98 LAFAYETTE ST - BUILDING INSPECTION (2) 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-Family D ell'
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official
n SECTIONN 1:LOCATION(Please indicate Block#and Lot#�/for locations for which a street address is not available)
�'I S �ACG\llYfC ST1{M�r I/f DI C7 TD
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 Or Repair❑ Alteration 0 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other 0 Specify: f b on 06t4
Are building plans and/or construction documents being supplied as part of this permit application? Yes ;8L No ❑
Is an Independent Structural Engineering Peer Review required?Ir I /` I Yes ❑ No ❑
Brief Descri tiono Proposed Work: 100-4 of 4v-4;V•0n 0( r f4t
,c5 hore 'if
E(CL<C u l d Fin'i� w ��o LG tn (_D(. cG-'-
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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): _�os'ey-� Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) �-op g0
Total Area(sq.ft.)and Total Height(ft.) 68Ka t �v(o 5-
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❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ 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 Zo71s
ation: Sewage Disposal:
Trench Permit: Debris Removal:
Public Check if outd Zone f,$ Indicate municipal A trench will not be Licensed Disposal
Private❑ or indentify 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 Structure within airport approach area? Is their review completed?
or Consent to Build enclosed Yes ❑ or Nod 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:
The Commonwealth of Massachusetts
Department of Public Safety+ � Massachusetts State Building Code (780 CMR)
yJ ?� Building Permit Application to Construct, Repair, Renovate or Demolish any
Building other than a One-or Two-Family Dwelling
Code and Other Requirements for Building Permits
The Department of Public Safety has issued these building permit application forms so that municipalities
across the state can move toward use of a single permit form and consistent permit application process.
The MA State Building Code specifies the requirements of building permits and the applicant is advised to
review and be familiar with these requirements in order to avoid some of the common permit application
problems. Likewise the applicant should be aware that some municipalities require that the owner confirm,
even prior to acceptance of the building permit application, that no outstanding property taxes, water fees,
etc. exist.
Filing Instructions
1.Please contact the city or town where the work will be done to ensure that the city or town will accept
this application form and if any additional information is required, and obtain the correct mailing
address. After doing so, print the application, fill in completely and then submit to the local city or
town where the work will be done.
2.All applications shall be considered complete and will be reviewed if construction documents,
specifications, fee, and other materials that may be required as indicated in the Building Permit
Application are included with the application.
3.Please include a check for the Building Permit fee. The fee may be calculated using the information to
be supplied in section 12 of the Building Permit Application. The check is to be made payable to the
local city or town where the work will be done.
SECTION 9: PROPERTY OWNER AUTHORIZATION
' Name and Address of Property Owner (I VI p
Name(Print) No.and Stree City/Town Zip
Property Owner Contact Information:::--son na �D�f� `(� N961 �L65- 3/3f c^So/N e— / f'4"I'
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Title Telephone No. (business) Telephone No. (cell) e-mail address J
If applicable,the property owner hereby authorizes
0:40acr (,,5�r,Ae„ 13 L1,, S¢ pl+ or
Name Street Address City/Town State Zip
to act on the 2roperty 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❑and skip Section 10.1
10.1 Registered Professional Responsible 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 / I
0 t/1A1 0tK` co
ompany Name
osQ40VL I-' swetuey CS - a�586b
Name of Person Responsible for Construction License No. and Type if Applicable -
J3& MANc-NE57ER I-1A 0(4N
[Street Address Gam,/ City/Town State/� Zip
trv-Sx� �r{(t7 1'f>5_ �p Sat �Wjwer'_ CO^'i
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 ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor O
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ C Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ h appropriate municipal factor) _$
3.Plumbing - $ n _
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ p (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 9'y knowledge and understanding.
J ` Pro' c uyl q �r 13
Please print and sign name itle Telephone No. Date
✓�f}r'1 D(4
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)
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 ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ 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
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 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.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 1 Existing Building Survey/Investigation
16 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(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
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 Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration Date
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WINDO-4 OP I0::6Sy
'4�Rya CERTIFICATE OF LIABILITY INSURANCE OATE(MM/D 08/07111N 3DNY )'
3
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(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 endomement(s).
PRODUCER Phone: 781-665-2775 CONTACT William B. Markhard, CPCU
NAME:
McLaughlin Insurance Agency[]I] Fax: 781-665-0295 PHONE 781-665-2775 FAA 781-665-0295
828 Lynn Fells Parkwayoo ac IN Ex: ac No:
Melrose,MA 021760❑ E-MAIL hlininsurance.com mclau
William B.Markhard,CPCU ADDRESS:wmarkhard @ g
INSURER(S)AFFORDING COVERAGE NAIL If
INSURER A:Associated Industries Ins.Co. 23140
INSURED WindoverConstruction, Inc.O❑ INSURERS:Commerce Insurance Company 34754
Attn: Mr. Paul Bogart00 13 Elm Street[l0 INSURER c:National Union Fire Ins. Co. 19445
Manchester, MA 01944 INSURER D:Associated International Insur 27189
INSURER E:Lloyds Of London
INSURER F:
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. 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.
INSR kDDL SUBR POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MMIDO MMIDD
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
A X COMMERCIAL GENERAL LIABILITY AES1025373 01/01/13 01/01/14 PREMSES jEa occurrence) $ 50,00
CLAIMS-MADE Fy] OCCUR MED EXP(Any one person) $ 10,00
X ISO Form CG0001 12107 EDITION PERSONAL SADV INJURY $ 1,000,00
X Contractual Liab GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,00
POLICY LK PRO- LOC $
JECT
POMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,00
Ea accident $
BANY AUTO 12MMBDJGRM 06/15/13 06/15/14 BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
X AUTOS
AUTOS NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS X AUTOS Per accident
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00
D EXCESS LIAB CLAIMS-MADE CUBW4269613 01101/13 01101/14 AGGREGATE $ 5,000,00
DED X I RETENTION$ 10,000 $
WORKERS COMPENSATION X WC STATU- OTH-
AND EMPLOYERS'LIABILITY TORV LIMIT ER
C ANY PROPRIETORIPARTNERIEXECUTIVE YIN
WC.001652538 03/20113 03/20/14 EL EACH ACCIDENT $ 500,00
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,00
I(yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00
E Property 001982/1300 01/01/13 01/01/14 BPP 52,50
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required)
Evidence of insurance for operations usual to named insured 00
00
00
00
CERTIFICATE HOLDER CANCELLATION
WINDO-1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
WindoverConstruction, Inc.O❑ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
13 Elm St.El❑
Manchester, MA 01944 AUTHORIZED REPRESENTATIVE
01988-2010 ACORD CORPORATION. All rights reserved.-
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