63 1-2 JEFFERSON AVE - BUILDING INSPECTION t.
The Commonwealth of Massachusetts
( Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-'or Two-Fa ' y Dw li
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is ar able)
63'(a Te Fri.• �� SA 14, vita y t ti-1 o £AAX ORywRLL
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 Repair❑ 1 Alteration Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 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? p Yes ❑ No fill
Br* f Descnption of Proposed Work: E (A cE 3 O�<,'2 LGOU Zo-a& w A' , 1V.ti. G fnCc_
trvw` 3 rP,.A,.:t yaj& eV HAI AL f4P%A Ct £u(V,?. Cc .
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.) Toe- -7�do
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 ❑
R Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage Sl ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA. ❑ IB ❑ IIA ❑ IIB O HIA ❑ III11 ❑ IV ❑ 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:
Public Check if outside Flood Zone Indicate municipal A trench not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation MA Historic Com mission Review Process:
Not Applicable y' Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No 0," Yes❑ No Qv-�
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:;i'E S-1 Occupant Load per Floor:
Does the building contain an Sprinkler Syste� Special Stipulations:
e
1
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
R� zZ K® NoM.- �y G 31(61 � uzs.s A�� S�fc^ wtA �tr.7o
Name(Print) No.and Street City/Town Zip
Pro rty Owner Contact Information:
P0,,'\- q')b 7t&_ so-sr, 6 r� �3� sax b���@2 .a�n�✓+I (. c� _
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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)
f building is 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
61)_ 831, sosc3 bolos@E",P-kry,,ry t
Name(Registrant Q� Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Z ✓vim
ComR any Name
Name of Person Responsible fo Construction License No. and Type if Applicable
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Street Address City/Town p Stra�e Zip
9 7�Fk �osc� (,t� _�3S SoSa �0\0 (Pe .rzcY *�.r�\\•a--
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 the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes[] No O
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ I C) W 0 Building Permit Fee=Total Construction Cost x_(insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ (O, ao0 Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby in der the pas and penalties of perjury that all of the information contained in this
application is true and accurate to best of ty knowledge and understanding.
Q.I-c,,� Lcvmt,, (rvA4L &Q_ 1335 �aSo
Please not�nd si n p �+ Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
Appendix 1
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)
P4g 12astti sa d tQiCi'70
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 Provider notified and Release obtained? Yes ❑ No M'*'
Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No MI/
Electricity Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No [W
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No I(d
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
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'Y'where applicable
No. Item Submitted Incomplete Not Required
1 Architectural -
2 Foundation
3 Structural
4 Fire Su ression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical (�
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other ✓
10 Surveyed Site Plan(utilities,Wetland,etc. ci
11 Specifications
12 Structural Peer Review ✓
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report ✓
15 1 Existing Building Survey/Investi ation
16 1 Energy 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 S
*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
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration•Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State Zip
,< CITY OF S.U.EN1, TIASS.A.CHUSETTS
• BuMI)LNG DEPARTNEIRNT
• 130 W.{SHLNGTON STREET,3'°FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
7l-tgRRi F.Y DRISCOLL
MAYORTrtOMAS ST.FtERRB
DIRECTOR OF PUBLIC PROPERTY/BUUZLNG COMNOSSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
CGSS`c flA -
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit applicant
q fay �,3
date
JcbrivtTdx
i CITY OF SM E.NI, NL-�SSACHUSETTS
BUILDING DEPARTNIEINT
• M 120 WASHINGTON STREET, 3r FLOOR
TEL (978) 745-9595
Fax(978) 740-9W
KimBERLEY DRISCOLL
MAYOR THom%s ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\WMIONER
CONSTRUCTION CONTROL DOCUMENT
Project T a 9itle: R k5E x 51 Date: 011-3/a 3'l
Project Location: Q9 q 5 \
Scope of Project: R4 \ e,F Sub 5�a da� Roo rr P�PJAc4 ti F. �t
In accordance with SECTION 116.0-116.4.2 of the 6th edition of the Massachusetts State Building Code :
l Mass.Registration Number
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:
[fJ—Entire Project [ ] Architectural [ J Structural [ J Mechanical
[ J 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 all
applicable laws for the proposed project.
Furthermore,I understand and AGREE 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 by the building permit and shall be responsible for the following as specified in section
116.2.2:
1. Review of shop drawings,samples and other submittals of the contractor as required by the construction
contract documents as submitted for the building permit,and approval for the conformance to the design
concept.
2. Review and approval of the quality control procedures for all code-required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine, in general, if the work is being performed in
a manner consistent with the construction documents.
1 shall submit periodically, in a form acceptable to the building official,a progress report together with pertinent
comments. Upon completion of the work,I shall submit to the building official a final report as to the
satisfactory completion and readiness of the project for occupancy.
Signature and Seal of registered professional:
1.11 Y ur Jt11 .0 iVls i'VIAbb Curl t,ar,i 1.a
"r BUMDLNC;DEPAI1 Rm
120 WAsH1NGTON STREET,3"FLOOR
F TEL (978) 745-9595
FAX(978) 740-9W
1CIJBFRT FY DRISCOIl.
MAYORTHO"ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMStONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information y Please Print Legibly
Name (Businoss;OrganizationiIndividual): (Vl or, v A N
Address- 631(a InXs—" --• P-''s-
City/State/Zip: SA lE h ( Ci197� !'hone #:
Are�y u an employer?Check the appropriate box: Type of project(required):
1.L"J I am a employer with 30 4. 1 am a general contractor and 1 6. ❑N w construction
employees(full and/or part-time).* have hired the sulscontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet: 7. Remodeling
ship and have no employees These sub-contractors have V. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. DBuilding addition
[No workers'comp. insurance 5. We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,$1(4),and we have no 12.❑Roof repairs
insurance required.)t employees. [No workers' l3.❑Other
comp. insurance required.j
•Any applicant that chicks box!1 most alto fill out The locum below showing their workers'compensation policy information.'I4wrwawmss who submit this affidavit indicating they am doing all work and then hire outside emnraetm most submit a cow afttdavit irdimin each,
;Comnirton that check this box must attached an additional short showing am mare,of the subavmrssmm and their workers'comp,policy inset slim.
I am an employer that lr providing workers'compensation Insurance for toy employees. Below Is the pollcy and fob site
information.
insurance Company Vame:. . ��a�c-SCo SivSe�4a.c� CU•^+�A.s y
Policy#or Self-ins. Lie.M V-WC 30Q a-709 Expiration Date: h I �Ut//y
Job Site Address: 54' , 5^ke VVA City/State/Zip: SA[ ANa
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. 132 can lead to the imposition of criminal penalties of a
fine up to 51.500.00 and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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 hereby c Ilfy and r the pains and penalties of perjury that the informatlon provided above is true and correct
SiunatuTre: erE&,Sc-r\ Date: 9_ /a 3 /13
Phoned: 1�� 74f{ SO Sp
Offlcial use only. Donor write in this area,to he completed by city or town offniat
City or Town: Permit(I.)eense#
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other ,_..
Contact Person: ______ . Phone#:
,ac_,o�v~ CERTIFICATE OF LIABILITY INSURANCE °"'0"M°°�
08109/13
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,the policy(les) 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 endoreemen s .
PRODUCER Phone:781-935-8480 21TIE ACT
DeSanctis Insurance Agcy,Inc. Fax:781-9335645 PHONE Fax No):
100 Unicorn Park Drive E-NNL
Woburn,MA 01801 AooREss:
PRODUCER ,EMRDR-1
CU TO D
INSURE S AFFORDING COVERAGE NAIL$
INSURED E.M.R.Drywall, Inc. INSURERA:Acadia Insurance Com an
631/2 Jefferson Ave. INSURER B:We6CO Insurance Co
Salem,MA 01970 INSURER 6:Torus Specialty Insurance Co
INSURER D:
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: .REV]SIONNUMBER:
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.
DISK TYPED INSURANCE B POLICY NUMBER MMN9 EFF WOmDr EXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000,00
A X COMMERCIAL GENERAL LIABILITY CPA507086910 12/31/12 12131113 PREMISES EeoxVnenn $ 250,00
CLAIMS-MADE �OCCUR MED EXP(Any one Person) S 5.00
X Contractual Llab. PERSONAL SADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2,000,00
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPAOP AGO S 2,000,00
POLICY X PRO- LOC E
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,00
(Ee acddaM)
ANY AUTO BODILY INJURY(Per person) S
ALLOWNEDAUTOS BODILY INJURY(Per acadeM) $
A X SCHEDULED AUTOS MAA507087210 12/31/12 12/31/13 PROPERTY DAMAGE
X HIRED AUTOS (Per acddeM) E
X NON-OWNEDAUTOS $
$
X UMBRELLA I" X OCCUR - - EACH OCCURRENCE S 6,000,00
EXCESS We CWMSAIADE AGGREGATE E 6,000,00
A CUA507087310 12/31/12 12/39/93
DEDUCTIBLE $
RETENTION $
WORKERS COMPENSATION X WC STATU- OTN-
AND EMPLOYERS'LIABILITY 01M1N3 01/01/16 1,000,00
B ANYPROPRIETORIPMMERIEXECUTNE YIN C3048709 E.L.EACH ACCIDENT $
OFFICERMEMBER EXCLUDED? NIA
(MeMalory In NH)
MA E.L.DISEASE-EA EMPLOYE $ 1,000,00
I de !v under E.L.DISEASE-POLICY LIMIT E 1,000,00
DESCRIPTION OF OPERATIONS Eebx
A Equipment CPAS07086910 - 12131112 1 12/31/13 ISchaduled 62,77
C Excess Umbrella 811T7DI20ALI 08/11IM2 (HIM1113 Limit 4,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Alaeh ACORD 101,AddNloMI RaMarks Sdsedula,N P span la repulree)
"ADDITIONAL INSUREDS LIMITS ARE NO GREATER THAN THOSE REQUIRED BY WRITTEN
CONTRACT.11 PROJECT: Avalon Exeter, 77 Exeter Street, Boston, MA 02116 - Job
8MA419. Additional Insured as respects to General Liability, Automobile
Liability, Umbrella/Excess Liability: Ipswich Bay Glace Co. , Inc.;
valonBay Communities, Inc. , CONTINUED.
CERTIFICATE HOLDER CANCELLATION
IPSWI-6
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Ipswich Bay Glass Co., Inc. ACCORDANCE WITH THE POLICY`EfIOVISIONS.
PO Box 511
Rowley,MA 01969 Au`rHOIUZEK3iPRESE T
n 988-2009 A RPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD