16 HOLLY ST - BUILDING INSPECTION r
RFCFjVFp
The Commonwealth of Massac us RLIONAL I SERVICES
Department of Public Safety
y'Q ltlassachusetlsState Build ing Code(780CM414 DEC 30. P 2:. 40
Building Permit Application for any Building other than a One-or Two-Family Dwelling '
(This Section For Official Use Only)
Building Permit Number: Date Applied; Building Official:
SECTION 1:LOCATION(Please indicate Block ff and Lot N for locations for which a street address is not available)
u 61SA-e-1k E14y70
No.;md Street City/Town Zip Code Name of Building(if applicable)
SECTION2 PROPOSED WORK
(� Edition of MA State Code used If New Construction Bieck here❑or check all that apply in the two rows below
Existing BuiIding*:[:REp:i;jX I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix l)
' Change of Use Cl 1 Change of Occupancy ❑ 1 Other Cl Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
IFV`� Is an Independent Structural Engineering Peer Review required? _ Yes ❑ No ❑
B •f Description of Proposed Work: �` -C✓t�� -
V?O 0,r�-X6 —
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 CNIR 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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ II: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-I❑ H-5❑
1: Institutional 1.1 0 1-2❑ 1-3❑ 1-4❑ 1 NI: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-I ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION'TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ l[B ❑ IIIA ❑ ❑IB ❑ I IV ❑ 1 VA ❑ VO ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
A trench will not be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ hulicate municipal required❑or trench or specify:
Private❑ or indeolify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Ilazards to Air Navigation: \I:\Ili (_,rn mu i n 1 .ic•r 1 r vsa:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No ClYes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): type of Construction:_ Occupant Load per Floor:--
[)ties the building contain an Sprinkler System?: --Special Stipulations:. ----
� Q Ob Co w4l4 -
' t
SECTION 9: PROPERTY OWNER AUTHORIZATION
N e and Add less of Property Owner ar
Nanie(Print) No.and Street City/Town Zip
Property Owner Contact Information: t
col �� �u1. 38Q 6 3Z7 Sc�i�� rkit
Title Telephone No. (business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf, mail matters relative to work authorized by this budding 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 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
C .inl Name
3�alus (may — 05- 3
Name ofPeerjoon RResponsible for tonstruction r / License No. and Type if Applicable _
Street Address City/Town State Zip
9M 3Z -6 't zr
Telephone No. business Telephone No. cell e-mail address
SECTION 11:1V0RKF.RS'C(,A1PFNSAI ION INSURANCE AFFIDAVII QvLG.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 signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ O Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)-S
3. Plumbing S
d. Mechanical (HVAC) S Note:Minimum fee=$ (coat - municipal't )
5. Mechanical Other $ Enclose duck payable to �� V
6.Total Cost $ jr �j�� (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
application is true,nd accurate to the best of my knowledge and understanding. -
s o�rRr—i -2g1- to3q �e� !
Please print an Zxee
Title Telephone No. D,to _
_ ,y��f� !Y
Strrt'V Tres Cit S u Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
i
Y° CITY OF S.U.E.NI, NWs.ICHusETTS
Bt'LLDL\IG DEPARTIIE.\T
120 %VASNLNGTON STREET, 3r°FLOOR
TEL (978) 745-9595
F.A.r(978) 7404846
Kj.\IB R1 FY DRISCOLL
i;VLIYOR TwatAs ST.PfEnE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COXNISSfONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t licant ►nformatinn Please Print Le ibl
V;IIOC InusirtessOrgmtiratinn,'Individual): II
Address:
City/State/Zip: Phone#:
Are you an employer"Check the appropriate os: r7dt
or project(acquired):
1.❑ I am a employer with 4. 1 am a general contractor and Iow construction
employees(full and/or pan-time).' have hired the subcontractors
2.❑ lam a sole proprietor or partner- listed on the attached silent. Iemodeling
hip and have no employees These sub-contractors have emolition
working for me in any capacity. workers'comp.insurance ilding addition
No workcri comp, insurance S. ❑ We are a corporation and iusrequired.) officers have exercised their ectrical repairs or additions
3.❑ I am a homcuwner doing all work right of exemption per MGL mbing repairs or additions
myself.(\o workers'comp. c. 152,¢1(d),and we have no of repairs
insurance required.l t employees.(No workers' er
comp.insurance rcquin:d.)
'Any applicant nut chscks boa al most also fill out the section below showing their werleri eumpensalu,policy udinmadon.
'1 hunoowm"Oo sul oit this atlithvir indicating they am doing all work and then hire outs ideconiractma man suhmil a new aaldavil indicting such.
:C.,,o=tun tAot check Ihit box mue mtachai on addiliumd ahraa showing the name of the mb malmelon and their woken'comp.policy infunnalian.
stain un turpluyrr N�a1/r pruvldlnx workers'romptnradun insurance for my etnp/uyers. Ueluw/s the polley and Job site
iujaruralion.
insurance Company Name: ' , PY V�' S• Cz r
Policy it or Srlf--ins. Liu.H: W �C � Expiration Date: ( z�
Job Site Address: lLo 0oYw 31 6L Jul."j (try City/State/zip:
Attach copy of the woriters'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 ofcrinainal penalties of a
tine up to S 1.500.00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Ilt advised that a copy of this statement may be furwarded to file 01'lice of
Invesfigwiuns ol'the MA for insurance coverage verification.
/du hereby certify render Ilse is ad r old. of perjury that Ilse/nfunnulloe provided above is true andcorrect.
5il I e' f )afe.
4
f7//iciul use mrly. Do our rvrire in this area,to be cuarpfd¢d by airy ur town a/J1riu[
i
City nfTown: _..- .__ PerrnlU1.lc°nseM--'.----
Issulag Authurify(circle line): I
1. Board of lleallh 2. Building Department i.ciiyffuwu Clerk J. F.leetrital luspectur 5. Plontbing Inspector I
6. Other
Cantos I`erum:
1 �
r QTY OF SALEK MASSAMUSEM
BUILDING DEPARTMENT
120WASHINGTON STREET,3" FLOOR
11EL. (978)745-9595
KIMBERL.EY DRISCOLL FAX(978)740-9846
MAYOR TrIOMAS ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
L yrcr��
(name of facility)
(address of facility)
Signature of a pli ant
Date
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE R$WDO YYYYJ
04/02/2014
PRGOUCFA. (978) 922-0086 THIS CERTIflCATE IS ISSUED AS A MATTER OF INFORMATION—
Carmen-Kimball-Insurance Agency, Inc MOLDER NTIIISONFERTiFI NO DOES NOT A THE MEND, CERTIFICATE
OR
48 Beck£ord Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO Box 73
Beverly MA 01915- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA:Technol0 Insurance CO
Sheldon Frisch Development Inc. INSURERB:Esaex Insurance Cc
PO Box 811 INSURERQ
218 Humprhey Street INSURER D:
Marblehead MA 01945— INSURER E:
COVERAGES El
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
L MINIM TYPE OF BNBURAgCE POLICY NUMBER DAME EP&W OAIE F]tPIPATON
B X GF�RALUIII&M 3D88834 04/15/2013 04/15/2014 EACH OCCURRENCE UNITS$. 1,000,000
X COMNERCUILGENERALUABILITY DAMAGE TO RENTED
PREMISE$ Fa PmirtttroeI $ 50,000
CLAMS MADE ®OCCUR 3DK8834 04/15/2014 04/OS/2015 MEOEXP(A,ry ore IS 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERALAGGREGATE $ 2,000,000
GENLAGGREGATE ppLpIIM�ITAPPLIES PER: PRODUCTS-COMPAIPAGG $ 2,000,000
POLICY JECT LOG
AUTOMOBILE LIABILITY COMBINED SINGLE LIMITANV AUTO (Ea accidw) $
ALLOWNEDAUTOS BODILY INJURY
SCHEDULED AUTOS $
HIREDAUTOS / / / / BODILY INJURY
NONOWNEDAUTOS (Par waderd) $
PROPERTY DAMAGE
GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT $
ANY AUTO / / / / OTHER THAN EAACC E
AUTOONLV: AGG $
IMICE53NMBRF 1•LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
..DEDUCTIBLE / / / / $
RETENTION $ $
A WORKERSCOMPESATONAND euxoTFJar uneartr NC9900o19 03/31/2014 03/31/2015 X
ANY PHOPRIETONPARTTNFAIEIECURVE EL EACH ACCIDENT $ 500,000
OFFlCEVMEMBFA EXCLUDED? E.L.DISEASE-EA EMPLOYEE$ 500,000
X Yee..desaMe uMv.SPECIAL PROVISIONS EL DISEASE-POLICY LIMB $ 500,000
OTTER
DESCRIPTION OF OPERplON51LOCATNNlSNEHICLESIEJLCLU$ION$ADDED BY ENDORSFMENTSPECULL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Building Inspector EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO AWL
010 DAYS WRITTEN NOTICE TO 7HE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
- Town of Marblehead FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE-
188 Washington Street NSUREFL ITS AGENTS OR REPRESENTATIVE.
AUTHORED REPRESENTATIVE
Marblehead MA 01995-
ACORD 25(2001108) 0 ACORD CORPORATION 1988
INS025(weeps Pap I of 2
t`.
1
Massachusetts -Department of Public Safety
Board of Building Regulations and
Standar
ds
„ Construction Supervisor
License: CS-051138
w.rrs
SftELDON W s
PO BOX 811
Marblehead MA IN
a
` _.,riu" Expiration
Commissioner
07/1412016
Cie r�iamma�uaea�l/o�Vv[aaJac
Office of Consumer Affairs&Bosiuess Regulation
VP ME IMPROVEMENT
CONTRACTOR
istration 104548 Type:
iration: ,.. 14M , Private Corporatior
.E-L Y..."_ ..
SHELDON FRISCH DE1/EF.OPMEN,`f:iNG. ,
Sheldon Frisch " -
218 HUMPHREY STREET
Marblehead,MA 01945 Undersecre "
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