j/
LYNN MA 01905 ���
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
Young Construction
53 Briar Hill Dr.
Lynn MA 01902
781-632-8594
CS Lie # 103422 HIC Lie # 290751
Proposal
300 Highland Avenue
Salem Ma 01970
1/30/2012
Metro PCS office windows
1) Remove sliding doors at front left
2) Frame opening for 59"h x 140"w glass window. (owner supplied)
3) Finish inside and out. Outside will be vinyl sided to match existing as
close as possible.
4) Insulate where possible.
5) Install new window frame at left side store as discussed. Window will
be approximately 59"h x 63"w as discussed
Notes: Exact window sizes will be finalized when windows are ordered by
owner. Price includes permit, labor, materials and trash removal. Owner will
supply window glass and glass installation
Total price: $1,950.00
Builder date
Owner date