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63 JEFFERSON AVE - BUILDING INSPECTION (11)
5 25 v The Commonwealth df) satc,�l{sViCES �1 I� Department of Public Safety Massachusetts State Building��,^,%e�j 0 CMR) Building Permit Application for any Building of%triaxi�d-OltPr}o}�'c+ F 'ly Dwelling a,...(This Section For Official Use Only)'. ..... 21 Building Permit Number: Date Applied `'` r`-. Building Official: 9 '• ; SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 3 Jam^xroN lCt: ,Sv)TE !a 3 S�rc ,r, D l 57p No.and Street City/Town Zip Code Name of Building(if applicable) 1 • • ,. ,. ... .+ , , :"°`„,. 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,O I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) I Change of Use ❑ 1 Change of Occupancy ❑ 1 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? Yes ❑ No Brief Description of Proposed Work: w f �SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING.UNDERGOING RENOVATION ADDITION;OR if 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): 'PL'�.,,,.'SECTION 4:BUILDING HEIGHT,AND AREA.n , —'- „„„. ,..s:et,...r.. _ 4,: Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) !r,_".E,.A,):=:sfF ' U„SECTIONS:USE:GROUP(Checkas applicable)..a,4, A:a'1 iitr A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I�1❑ M: Mercantile❑ R. Residential R-1❑ R-2❑ R-3❑ R F❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: n-SECTION 6:`CONSTRUCTION TYPE.(Clieck as applicable) IA ❑ Ill ❑ 1 IIA ❑ IIB ❑ 1 ILIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ OF,,SECTION 7:SITE INFORMATION.(refer to 780 r q Water Supply: Hood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will 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 Commission Review Process: Not Applicable❑ Is Structure within airport approach area? - Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ -4—r,. .: SECTION B: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 ah+rtnu 1c&011 exej 31 XJV0a 40) Sy-- Smc-t, of quo Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Ce,4IC S7,C4sVjc- - '/f/_�>S 070t/ _ C-S7/C4Sylc/C®Co ma, 16S Cvn, Title Telephone No.(business) Telephone No. (cell) e-mail address If a plicable,th,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. i'°- SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) a building is less than 35,000- .ft.of enclosed s ace and or not under Construction Control then check here O apd ski'!Section 101 +c-: 10.1 Registered Professional Responsible for Construction Control i`.1 '' .`;:. _'I?r m; Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2/nG,eneral Contractor: s�•- '"�` ''+ . `s K - `*•' ? «.». ~ ..�_.:'.t - NY'U9✓l /YLD � 1 �u•a. Comp y Name/` (fACr.7n CA ?t7rvt6n-O C3 Z) 6 /V Name of Person Res onsible for Construction License No. and Type if Applicable /5- 5 Bt A&ivt S%, �wne—�JLetr &-+- O l4 ZQ Street Address City/Town State Zip ?e PAIL 3S// 7L1 i0,°e /C a5 ✓C aC1NJM6A--4 SB+G RA ' CO^ Telephone No.(business) Telephone No. cell e-mail address u�l tiae? ., ,. �„+iSECTION II:WORKERS'COMPENSATION INSMANCE'AFFIDAVW AG.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 I2:CONSTRUCTION:COSTSAND PERMIT FEE;�.,q,.�„,. w: €->� "v" Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ ;-/ 2•' • PD Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ - - 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact , rwi 'pa/li/ 5.Mechanical Other ` $ Enclose check payable to �� G f� 6.Total Cost $ Z.( 1 o a (contact municipality)and write check number here M 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 and accurate to e b/est of/ knowledge and understanding. ' Please raft and sign name t+ Title Telephone No. Date Street Address City/Town fate Zip Municipal Inspector to fill out this section upon application approval .. _ w„_. . .�'..'.': ��.Name—A: .::� - _.bd + � -Date. `-'<, d�W�..a Massachusetts -Department of Public Safety Office of Cousuiner Affairs&Business Regulation Board of Building Regulations and Standards . OME IMPROVEMENT CONTRACTOR Construction Supervisor egistration: �J' 99 Typo License: CS-081061 xplration: DBAv VCAIZr. p N CAPONIGRO CONS 18U'RRTf.T.CAP G ' iI CARLO CAPONIG SWAN2SCOTT 159 BURRILL ST SWAMPSCOTT,MA.019 '" Undersecretary J.�..•�.- '""�.v Expiration Commissioner 07/25/2015 1 r. OP ID:LK �Lco�Q CERTIFICATE OF LIABILITY INSURANCE DAr06111115 ) THIS CERTIFICATE IS ISSUED As%A�MATCER 05 INFORMATION ONLY AND CONFERS NO FIGHTS UPON THE;CERTIFICATE.HOLDER;THIS CERTIFICATE,DOES NOT AFFIRMATIVELY OR NEGATIVELY.;AMEND, EXTEND OR ALTER:THE COVERAGE AFFORDED BY THE-P.OLiCJES----- BELOW.' THIS''CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE"A CONTRACT'BETWEEN`THE ISSUING INSUR£R(Sy,,-AUTHORIZED REPRESENTATIVE OR PRODUCE"R,ANDTHE CEI;TIFICATEHOLDEk. ... IMPORTANT:- if the'certificate bolder;is efi ADDITIONAL INSURED,the pollcy(les) must be'endorsed. If SUBROGATION IS WAIVED, subject to the terms.and conditions of the policy,certain policies may require an endorsement. A statementon this certificate does not confer rights to the certificate holderin lieu of such endorsements : - - - - PRODUCEReSanis - CONTACT - - ' - Phone:781 935-8480 NAME:. DOO Unicloro Park privegcy,lnc.; - 1 `Fax:781-933-5645 p"c°NNo Xl• AONe: - Woburn;NIA 01801' EMAIPROL .- ., .ADDRESS: ,.CUSTOMER ER D 94CAPQN72. . INSURERS AFFORDING COVERAGE �NAICIf -INSURED .' CapODIgro Construction Co„InD - - INSURER A:Pilgrim Insurance'Company - - 159 Burrill Street` INSURERB:Associated Erri to drs Swampscott,MA 01907 INSURER C: ' - INSURER D:: - - INSURER E: INSURER F: COVERAGES- CERTIFICATE-NUMBER—- - - - -- - —:-== REWSION-NUMBE-R. - --'-- ----- 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 OROTHER 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, .EX CLUSION$ANDCONOITIONS.OF SUCH POLICIES:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - - INSR TYPE OF INSURANCE - "' F POLICY EXP. LTR POLICY NUMBER MMIDDNYY -MM/DD/YY —LIMITS. - .. .. GENERAL LIABILITY EACHOCCURRENCE. a COMMERCIAL.GENERAL LIABILITY p EM SES Me 2ma.nee) a CLAIMS-MADE Q OCCUR MED EXP An ,one Person) 9 '- PERSONAL&AOV INJURY E GENERAL AGGREGATE a - GEN`L AGGREGATE LIMIT APPLIES PER •PRODUCTS-CONNOR AGG a. POLICY PRO-- BLOC 6 AUTOMOBILE UAoiur" - COMBINED SINGLE LIMIT b. - 1,000,000 ANYAUTO' - _ (Eaaccidem) `- BOOILYINJURY(Perperson). OWNEDE' ALL OWNED AUTOS, 'BODILY INJURY(Per a<ddenl)1a A X SCHEDULED AUTOS PRC00001003551 06106115 0606116 PROPERTY DAMAGE X HIRED AUTOS' (Per accident) a X ANONowNEDAUros -a _UMBRELLA UAB .00CUR' � _ EACH OCCURRENCE- Is EXCESS UAB CLAIMS-MADE AG -DEDUCTIBLE RETENTION Y - :.$ .. WORKERS COMPENSATION - X WC STATO• OTH-, AND EMPLOYERS'LIABILITY B ANY.PROPRIETORRARTNEWEXECUTNE Y/N CCSOOSO138902014A 09/23/14 09/23/15 E.L.EACH ACCIDENT a 1,000,000 OFFICER/MEMBER EXCLUDED? N/A - - - (MandaloryInNH) (MA) E.L DISEASE-EA;EMPLOYE E S 1,000,000 If yaE,tlesaiC0 under - DESCRIPTIONOFOPERATIONShelox EL DISEASE.POLICY LIMIT S 1,000,000 DESCRIPTION,OFF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Addldonal Ramada Schedulo,if more apace is required)- Evideace' of .coverage". - CERTIFICATE.HOLDER - - CANCELLATION`. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION'DATE -THEREOF,. NOTICE!;WILL BE DELIVERED' IN ACCORDANCE WITH THEP.OLICYPROVISIONs.. - -' AUTHORRED REPRESENTATIVE .. _ ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD'25(2009109)' The ACORD name and logo are registered marks of ACORD - �'•'"� m ._ DALE(nmvoomYY). ,awe Rc, CERTIFICATE OF LIABILITY INSURANCE 6/23/2015 . THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND'CONF.ERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND 011 ALTER THE OOVERAGE AFFORDED BY THE POLICIES BELOW.` THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPREBENTATIVEOR:PRODUCER,AND T{1E CERT.IEICATE HOLDER..:.. - IMPORTANT: If the certificate holder Is an'ADDITIONAL INSURED,the policy(les) must be endorsed. If.SUBROGATION IS WAIVED,subject to theaerms 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 endorselne'nt(s). - PRODUCER - NAMEACT COnme rClal Lines - .r PHONE 78l 322-2350 FAX Prescott and Soil- Insurance Agency,Znc. ( ). . Arc No: ' :. .. EAIAIL' - 963. Eastern•Avenuc ADDRESS: INSURER(S)AFFORDING COVERAGE NAICi Malden: MP 02149 MsuaERAArbella. ltroteation 'Zns Co 11360 INSURED INSURER B: CaQonigro Construction Co- Inc. 159 Burrill -St. INSORERD: _ . INSURER E: " Swampscott .. - . . .MA 7 01907' - INSURERF:. • _ COVERAGES '" - CERTIFICATENUMBER:QL1473018938 - EVISION NUMBER' THIS IS TO CERTIFY THAT THE POLICI'm$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.CQNTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S,SUBJECT TO AU_THE.TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE.BEEN REDUCED BY PAID CLAIMS. - - INSR PE OF INSURANCE - POLICY EFF . POLICY UP TYPE -� - M POLICY NUMBER MIDD M1VOD.rry GENERAL LIABILITY EACHOCCURRENCE S 1r000,OC .. ... - ED".. 50,0C X1 COMMERCIAL GENERAL LIABILITYPREMISES a navnencel S. A CLAIMS-MADEx XP OCCUR 500061820 - /27/2015 /27/2016 MED E (ABY ode 0-MI) S - 5,0C PERSONAL 6 ADV INJURY $ 1r000,0C . GENERALAGGREGaTE• E 2,000,OC GENL AGGREGATE UMn'APPUES:PER: PRODUCTS-COMPIOP AGG $ 2,000,0( X POLICY _ PRO- LOC $ AUTOMOBILE LIABILITY CAMaBm1N I5INGLE LIMIT S BODILY IMARY(Perperson) $ ANY AUTO ALLOWNED SCMEOUI.ED - BODILY INJURY(Per attidenq $ AUTOS NON-0WNED - PROPERTY DAMAGE _ S HIRED AUTOS AUTOS _ erarridenl S X UMBRELLA LDLB' X OCCUR I EACH OCCURRENCE $ S,000�0( A EXCESS UAB CLAIMS.MADr Ii600062468 /2T/2015 /27f.2016 AGGREGATE S 5,000,01 _ ,DED RETENnONS II S N/C STATII. OTIV WORKERS COMPENSATION - ANDEMPLOYERS'LUIBRM YIN - - ANY PROPRIEfORJPARTNERlEXECUTIVE❑ N/A - - - E.L.EACH ACCIDENT . S OFFICERIFAEMBER.EXCLVDE07 - - E.L.DISEASE-EA EMPLO 'S - (Mandatory in NH) tt yyeea,describe under - - E DISEASE-POLICYUMIT -II_ DESCRIPTION OF OPERATIONS bebw L DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(AVach ACOR0101,Additional Remarks Schedule,It more space is required). - CERTIFICATE HOLDER - CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED II ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORQED REPRESENTATIVE J S Scholnick/MPB gCORD 25(2010/0S) 01988-2010 ACORD CORPORATION. All rights reserv- INS02S rMIMsCnI Th.Ar:r1Qn namn anri Innn am rnnic4nrnd mar4e of Ar.nnn