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48 HOWARD ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Department of Public Safety II�-� �➢U Massachusetts State Building Code(780 CM Building Permit Application for any Building other than a O or T Fa al' D i TTT (This Section For Official Use Only) Building Permit Number: Date Applied: :Budding t1fick SECTIO`N 1:LOCATION(Please indicate Block#and Lot#for locations for-which street a dress' avar a le) 4 C)II No.and Street City/Town Zip Code Name ofAuilding(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair`)I Alteration ❑ Addition❑ Demolition A (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Ot Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brs,of Description f Prop ed Work: c�c� 'Kew '(2ceE rarx kwL) _\t 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 - OO\ 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❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi It Hazard H-1 ElH-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2 Cl R-3❑ R4❑ 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 ❑ 1II110 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR111.0 for details on each item) Debris Removal:i h Trenc Permit:Water Supply: Flood Zone Information: Sewage Disposal: Trench Disposal Site❑ Public❑ Check if outside Flood Zone El Indicate municipal❑ A trench will not be P Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: YL\I listoric Cummi si n Itc}.ji I r xrss: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ 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 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address s ` If applicable, the property owner hereby authorizes e)Se �d� �3 Ck6 Avg C 1s Rk czsp 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 buildingis less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control ,LI1me Registrant Telephone No. e-mail address y Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name S ae A C406tr'Au cS -09"66G - Name of Person Responsible for onstruction License No. and Type if Applicable 10P WOQA tawyt S Fymcc* 9 IO i Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:4t ORKENS CONE FNSA"LION INSURANCE AFFIDAV1 Y 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 the ksuance of the building permit. Is a signed Affidavit submitted with this application? Yes Kf No ❑ SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ 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 11 P�Y� 6.Total Cost $ 16` ,p� (contact municipality)and write check number here SECTIO 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 V application true and accurate to the best of my knowledge and understanding. �` y� orb U'1 -e3-�i. a' �-( - k^ qr� i .-OLgLase si&n name G1^ Title „r aTelephone No. Date Street Address City/-town State Zip Municipal.Inspector to fill out this section upon application approval: Name - Date CITY OF S.'1I.E-%V1 1ASSACHUSE-ITS B13LDI1NG DEPART.%MXT 120 WASHINGTON STREET, 3"'FLOOR TEL. (978)745-9595 F.�,c(978)-740-9846 KIJIBERLEY DRISCOLL THO&USSL RI3: MAYOR DIRECTOR OF ITUBLIC PROPERTY/BUILDIING CONMIISUONER' Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Piumbers a licant Information / A yl Please Print`LeeibiY Nance(Businuss:OrganizatiaNlnoividuall: Address: T�T 0' Y\ A-i et, City/State/Zipai k.6ea, Mlle QLJ,2 Phone H: (9 Are you an employer?Check the appropriate box: Type of project(required): l.m 1 am a employe with _ 4. 0 i am a general contractor and l 6. EI New construction employees(full andlor part-time).' have hired the sub-contactors ' 2.❑ 1 am a sole propricto, or parmi:r listed on the attached sheet • 7. ❑Remodeling ship and have no employees . : These sub-contractors have S. 0 Demolition working fur me in any capacity. workers'comp insurance. 9. Building addition [No workers comp.,insurance - 5. ❑ We are a corporation and its IO.0.Electrical repairs of additions ' required.]- officers have exercised their ..-. p right of exem lion r MGL I LEI Plumbing raped or additions. - 3.El (am a homeowm:r doing all work B P e myself.[No workers comp. c..152,§1(4),and,we have no 12.❑ Roof repairs t ram to ees. 'o workers' insurance required.] P Y. 13.❑Other comp.insurance mquirdd.j 'Any applicam rlrt checks box el must also rill uut The section below showing their worker'compensation polity mfurmatfon, t 11,r' rai who submit this ieldwit indicting they ale doing all work and that him inside comment,most submit new onldavit Wioting,sucit :Cunuacton that check this box must attuhed an additional she's showing the name of the sube atmctom and their workers',comp.polity'information. I air an employer that isproviding workers'compensation Insurance for my employees. Below/s the policy and Jab site InsurdoccCompanyName:�h� `Y qp ] pn,,�D`�� Policy H or Self-ins.Lic.#: r C,\``A gg_Lt _1 ` �f 1H3 Expiration Datter���� Job Site Address:1B tnyA �Y ex' City/Statcalp• "Vn ,knacb 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 S 1.500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to$250.00 a day against The violator. 13e advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. - - l do hereby certify under the inns and penahlas of perjury that the tiefarAiatlon provided abtiver is true and correct Date, o' kkv OJJfcial use arly. Do not write in this area,to be completed by city or town nfJfrinL City or Town: Peimitil.lcense# Issuing Authority(circle one): 1. Board of licallh 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: __. Phone tt: 1 _ CITY OF s4v-Em i Gt:=LYG DEPmantFuNT t 110 WASI-INGTON STREET, Yd FCOO(t TEL. (979) 745-9595 <!1[0&UEY ORISCOLL F•10C(973) 7.10-9344 N LAYOtt MOSLU ST.PIERM DIXECCOR OF PLOUC PROPER7Y/8LUMLN(3 COSLMISSIO,NER Construction Debris Disposal Affidavit (required for all demolition and renovation work) fn accordance with the sixth edition of the State Building Coda, 730 C&M section It 1.5 Dcbris, and the provisions of tbIGL c 40, S 54; Building Permit i1 is issued with the condition that the debris resulting from this work shall be disposed of in a property licensed waste disposal facility as defined by tYIGL o I11. S 150A. The debris will be transported by; Qtn tC? e.C- Id V, (name of utar) - The tljbris will be disposed of in : -- (name ur facility) r ' eiyuatjral�fpermit.tpplican Itll� — NOTICE w NOTICE W TO 0 TO EMPLOYEES EMPLOYEES W The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22& 30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: THE TRAVELERS INSURANCE COMPANIES . NAME OF INSURANCE COMPANY P .O. BOX 1 450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (7PJUB-4221P77-4-13) 05-07-13 TO 05-07-14 POLICY NUMBER EFFECTIVE DATES V A BELLINO INS AGCY 156 MAVERICK ST m� EAST BOSTON MA 02128 NAME OF INSURANCE AGENT ADDRESS PHONE # o� MIRANDA, JOSE DBA UNION 73 CLARK AVE GENERAL CONSTRUCTION CHELSEA - '— MA 02150 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT ti— The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS as W20PIG02 TO BE POSTED BY EMPLOYER CERTIFICATE OF LIABILITY INSURANCE 25/ DATE(MM3i )13 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), AUfHORRED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) mu;t 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 endorsemengs). PRODUCER CONNATACT ME: V. A. Bellino Insurance Agency PHONE 617 567-6558 1 Fwx N,: (617) 568-3089 156 Maverick St mhakADDRESS: East Boston, MA 02128 INSUWRISIAFFORDING COVERAGE NAIL# INSURFRA:ESSEX INSURANCE _ INSURED _ INSURER B: JOSE MIRANDA INSURERC: UNION GENERAL CONSTRUCTION I INSURER D: . 73 CLARK AVENUE INSURER E: —_— CHELSEA, MA 02150 INSURER,: 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AMLSUBR POLICY EFF POLICY FXP LTR TYPEOFINSURANCE WVD POLICY NUMBER MiMIY Wrau YYYj LIMITS A GENERALUABIUTY 3DJ1410 9/17/12 9/17/13 EACH OCCURRENCE $ 1,000,000 X CONWAERCM4U,L GE NER�AL LIABILITY DPREM AMAGE TO RENTED $ 50 00Q CIAI1rIADE ( X IOCCUR MEDEXP( Moreperson) Is 1 000 PERSONAL&ADV INJURY $ 1.000.000 GENERAL AGGREGATE $ 2,000.000 GEN'L AGGREGATE LPAITAPPUES PER PRODUCTS-COMPIOP AGG $ 1,000,000 POLICY 71 PRO- LOC $ AUTOMOBILE UMIUTY COMBINED SINGLE Lrdn a eceidart $ ANY AUTO BODILY INJURY(Per Person) $ ALLOWI,ED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTYDANAGE $ HIREDAUTOS _AUTOS eramidenl $ UNBRELLA LIM OCCUR - IEACH OCCURRENCE $ EXCESSLIAS CLAIMS-MADE AGGREGATE $ DED RETENTION$ - .$ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANYPROPRIETORIPARTNERIEXECUTIVE --I NIA E.L.EACH ACODENT OFFICERMIEMBER EXCLIDED9 (Mandalory in NH) _ E.L.DISEASE-EA EMP LOYE $ If s describeerW , DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMB $ DESCRIPTION OFOPERATIONS I LOCATIONS]VEHICLES (Attach ACORD tel,Additional Renerks SchedWe,if more space is requ red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN FF PROPERTIES, LP ACCORDANCE WITH THE POLICY PROVISIONS. C/O RMIS, INC. 5703 CORSA AVE. AUTHORIZED REPRESENTATIVE WEST LAKE VILLAGE, CA 91362 ATTN• O —FAX: RICITARD A SPATARO ©1938-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: Office of Consumer Affairs and usiness Regulation 1 �1-1 10 Park Plaza - Suite 5170 _ Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 167593 Type: DBA Expiration: 1 01412 01 4 Tr# 231668 UNION GENERAL CONTRACTOR CLEANIN _.-----—-- __ —_ JOSE MIRANDA 73 CLARK AVE. _. -- --------------— —.—.__ CHELSEA, MA 02150 update Address and return card.Mark reason for change. Address j_i Renewal (_, Employment Lost Card PS-Gi i Li OM-0 /0,:-G10121 (�z,r�uorer� //_.. License or registration valid for indnndni use only Office or Consumer Affairs&B1 suiess Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Type office of Consumer Affairs and Business Regulation t q1 Registration:; 167593 10 Park Plaza-Suite 5170 Expiration: -10/412014 DBA Boston,iY1A 02116 UNION GENERAL CONTRACTOR CLEANING SER. / JOSE MIRANDA —(s— Z� 73 CLARK AVE `- `-Not valid. rthout signature CHELSEA, MA 02150 Undersecretary - �. "oi25S2G'"e 4.oeYFS-'3eiJ- ?re'r r Pu3,: JOSE A GARCYA.` ins WOODI—,kwN ST - - - l v UAL %-Ac� �TD�DS'�Y Page of pages A r r PROPOSAL SUBMIrfED TO: JOB NAME JOB# I Deg 0 /1 ADORES JOB LOCATION <. C~ K ar S F a _ DATE - DATE OF PLANS PHONE# �, FAX# - - ARCHITECT. .. j. � Ive hereby submit specifications and estimates for: - ---------- r r - me propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: _ g3t7 © Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs Respectfully ' - willbeexecutedonlyuponwrittenorder,and will become an extra charge , submitted . — over and above the estimate. All agreements contingent upon strikes, accidents,or delays beyond our control. Note this proposal may be withdrawn by us if not accepted within days. 2cceptance of Propool The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specked. Signature �/����►��--/{I��n' Payments will be made as outline above. Date of Acceptance 6 l a U Signature anraersrraaw os•a _. - 1. All work shall be completed in a professional manner and in compliance with all building codes and other applicable laws. 2. To the extent required by law, all work shall be performed by individuals duly licensed,and authorized bylaw to perform said work 3. Contractor may at its discretion engage subcontractors to perform work hereutlder,•provided- r*% Contractor shall fully pay said subcontractor and in all instances remain responsible foi,the proper completion of this Contract. ;''ti,' { • :'. ,; =; 4. Contractor shall furnish Owner appropnate rele''ases or waivers 6f lien for all work performed or materials provided at the tirrie,'the'next periodic pd }merit shall be due 4r i - 5. All Change Orders and/or Additional Work Authorizations shall be in writing.and signed by both, Owner and Contractor. _ 6. Contractor warrants it is adequately insured for an3urytd�its.`empl'oyees`ati others ricuiring loss or injury as a result of the acts of Contractor or its employees and subcontractors. 7. Contractor shall, at its own expense, obtain all permits necessary for the work to be performed. . 8. Contractor agrees to remove all debris and leave the premises in broom-clean condition. 9. In the event Owner shall fail to pay any periodic or installment payment due hereunder, Contractor may cease work without breach pending payment or resolution of any dispute. Failure to make payment within days from the due date of payment shall be deemed a material breach of this contract. 10. All disputes hereunder shall be resolved by binding arbitration in accordance with the rules of the American Arbitration Association. 11. Contractor shall not be liable for any delay due to circumstances beyond its control including strikes, casualty or general unavailability of materials. tt 12. Contractor warrants all work for a period of days following completion. Note: This form is not a substitute for the advice of an attorney.Legal advice of any nature should be sought from competent, independent,legal counsel in the relevant jurisdiction.Absolutely no warranties are made regarding the suitability of this form for any particular purpose. { i E Page If of Pages PROPOSAL SUBM DTO: JOB NAME JOB# nrofa) d' oed loptiqli� ADDRESS JOB LOCATION 1-1 o c.,ua*j S f Sr- CAM DATE DATE OF PLANS PHONE# 30 9� ARCHITECT A We hereby submit specifications and estimates for: V / 1—a✓1 P- O CJ fIf ---y -- ---- ---- - f C�n ,-�F CiCi l"c.L Gl n�'� — -- _ 7 n < -1 ti�s rig !1 r,�y Q ✓-�- -- fr $ 7Xropose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: 16, 1 u� '0 0 Dollars 1 with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs Respectfully will be executed only upon written order,and will become an extra charge submitted over and above the estimate. All agreements confingent upon strikes, accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. Acceptance of Propont The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Signature "�/I I(iGl ✓� G''I Payments will be made as outlined above. �— Date of Acceptance b I 1 a I �3 Signature A-NC3e19/Ta O 9&11 .,,.� t'Oug�� Page.# of pages 1 '1�" PROPOSAL SUBMI ~D TO: JOB NAME JOB# ADDRESS JOB LOCATION frl �(r L DATE DATE OF PLANS w PHONE# 7 FAX# t; :, ARCHITECT 4 Ve hereby submit specifications and estimates for: —---- cln2---J—1_�� C _-- ------- ----- Y r 1� - � -- -- - - --- ---_-_ _ -7t r (, 11 �e ropose hereby to furnish material and labor-complete in accordance with the above specifications fdr the sum of: 0 Dollars with payments to be made as follows: a. Any alteration or deviation from above spechcations involving extra costs Respectfully will be executed only upon written order,and will become an extra charge submitted aver and above the estimate. All agreements contingent upon strikes, accidents,or delays beyond our control. Note this proposal may be withdrawn by us if not accepted within days. 0(cceptance of joropont The above prices,specifications and conditions are satisfactory and are Et I f I hereby accepted. You are authorized to do the work as specified. Signature "`/�'h(' ✓r `� �it Payments will be made as outlined above. { Date of Acceptance �' I 113 Signature A-NC3919/T3&50 09-11 The Commonwealth of Massachusetts '0u'wggg... City of Peabody State Board of Building Regulations and Office of the Inspector of Buildings Standards - 24 Lowell Street Ulf Massachusetts State Building Code b Peabody,MA 01960 780 CMR EIGHTH EDITION 3v, Tel: (978)538-5786 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING c Ma This Section For Use Only X_ - Bu lding Permit Number: k» tiZn =L f e Date Issued <x= Z a, Signature = 0 r Building Commissioner/inspector of Buildings Date T °� - - =mom iSECTION 1=SITE INFORMATION 1.1 Prto��,p(erty1Address: 1.2 Assessors Map&Parcel Number 4 CZ `�Qt.JC1`C ICI -1 � Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Property Use Lot Areas Frontage ft 1.5 Building Setbacks ft Front Yard Side Yards Rear Yand Re aired Provided Reg aired Provi ded Re aired Provided / I ' 1.6 Water Supply(M.G.L.c.40.§54) 1.7 Flood Zone Information: 8 SewagejDisposal Syste Public El Private O Zone: Outside Flood Zone❑ MunicipalllO On site dispo)t system❑ SECTION 2-PROPERTY,OWNERSHIP/TENANT/AUTHORIZEDAGENT I T ' ( ' 2.1 Owner/Tenant: r , Name(print) e� Address/� Signature T�lephgne I 11 i /1 2.2 Authorized Agent j f 1 ( 4 10 Name(Print) i si //Ad rdss i Signature / 1 I ( I I (. ITele hone A -SECTION 3-CONSTRUCTION SERVICES FOR PROJECTS LESSLLTHAN 35,000 CUBIC FEET OF ENCLOSED SPACE` b F - I Licensed Construction 'pervisor. ) r t f \,t Not Applicable❑ Licensed Consuucuop Supervisor: License Number Address Expiration Date Signature Registered Home lmpr6veine6t Contractor Not Applicable❑ Company Name Registration Number ddress�� ry / Y ' `OVI W��1 Expiration Date Signatur Telephone i r SECTION 4 f WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.'c.152§25C(6)) Workers Compensation Insurance affidavit 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. SECTION 4-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES FOR BUILDINGS AND STRUCTURES jV. SUBJECT TO CONSTRUCTION CONTROL PURSUANT,TO780 CMR J 16(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE ' 5.1 Registered Architect: t Not Applicable❑ Name (Registrant) License Number Address Expiration Date Signature Telephone 5.2 Registered Professional Engineer Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number i Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 53 General Contractor UyOlrN C C \ Not Applicable ❑ Company Name Noee, da. Responsible In Charge of Co stmction m er 6&\ AW oso Address t7 b , #D1 CAA�I - Signature Telephone (,� 'r SECTION 6'-'DISCRIPTION OF:PROPOSED WORK(CHECK ALL APPLICABLE) New Construction ❑ F Existing Building EjZ Repairs ❑ I Alteration ❑ Addition ❑ Accessory Bldg❑ Demolition Other❑ Specify: Svlo De reposed Wor 11 1 \r\0, �� lh8i�t1� \'lO� SoF�F or(,. tW0 SkVWvn��S CX\C 0�\ P-C, \f\ ;Ap O`C vin _ or SECTION 7=USE GROUP AND CONSTRUCTION TYPE 4- Use Group Check as Applicable) Construction Type A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1 A ❑ A-4 ❑ A-5 ❑ 1 B ❑ B Business ❑ 2A ❑ E Educational ❑ 213 ❑ F Facto ❑ F-I ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑ S Storage ElS-1 ❑ S-2 1-1113 ❑ U Utili ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: A..-=COMPLETE THIS:SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS AND/OR-CHANGE-IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index(780 CMR 34) Proposed Hazard Index(780 CMR 34)— P SECTION 8=BUILDING AND HIGHT AND'AREA�`_ BUILDING AREA Existing(if applicable) Proposed Number of Floors or Stories Include - Basement Levels Floor Area Per Floor(SF) Total Area(SF) Total Height fX'°A.SECTOO9 STRUCTURAL PEER REVIEW(780:CMR-110.11} Independent Structural Peer Review Required Yes... ❑ No...❑ SECTON 10a=OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS W- y 37AGENT OR CONTRACTOR'APPLIES FOR BUILDING PERMITR 9-404 I n c` as owner of the subject property hereby authorize 9 ti yw �nf�tx(2CR1 Cl?th�'\cUC C6rV' to act on my behalf, in all matters relative to work authorized by this permit application.0Ca&1'v'\ C-yl�_) �o x�t j? ��Y\,'T �'lis & 1 Signature of Owner Ddte %FSECTON l0b-OWNER-]_AUTHORI,(Z�jED AGENT DECLARATION , 1, VY`S yir\ 6-''� `` C�='C1kQCr-%-e1n as owner/authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief tSigned under the pains and penalties of perjury. Print Na N1911\3 Sign re of O r ent Date SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be 7 ' =Ofcial Use Only completed by pemmit a22ficant = -- = t I 'A _ a Building Permit ti Tier ` t-a f- `=`s` I. Building r �,fJ(� ,( )Bild _.._ g Pemit F Mul ._.., - _ p R ` - w� s . 'r (b)Estimated Total Cost of 2. Electrical Construction from &C, 3. Plumbing *Building Permit Fee - 4. Fire Protection (a)x(b) * w a 5.Mechanical HVAC Check Number -' f —,' t ''_ -I 6. Total=(I+2+3+4+5) i tr. *All Building,Wiring,Plumbing,47ire Suppression and Alarm Permit Fees will be paid by the general contractor or owner at the time of issuance. om ".THIS SECTION FOR OFFICIAL USE ONLY V', PERMIT FEE BREAKDOWN ESTIMATED COST: ;NOTES W ft- yj TYPE MULTIPLIER FEE OR ,_ AS Building . M _ _ _ Electrical Plumbing Y Gas * a g 4 r Sprinklers WE _ _ v Mechanical FA, ' Total - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 IV www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 11 //�'�.,,� �� � � ^ Please Print Legibly Name(Business/Organization/Individual): U Ywk &r/ C?\sak C&-lAcu(.Qxnn Address: 3 C.k Aiu E CV%ek g eA K ®m/_ City/State/Zip: JL% M(W - Phone#: (IaLl Are you an employer?Check the appropriate box: Type of project(required): 1.LN I am a employer with '7- 4. ❑ I am a general contractor and I. 6. ❑New construction employees(full and/or part-time)." have hired the subcontractors 2.❑ I am a sole proprietor or partner- listed onthe attached sheet t 7. ❑Remodeling ship and have no employees These.sub-contractors have 8. ❑.Demolition working for me in any capacity. workers'comp. insurance. 9. ❑;Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised.their ]0.❑Elect 'cal repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 P robing repairs or additions myself.[No workers'comp. c.152,§1(4),and we have no 12. Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp.insurance required.] Any applicant that checks box H I must also fill out the section below showing their workers'compcosation policy information .. t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such. ., IConuactors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information ` q Insurance Company Name: N 11c'- yo \IneveyS Tv, i,U�&Kcs coytl e�n4t Policy#or Self-ins.Lie.#.- C'r)y b'L„ k C` JJ -q-`Z Expiration Date: �i_�,,' �q�4 1 '- Job Site Address:/A1 q/1 -n SLr,4 6nkK City/State/Zip:.n'�,/J�F'G`R P N 0 vt� 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 is$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 Forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerfift uniier th p ' and penaIt' ofperjury that the information.provided above is true and correct. Signature: ''.. Date:�6 J Phone#:(DL - 4N^^ l (-�A Official use only. Do not write in this area,to be completed by city or town of wiat City or Town: Permit(License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3..City/1'own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M or '. 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 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 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. 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 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 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 most submit multiple perrmt/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 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. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-7274900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia CONSTRUCTION CONTROL .PROJECT: PROJECT OWNER: PROJECT LOCATION: ARCHITECTIENGINEER: IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUILDING CODE,I REGISTRATION NO. BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECT HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ARCHITECTURAL STRUCTURAL MECHANICAL FIRE PROTECTION ELECTRICAL OTHER(Specify) FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEDGE, SUCH PLANS,COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRACTICES AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION,I 16.2.2: 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for building permit,and approval for conformance to the design concept. 2. Review and approval of the quality control procedure for all code required controlled materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standard listed in Appendix B. PURSUANT TO SECTION 116.2.3, 1 SFIALL SUBMIT PERIODICALLY A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE PEABODY BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY. SIGNATURE SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF 20 NOTARY PUBLIC MY COMMISSION EXPIRES x ..'w x^r snt .�eN�{trt MO of PufiLc Saf�t/ Z massachuseft� sa Standar{!s„ and t Boair�;i�BwSdm?3� a S{cittr T,a< CFS-09606f DOSE AGXRCL4 WIVNLAL STE ? , 1 E CAO