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76 LAFAYETTE ST - BUILDING INSPECTION
3q- oy1 -� The Commonwealth of Massachusetts Department of Public Safety 1J�( Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family elling (� (This Section For Offf ial Use Only) Building Permit Number: Date Applied: z/ I Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for whic a street address is n available) yAo i�yetk A 5CLS evn AV i.; No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used B New Construction check here❑or check all that apply in the two rows below Existing Buildin I Repair❑ Alterations I Addition❑ 1 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? Yes ❑ No 19 Brief Description of Proposed Work: 7�mo 2 US0.\ 5 oo oixteR Mi eC6- worK nor \ 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.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ T B: Business E: Educational ❑ F: Facto F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutio -1❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ 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 ❑ IIIB ❑ 1 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: Public Jg Check if outside Flood Zone ElIndicate municipal9r A trench ill not be Licensed Disposal Si Private❑ or indentify Zone: or on site system❑ requiredior or or specify: permit is nor ❑ Railroad right-of-way: Hazards to Air Navigation: MA I4istoric Conunission Review Process: Not Applicableid 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 podgyrea A LL(. 17 .ZV0.,�w 5t Gmiat.�� 0714 Name(Print) No.and Street City/Town Zip Property Owner Cosltast I�rformation: ' .e.,. . -t-- (�(.C� 5> - V -Ld.d]f2-- bl -��- 2ZS!O 'a' A Title Telephone No.(business) Telephone No. (cell) a-mail address applica le,the property owner hereby authorizes -1 ZU Z07-si1'�Le.,- hit o It `( Name Stre A dress City/Town State Zip to act on the proper owner's behalf,in all matters tive to work authorized by 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 O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) elephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Sci revne &OAeg s Company Name scot_ AW sow, CS 676 Z 8 Name of Person Responsible for Construction License No. and Type if Applicable 59 G ka& k&1\124 q . aNNA tec, A14 0187-1 Street Address City/Town State Zip _ 781 _953.66 scolk�ws��revnebv�\der• net 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' suance 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 $ JP 0 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ Sv t appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ 5D I� U (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 the best of my knowledge and understanding. Salk, Auxic",_ �- C'v +V(ke�ot� 7 i Please prin{a d�sii ame ` Title Telephone No. Date S �i 4121 0f6'2I Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date f D L,dldYWUV QUCCL GflU MLWJ1 MML CIIU 7 Lafayette #2�3 78 Lafayette%4204 ApFEttx: 1?a0 Sq Ft RFP x: t52tJ $C}'Ff I New w4 s . W A4.L I! , s f A\ Remove } -- WAI1 � ! : 203 j j CITY OF S<ULEM, N'WSACHUSETTS a BuMDING DEPARTNIENT 120 WASHINGTON STREET,Sae FLOOR TF1. (978) 745-9595 FAX(978)7404846 KIN 78ERIEY ARISCOLL MAYOR THOMAS ST.PgnRE DIRECTOR OF PUBLIC PROPERTY/lIUM.DING COJIABSSIONER ........... .. .. Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information r� Please Print Legibly Name(Bushtess.Organizatiomiindividual) QYe1'IF tJ `: SuFyV\\ckkNS Address: �� \ Unn�\, Y City/State/Zip:�1 L OU C)I 1521 Phone #: 781— 953 — �003 �O Are you an employer?Check the appropriate box: Type of project(required): 1.151 1 am a employer with / 4. 0 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-tithe).• have hired the sub-contractors 2.0 t am a sole proprietor or partner- listed on the 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. 0 Building addition [No workers'comp.insurance 5. 0 We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions myself.(No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees. [No workers' 13.[1 Other comp. insurance required.) *Any applicant Chat checks box ill most also till out the section below showing their workers'canponattion policy intennatiaa. 1 bxra:uwtrcn who submit this aHldarvit indicating they ate doing all wodt atd then him outride conhtachora must submit a new affidavit indicating such. = 'ontraaon Cho check this box must anacl ed an sckli iatul.h rl showina the name or the soh-eontractore and their workers'comp.policy infommtion. I um an employer that is providing workers'compensatan insurance jar my employees. Below Is the policy and fob sfte inforaratfon. Insurance Company Name: Policy#or Self-ins.Lic.#: �to��(q Expiration Date: 7_Z Job Site Address: 76 taYaFeye 5�- City/State/Zip: SQleyy-, 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 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 certify under the pirins and penalties of perjury that the information provided above is true and correct, Sienahlre: � � Date, Phone#: 76/-QS3 &t23 6 QTlcial use only. Do not write in this area,to be completed by city or town ofrciaL City or Town: Permittl.icense q issuing Aulhority(circle one): ---- -- � I. Board of Health 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone fi: ACORD CERTIFICATE OF LIABILITY INSURANCE SUP DAR�Ml 08 18/11 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE F.J. LAROVERE INSURANCE AGENCY HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 492 BROADWAY ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. EVERETT MA 02149-3617 Phone: 617-387-9700 Fa K:617-387-9702 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A. NORFOS s DEDIAH INS. COMPANY 23965 INSURER B. COMMERCE INSURANCE 34754 SUPREME BUILDERS 6 DESIGN INC. INSURER c'. TRAVELERS 25682 SEAN S SCOTT ALLISON ---------- 58 GLAD VALLEY DR INSURER D'. BILLERICA MA 01821 --- — — -------- - INSURER E COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ON LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDDIYY PDATE MMIDOIW LIMITS GENERAL LIABILITY EACH OCCURRENCE s 1 r 000,000 A X COMMERCIAL GENERAL LIABILITY RS O48O95A 07/12/11 07/12/11 PREMISES(Ea oowrence) $ 5Or000 CLAIMS MADE OCCUR MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 1r000rOOO POLICY PRO- LOG 3 7JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 B ANY AUTO LH6115 09/24/10 09/24/10 (Ea accident) ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per aocidem) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY EAACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE — $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORYLIM ITS X ER A EMPLOYERS'LIABILITY 0664019 07/21/11 07/21/12 E.L.EACH ACCIDENT $ 1000000 ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBEREXCLUDEDi E.L.DISEASE-EA EMPLOYEE $ 1000000 If yes describe under SPECIAL PROVISIONS below I EL DISEASE-POLICY LIMIT $ 1000000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION RCGLLCO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN RCG r LLC NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL PETER KAPLAN IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 17 IVALOO ST. SUITE 100 SOMERVILLE MA 02143 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE TIMOTHY LAROVERE CPCU LIA ACORD 25(2001/08) ©ACORD CORPORATION 1988