275 LAFAYETTE ST - BUILDING INSPECTION j 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 Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION l:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
275 kaCtc 4 e AC Sinew% 0l9k0
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 0 Repair IPL Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: j
.Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No E
Is an Independent Structural Engineering Peer Review required? Yes ❑ No [If
Brief Description of Proposed Work:
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C .t r 4 la�,w�r1a 1., 1" A ra�..i S
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❑ 1 B: Business ❑ E: Educational
F: Facto F-1 ❑ F2 I H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4 ElH-5❑
I: Institutional 1-1 ❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 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 ❑ IIIB13 1 IV 1 VAO 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 C�
required l(or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable§K I Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No Pr-
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:
CieZ170tD- 9�5-11
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and
rAddress
(of Property Owner 1 1
p `CrCO4� C,S� 0&- Z r�astf" /t A /0 3 7tArJ5Vn 5t- ^YNN MA 01cl(�
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
�L_k 6Gu,rrt a. n� epema ,or
�1nr�.cw 13aumacr�ncr � � + � S
Title Telephone No. (business) Telephone No. (cell) e-mail addressC�
If applicable,the property owner hereby authorizes
Gfon" Iems4Lellvw R-te St.�rm/1'Ie Q 1} � SG(e W1..A � (q�
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)
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 10.7
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
100.2 General Contractor 11 11
6minn_ C ST/U C'ft tIH
Co I n Name (
Name of Person Responsible foii Constru tion License No. and Type if Applicable
7+6 Sw4rrtnifo If J2c� <G (e,t" 1'f6,4 6/
Ir
Street Address City/Town II State Zip
60 _ 212 gsif fdoUAFce-4v 0 gagmen
Telephone No. business Telephone No.(cell) e-mail address
SECTION 11:1RORKERS'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? Yeses No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$ — 0
1.Building $ ,6,lcw 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 $ '/0 pU-� (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the info0o. a
this
application is true and accurate to the b of my knowle{ d understanding.
uch,�-j -iv 6� d
Please print and sign name r� Title Telet
Street Address City/Town State
Municipal Inspector to fill out this section upon application approval:
Name Date
PAGE OF PAGE(5) PROPOSAIJAGREEMENT
Groom Construction Co., Inc. Licensed and Insured Contractors
96 Swampscott Road Member Better Business Bureau
Salem, MA 01970 Contractor Registration#104999
Tel.: (781) 592-3135 CC`T clti°on® Est. 1979-Fed ID#04-2866322
Fax: (781) 593-1480 —�®
Massachusetts Law:All contractors must be registered with the state.Notes direct all In uirie8 to:Director H.I.C.R.,One Ashburton PI.,Room 1001 Boston MA D2108 917 7278598
NAME DATE
Cerebral Palsy of Eastern Mass, Inc. September 14, 2011
ADDRESS JOB LOCATION
103 Johnson Street 275 Laffa ette Salem MA
CITY STATE ZIP CODE PHONE
Lynn MA 01902 781 -593-2727
We hereby submit specifications and estimates for:
Groom Construction Co. , Inc. will .perform work on a Time & Material
..... ..... . . .. ..... ... .................:......................................................................
Basis with a budget of $40,000 Forty Thousand Dollars. Groom
......................................................................................................................................................................I.............
Construction..will..follow_.and..,prioritize the scope provided by the
pwrle;•,•• and„ attached hereto ................ .,...• • „• •„•„
...................................................................................................................................................................................
....Rates.:......................................................................................................................................I..........................
carpenter...$57,.OU per Hour; Carpenter' s--Helper...$45:•00...per Hour...&........I................
....Laborers_$$38..0 0..per...Hour...........................................................................................1.4...................
..
......................................................................................................................... .................4...................
Mark •ups •ori••Mal teria1s,••Dumping..and.•other out...of...packet...expenses...shall..........
be..bi.11ed..at...Cost...Plus....Ten..Percent...(.1.Q J:..............................................................................
...................................................................................................................................................................................
....................................................................................................................................................................................
Al.l..Iztvo.icas...wi.1l..Be..Ia ccomani ed...wi.th..recei.pts,...detai led...payro.l l.........I...............
.....records...o£...who_&..whea............................................................_..............................................................
....................................................................:..:...........................................:.:..............:........:..........:......................
....
...............................................................................................r................................,...........................:......................
We hereby propose to furnish material and labor-complete in accordance with the above specifications for
Budget of Forty Thousand Dollars dollars 00/100
Payment to be made as follows:
All additional work shall be billd at the rate of per man hour. Materials are billed at co lus %
All materials are guaranteed to be as specified.All work to be conpleted In a workmanlike VAuthzed Signet eManner according to standard practices.Any alternation or deviation from above specifications
Involving extra coats will become an extra charge over and above the estimate.All agreements
contingent upon strikes,ecddents,or delays beyond Our Control.Owner is to tarty necessary
Insurance.Our Company workers are fully covevred by Workmen's Compnsatlon Insurance. proposal may be withdrawn
by us If not accepted within 00 days.
Additional Terms and Conditions: The terms and conditions on the reverse side of this document are expressly Incorporated onto this
ProposaVAgraement.
Special Provisions:
Acceptance of Proposal.The above prices and specifications are
satisfactory and hereby accepted.You are authorized to do the work x
as specified.Payment w I be made as outlined above.
Signature
x
Date of Acceptance Signature
Office of Consumer Affairs and usiness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
r-
Home Improvement Contractor Registration
Registration: 104999 -
Type: Private Corporation
Expiration: 7/16/2012 Tr# 298430
GROOM CONSTRUCTION, INC. -`'
Thomas Groom
96 SWAMPSCOTT RD #6
SALEM, MA 01970
Update Address and return card. Mark reason for change.
Address [:] Renewal F-] Employment Lost Card
DPS-CA1 G 50M-04104�G101216
Office ('Eod'SPiHf�Sth'if£'Yt'S2�`BYrSitr �T7c€•gat;f4i��° License or registration valid for individul use only _
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 104999 Type: Office of Consumer Affairs and Business Regulation
` Expiration 7/16/2012 Private Corporation. 10 Park Plaza-Suite 5170
- � Boston,MA 02116
CONSTRUCTION,iNC.
t
Thomas Groom
96 SWAMPSCOTT RID. #6Qo a
SALEM,MA 01970 �- Undersecretary Not valid without signature
Massachusetts- Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 77841 t•-�
TIMOTHY C`DOUGHERTY
21 COTTAGE ST
PEABODY, MA 01960x
Expiration: 8/25l2012
('ommissiuner Tr#: 2416
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Groom Construction Co. , Inc.
Address: 96 Swampscott Road
Salem, MA 781 -592-3135
City/State/Zip: Phone t
Are you an employer?Check the appropriate box: Type of project(required):
L® I am a employer with 75 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. 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'
[No workers'comp.insurance comp. insurancc.t 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself,[No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t a 152,§1(4),and we have no
employees.[No workers' 13.0 Other
comp. insurance required.] -
!My applicant that checks box#1 must also fill out the section below showing their workers'compan ation policy infomatim.
t Homeowners who submit this affidavit indicating they are doing all work and then him outside contraetms must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have arployees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job she
information.
Insurance Company Name: Liberty Mutual
I
Policy#or Self-ins.Lic.#: WC 7 Z 1 1 2 5 9 71 3 01 1 Expiration Date: 3-1 0- 12
I
Job Site Address;Al-4 S kc rG Vc O� City/State/Zip: SC lc wit MA U 1 T ?T)
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 a 152 can lead to the imposition of criminal penalties of a
fine up to$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 eovera a verification.
I do h by ce under the pain and n 'es of perjury that the information provided above.is true and correct
Signat re /� Date /0/L/If
10 Phone#: 4- Z I2
i
Official use only. Do not write in this area,ter be completed by chy or town official
City or Town: Permit/License# j
Issuing Authority(circle one):
1. Board otHealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector j
6. Other
Contact Person: Phone#:. �
�.uvu I.. co t I ao tJK V V M GUN,I
ACORD.. CERTIFICATE OF LIABILITY INSURANCE D TE mMDD YY)
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 endorsement(s).
PRODUCER CONTACT NAME: Certificate Desk
HUB International New England PHONE FAX
299 Ballardvale St a n Le Ext),978 657.5100 ac,Ne): 9769880038
Wilmington, MA 01887 ADDRESS:
C
978 657-5100 USTOMER ID N:
INSURER(S)AFFORDING COVERAGE NAIC p
INSURED INSURER A:Liberty Mutual Insurance Co
Groom Construction Co.,lnc.and Groom Realty LLC INSURERB:Starr Indemnity& Liability Com 38318
96 Swampscott Road,Suite 6 INSURERC:
Salem, MA 01970-7004 INSURERD:
INSURER E:
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
TYPE OF INSURANCE ADDL B DR POLICY EFF POLICY EXP
POLICY NUMBER MM/DD/YYYY MM/DD/YYW LIMITS
A GENERAL LIABILITY YV2Z11259713031 3/10/2011 03/10/2012 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY A G O
PREMISES Ea occurrence 8300,000
71 CLAIMS-MADE ❑X OCCUR
MEG E%P(Any one person) $5,000
PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $2,000,000
X POLICY PRO-.IFCTLOC $
A AUTOMOBILE LIABILITY AS6Z11259713021 3/10/2011 0311012012 COMBINED SINGLE LIMIT
X ANY AUTO (Ea accident) $1000000
ALL OWNED AUTOS BODILY INJURY(Per person) $
BODILY INJURY(Per accident) $
SCHEDULED AUTOS
X HIRED AUTOS PROPERTY DAMAGE $
(Per accident)
X NON-OWNED AUTOS $
B UMBRELLA LIAB X OCCUR SISCCCL00011111 3/10/2011 03/10/2012 EACHOCCURRENCE 110000000
EXCESS LIAB CLAIMS-MADE AGGREGATE $10000,000
DEDUCTIBLE
$
RETENTION $
A WORKERS COMPENSATION WC7Z11259713011 3/10/2011 03/10/201 WC STATU- OTH-
ANY
AND EMPLOYERS'LIABILITY YIN Ll ER
OFFICERIMEMBER EXCLUDED?ECUTIVEF_N] NIA E.L.EACH ACCIDENT $1,000,000
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS be. E.L.DISEASE-POLICY LIMIT 1$1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required)
Blanket Additional Insured and Waiver of Subrogation in favor of; Lessor of Premise, Lessor of Leased
Equipment, and Blanket Additional Insured and Waiver of Subrogation -Person or Organization where required.
(See Attached Descriptions)
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Proof of Insurance ACCORDANCE WITH THE POLICY PROVISIONS.
96 Swampscott Road
Salem, MA 01970 AUTHORIZED REPRESENTATIVE TH,
01988-2009 ACORD CORPORATION.All rights reserved.
ACORD 25(2009/09) 1 of 2 The ACORD name and logo are registered marks of ACORD
#S506636/M506610 WR001