Loading...
102 JACKSON ST - BPA- (c LK 2© (O-q The Commonwealth of Massachusetts VV Department of Public Safety 11ED Massachusetts State Building Code 780 ���pp11 �_F��7(CES Building Permit Application for any Building other)11 � tft Two-Famtly Dwelling _ 1 (This Section For Official Use Only) `v Building Permit Number: Date Applied: Buildin f SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) , ( Vol- 7AG1�,So�/ S sg/�.,-. pi'7o u�Qr�Lrla�.e NigRrwf U , No-and Street City/Town Zip Code Name of Building(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 MI RepairWIT 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 la/ Is an Independent Structural Engineering Peer Review required? Yes ❑ No IJ-� Brief Description of Proposed Work: A/ Al S fA " o d 0 J k o d e ,oN , 'e. a.✓d 9 G v ' C„hw,6 It,:J IA'94&AtP 4" Rat^ /USet--f Lb-Ah1;0 6J A,e. c1,�tA,u 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.) fW67 1 f C) 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: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ 1-3❑ Ill❑ M: Mercantile❑ R: Residential R-10 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) Lk IB ❑ IIA ❑ IIB ❑ 1IIIA ❑ IIIB ❑ I IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 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❑ Indicate municipal❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: 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: Appendix 1 A M For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location(Please indicate Block # and Lot #for locations for which a street address is not available) Aa 3omise-�-j . P� —SA&&I 014 ,70 /u aq SNaey, AVIXI-e No. and Street City /Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No R' Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No Or Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No 13'' Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 t, Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where aPplicable No. Item Submitted incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may r uire repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Pro ane,Medical or other 10 Surveyed Site Plan(Utilities,Wetland,etc. 11 S ifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energv Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Jb6 t 4,ttcj&A L 7Y - foll- q1 J'JatrNeat R��arss,vt¢.�F.� Name(Registrant) Telephone No. a-mai address � Registration Number 5— c0.M P/`c 02tarO bey- I—to '61 �z Bt Discipline Expiration Date Street Address City/Town State Zip Registration Number Name(Registrant) Telephone No. e-mail address Discipline Expiration Date Street Address Ci /Town State Zi Name(Registrant) Telephone No. e-mail address Registration Number Discipline Expiration Date Street Address City/Town State Zip SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner _ A/oRT"H SHogr Vxg l 91,TA&kSaO, 2r- o '5,A t E14 OMA o ( f7 v Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Pies fly" — Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Keytn/ Pe.!lellee SPfCk;0-u 0&1 -IM 0(177� 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. SECI70N 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) 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 Re istered Professional Res onsible 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 PRO(KE SS[W' RAOOE(NG //0C Company Name }.4oslt-Vea C S—D378/N Name of Person Responsible for Construction License No. and Type if Applicable 2 ► 2� IVA 57-lee-r A4yew1,1( /�/4. oil 2 Street Address City/Town State Zip Telephone No. usiness) Telephone No. cell e-mail address SECTION 11: .G.L.c.152.a 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 is ante of the building permit. Is a Signed Affidavit submitted with this application? Yes[� No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor �3 ./CEO 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 $ Note:Minimum fee=$ (contact municipality) 4.Mechanical (HVAC) $ r 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ 73 /9 O (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT tBntering my e below,I hereby attest under the pains and penalties of perjury that all of the information contained intion is e d accurate to the best of my knowledge and understanding. vbNa v r sprint and sign name 6'C /1 Title Telephone No. Date 4"✓;-T 2tttiL �9e l UcrlAA4 Q12d f Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: ? 4;�4 Name ate �co ® CERTIFICATE OF LIABILITY INSURANCE E "°°"""' 0911612016 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, file 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 endorsement(s). q PRODUCER 06175-001 IIQIAEACT LRIK WTK TDA Inc dba The Driscoll Agency 1118 ,E,n: (Tel)681-6656 I fRC Nu_: (9e1)68L-6686 93 Lou water Circle XGBkEM_kselp1drf scollagency.com Norwell,MA 02061 — — _---'-- - IIl6UREHISIAE� RDINe COVERAOE__-__ ___ DAIC Rlsu A: A.I.M.Mutual Insurance Company INSURED INSYBER B: Progressive Roofing Inc, As Per Schedule261 ----- ---"-----River Street -- 1 SU - ru Hav - Naverhill, MA 01832 JN y RMO, _-__--___ , INSURER E: 'See Addillonal Nsned Insured Endorsement _ - 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. NDTV,11HSTANOING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT MATH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORCED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, gEqXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UPMTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTfl TYPE OF INSURANCE A,%Dk WV80- POLICY NW mER MMIDO EFF 110L�C Ip PY) LIMITS GENERA-LIABILITY D EACH OCWRRFlhCE S COKMERCIALGENERALLIABILITY DAVAGEIOREN- ED -- .5-- ---- PR VISES eaoaun_engel__ _ CLAIMS-MADE L�OCCUR MED F_XP(Any one person) $ PERBO,VA-B AOVINJURY S f,ENERAL AGGHEGAIE S .EN'L AGGRF.CaATE 1.11.1iT MPLIF.S PF.A' PHODDCIS.CGIAP:OP AGG $ OLICY -- EO OC AUTOMOBILE LIABILITY - COLA ei NE6 SINCLC f1LNT S .(Ezeccder.0____- ANYAInO BODILY INJURY[Par person) S ALL OHNED - SCHEDULED - AUTOS AUTOS BODILYINJURY(Pora[utlenn S f-- - NONORNED PROPERTY DAL'A(SL---- ----- - NIREDAUTOS i_- AUTOS .1P4t9cdee.91___.._..._.-- S — ...._. _-_-_— UTAOREI-ALIAR OCCUR I ff C4 OCCURRFI.6E 6 _._. EXCESS LIAR CW..15 MADE A CRCGATE 5 UED ftE1F.NTION S 5 MAR 01,1 SQTI 1 I SL1TU. OTI1 AIPo EM11PLUYER3�C1A0114T4 X TGRY LIIAi Eti A pTIQ�ID+P�I��tl�� ECUTIVE Y! E.L.EACH ACCIDENT 5 1,000,000.00 q o IC .I. + MIA VWC-100.6020316.2016A 91112016 9l112?i6 ------ ---- — ---- ImanaalprylnNRl E.L.InsFnsE fA E'APLOTEE s - 1,000,000.00 pb tltl�� _ . D�C�MRIRIN 9FbPERATIONS be'on _.—_. FI DISEASF POUCYLIPAIT I S 1,000,000.00 I DESCRIPTION OF OPERATIONS/LOCATIONS VEHICLES(Altacb ACORO 101,Additional Remarks Sclretlula,Ilmore space is regwretl) WC coverage applies to MA employees only i I I I CERTIFICATE HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ! THE EXPIRA7104 DATE THEREOF, NOTICE WILL BE CELIVFRED IN ACCORDANCE WITH TILE POLICY PROVISIONS. AU THOIIIZF.D REPRESENTA LIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 26(2010106) The ACORD name and logo are registered marks of ACORD i 1� Massachusetts -Department of Public Safety Board of Building Regulations and Standards i e Construction isor License: CS-037814 JOHN V HOSTET)MR S Camelot Drive Boxford MA 01921 f , Expiration Commissioner 1 04117J2010