260 JEFFERSON AVE - BUILDING INSPECTION (3) 4
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)Seventh Edition
1 Building Permit Application for any Building other than a One-or Two-Family Dwelling
S� (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION Z PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 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 0 No ❑
Is an Independent Structural Engineering Peer Review r�q1uired? J Yes ❑ No ❑
Brief Description of Proposed Work: /`(E CV
Brief '
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,QR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s):
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ 1-3❑ I4❑ 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)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑' IIIB ❑ 1 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 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: NIA Historic.Conunission Review Process:
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 Pro rty Owner
Name( rint) No.and Stree� City/Town Zip
Property Owner Contact Information:
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 bv this building 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(R gistrant) lep a No. e-mail address Registration Number
L47/ .
Street Address City/Town State Zip Discipline xpiration Date
10.2 General Contractor
i
r rr CG~ GL��
Com any. ame:
Name of�Perso��n�///Resp fons�tb�e for Construction C cense No. and Type if Applicable�r�
LIP
Sireet Address ��3� City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COM14.PENSATION TNSUR..ANCE 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 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
1.Building $ �c�- 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
6.Total Cost $ (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 and accurate to"es, owledge and understanding.
Please print aj�d sig9 name T' le Telephone No. Date
�,`771 /C �6� r 21 Qlv !�Izl�-,
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: 1,1 ,4 iv
Name Date
ujjice of tnvesugarzons
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'bl
Name(Business/Organizationn//hWividual):
Address:
City/State/Zip: h '7G DK kO Phone#:
Are you an employer? Check the appropriate boa: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6
employees(frill and/or part-time).
have hired the sub-contractors El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp.insurance comp. insurance.t
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner.doing all work officers have exercised their I LE]Plumbing repairs or additions .
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors most submit a new affidavit indicating such.
tContmctors that check this box must attached as additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employccs,they most provide their workers'comp.policy number.
lama n employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name: `�l Y/S IG L'- � ���•!�`Y GG�c � _� --
Policy#or Self ins.Lic.#: [ S /�i /l i—2 Expiration Date: e�� 18�1
Job Site Address: _/^ '� /J t r<— City/state/Zip: r'
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 to S 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 be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pans dpel es ofperluat the information provided abovLe is true and correct.
Sitmature- —yam l cl/��L/l Date 9/4'_
Phone# �' ✓�;7" 2'! �r z� /
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
•
04-12-' 10 10:30 FROM- T-552 P001/001 F-313
Ae<>& CERTIFICATE OF LIABILITY INSURANCE
9/12 SO
NwawcER - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Phil Richard s Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
491 Maple Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Suite 102 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Danvers, MA 01923 ,INSURERS AFFORDING COVERAGE NAIC0
I" ut® r INSURERA SCOTTSDALE INSURANCE COMPANY
Pearson Builders, Inc. ,r{_ �se55;,J INSURERS: Arbella Protection !
15OR Winona Street �� IMSUPERC Granite State In_s AIG
Peabody, MA 01960-, INSURERD
INSURER E:
COVERAGES
THE POLICIESOF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FORTHE POLICY PERIODINDICATED.NOTWIn-6TANDIN3
ANY REQUIREMENT.TERM OR CONDITION OF ANY COW RBLCT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIR THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THETERMS,EXCLUSIONSAND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS. _
MOO PODGY EFFEC"VE POU GY F7(PIRATON ._
`.. POLICY NUMBER LIMITS
GENERAL LABILITY EACH OCCU ENCE S 1 000 000
A X COMMERCIAL GENERAL LIABILITY CLS1445653-2 11/28/09 11/28 1010ALXGE TO REI TIED
/ PREMISESIJ � i 100,000
CWMS MAOE ❑X OCCUR I Meo Ew DArP ore Breen . 1 5,000
PERSONAL&ADVINIURY i 1,000.000
I GENERAL AGGREGATE S 2,000.000
GEN'LAGGREGATE LMITAPPLIES PER PRODUCTS-COMPIOP AGG S 2,000,000
IX
POLICY PR LOC
AUTOMOBILE LIABUTYCO
i
B I ANYAUTO j37262400001 7/18/09' 7/18/10 MBeaiED SINGLE LIMIT f
ALL O WNED AVTOS -
BODILY INJURY 4 250,000
IX BOMEDULEOAU P TOG ) &Pv.)
' HIREOAUT08 BODILY WJV0.Y
j NONOwNEo AUTOS. (Pee�rn) E 500,000
PROPERTY DAMAGE S 100,000
Q eV 9oc0em
GARAGEUABSJTY i
I AUTO ONLY•EA ACCIDENT S
ANYAUTD I'OTNEQ THAN EAACC S
I AUTO ONLY: AGG 1
EXCESSIUMBRELLALABILITY I EACH OCCURRENCE d
OCCUR CLAMS MAOE AGGREGATE IS
IS
DEDUCTIBLE
a
I N f
1
AND EMPLOYERS'
YERS'COMPENSATION X WC ATU- OTH-
AND EMPLOYERS'ARTNELIABILITY
C ANYCERIMEETOR EXCLUDED?
YIN
TBD 3/17/10; 3/17/11;E.L.EAOH ACCIDENT S '100,000
OFflCE Rb1EMBER EXCLLOED7 �I
(Mawabry in NMI E.L.DISEASE-EA EMPLOYE S 200,000
SPECALPReISIO E.L.DIS EASE-POLICYLIAR 1 500,000
SPECIAL PROVISIONS Edaw
I OTTER
CE SCRIPTION OF OPERATIONS I LOCATIONS I VCRCIES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS
EVIDENCE OF INSURANCE
CERTIFICATE HOLDER CANCELLATION "
SHOULD ANY OFT HE ABOVE DESCRIBED POLICIES MCAM66L O aEFORE THE EXPIRATION
DATE THEREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL 15 DAYS WRITTEN
TO WHOM IT MAY CONCERN .NOTICE TO THE CERTIFICATE HOLDER NAMED To THE LEFT BUT FAILURE TO 00608"?41.
IMPOSE NO OBLIGATION OR LIABILITY OF ANY IONDIPON THE INSURER RS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTAT IE
STEPHEN TURNER
ACORD25(2009101) - 01988-ZO09 ACORD CORPORATION. All rights resorued.
The ACORD name and logo are registered marks of ACORD
PEARSON BUILDERS
eenand Contractor
Warren A. Pearson
° 150 FL Winona SL Phone&Fax 978-535-6555
W.Peabody,MA 01960 Cell 978-758-2938
77=D'[assac-husetts ]Department of Public Safet3t
Board of 1mliLng Regulations and Standarrla'
�y- ,supervisor License.
,.1�s'eiise. CS' 40M -
WARRI=
50RVFb'I 5
v P 611
_� :... . Expiration: 411=011 -
. Trlf: 13734 .
�/+e '�omi+xaouve /c o�✓�aaa¢�i".ae - License or registration valid for individul use only
Onice of Consumer ARaus&BKsiaess Regutanoa
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: .
.Registration•�1.07999 Type: 10 Pa of Consumer Affairs and Business Regulation
�'��'� 10 Park Plaza-Suite 5170
• Expiration: 012 Individual Boston,MA 02116
MEN A.PEA — -
Warren Pearson
- 150R Winona$t. � /= �s�--•,6.� -
Peabody,MA 01460 '�„ / Undersecretary Not valid without signature