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17 LEAVITT ST - BUILDING INSPECTION (3)
f 0-7 -4f7b The Commonwealth of Massachusetts o f j Department of Public Safety Nlassachusetts 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) It , Building Permit Number: Date Applied: Building Official: - SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a s et address is not available /7 / Ail 7r S4 S" b.-Ptl mA 0/57d No.and Street City/Town Zip Code Name of)h4javg(if applicable) SECTION 2:PROPOSED WORK. Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use. ❑ Change of Occupancy ❑ Other 9 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes 9 No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No a Brief Description of Proposed Work: 9�eane) eKisTong 2.—cTcrfv oeGc ANQ CrMS—rcUc7r "ew � cTo2� Qrccic nN (=x�.e� S�F1rv.� —oTP2S/�1`T SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if in Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): K& Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) 3 '— Total Area(sq. ft.)and Total Height(ft.) S`/O 1 27 SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-s❑ B: Business ❑ E: Educational ❑ F: Facto F-L❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ FI-4❑ H-5❑ 1: Institutional I-L ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R=1❑ S: Storage S-1 ❑ S-2 Cl U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCrION TYPE(Check as applicable) IA ❑ IB ❑' IIA ❑ L ❑B ❑ ILIA ❑ 1110 ❑ I IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit: Debris Removal: Water Supply: .Flood Zone Information: Sewage Disposal: Licensed Disposal il Site El ❑ Check if outside Flond Zone❑ Indicate municipal❑ A trench will not be P s required❑or trench or specify: Private❑ or indentify Zone or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazuds to Air Navigation: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ 01 1 Yes❑ No ❑ . SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Flour: Does the building contain an Sprinkler System?: Special Stipulations: a r SECTION 9: PROPERTY OWNER AUTHORIZATION Namni and Addre roper ty Ownr 1-7L-e U IT s1 Sfi�B Sin vh A o1S7d Nnm hr No,and Street City/Town Zip Proper n, on tact lnformationq??_-N/-3g2;7 s,c sly_- - �78-- 968'8-/90 iYUnW, ell 6S3dMEQ c� , Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes SaHnf QAr/T19PR5 Dc . (a0x yoras— Pc,�t3�o�� vn,g o/SG/ 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 O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control -:3;HN PANT19985 57063 Name(Re�istmnt) Telephone No. e-mail address Registration Number yo7 � ax ILL, sl . QEA3oo4 pAA o%q&o i,tv V"_reacA Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name JoWV OAW APAF Name of Person Responsible for Construction License No. and Type if Applicable y 07 1 owL'LC, 51 t'c-�fl(30d-/ , yh f9- O) C1,6 b Street Address City/Town State Zip `L79-"�O 7AOf D!--Y01. 7kUISQ,lr AQI)y0- IAtTVn 1 Telephone No. business Telephone No. cell e-mail address SECTION 11:t-V0RSEIZ9'Conil'L:NSYI[ON INSURANCE,AGPIDAVCC 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 ❑ SECTION 12:,CONSTRUCTION COSTS AND PERMIT FEE ' Rem Estimated Costs:(Labor and Materials) 'Corot Construction Cost(from Item 6)_$ 1. Building - $ Od Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ — appropriate municipal factor)_$ 3. Plumbing $ d. Mechanical (HVAC) $ = Note: Minimum fee=$ (contact, ricipality) 5. Mechanical Other $ Enclose check payable to I 6.Total Cost $ ' $Od g (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 be t of y kno led e and understanding. ,Tohry gf�r1Tow � �G . --L?1-1, /3 Please print and sign name Title Telephone No. Date _i07 vviA oiSGa Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date CITY OF SUENI, AyLkSSACHUSETTS r BulLDING DEPART\ff—NT c ft• 120 %VASHLNGTON STREET, 3"O FLOOR s�,aJ TEL (978) 745-9595 FAx(978) 730-9W KI\fBERLF-Y DRISCOLL Vf iYOR THOh1As ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Elect ricians/Pfumbers Applicant Information Please Print Legibly Name (13usine>sOrgani7atioMndivi(Iua1): .1 df{ Address: ,rj , 9,oX Honor City/State/Zip:PEA&UQ�I , t/trtf4 O1gGl Phone #: Are you an employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors 2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. CgRemodeling ship and have no employees These subcontractors have 8. f01 Demolition working for me in any capacity* workers' comp. insurance. 9, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. [No workers' cutup. c. 152, §1(4),and we have no 12,❑ Roof repairs insurance required.]1 employees. [No workers' 13.0 Other comp. insurance required.) •Any applicant dui checks box 01 must also 611 out the action W,ow showing their workers'compens,iun policy inhumation. '11,.cowsxrs who submit this A iclavit indicating they am doing all work and then hire outside contractors must submit anew affidavit indicating such. $ClnitWon that ch n:k ibis box must anached an additional sheet showing pie nmne of the subwontnctorx and their workers'cutup,policy infatuation. /am an employer that is providing workers'c•umpensadon insurance for my employees. Below is the policy turd Job site information. Insurance Company Name: Policy 4 or Self-ins. Lic. ii: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGf.c. 152 can lead to the imposition of criminal penalties of a tine 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 I nvestigutions of the DIA for insurance coverage verification. i do,hereby e•erit un er the pal s and renulties of perjary that the information provided above is true and correct. Sim t nc' Q G Date: Phone tt: l70 —yG�— 7,2O/ . 0f]hial use only. Do not write in this area,to be completed by city or town oJJic'lal a} City orTuwn: . _...._._._..__ PermitfUcense# Issuing Authurily(circle one): t. Board of licalth 2. Building Beparnncnt 3.C'ityfrown Clerk 4. Electrical inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: [ CITY OF S�UENf, %WszS m!USETI'S t' BI:ILDI.\G DEP.IRTJLENT r - 120 WASHLNGTON STREET, 3'FLOOR "= TEL (978) 745-9595 KI\BERT EY DRISCOLL FAX(978) 740-9846 tiL.1YOR THo.%w ST.PLERRH DIRECTOR OF PUBLIC PROPERTY/BCILDLIIG COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of tNIGL c 40, S 54; Building Permit # is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by tNIGL c t It, S 150A. The debris will be transported by: yP(;vnla •Thvc.,k (name of hauler) The debris will be disposed of in _PAR.U��iZ_�Ns`�F 2_TwT;ur., (name of facility) JaJ� csT c-lRe PT (address of facility) oV signature of permit app icon[ --Z 2�kJX3 date Jchn,aiYl.,c 7 ® DATE(MM/DDIYYYY) ACORO CERTIFICATE OF LIABILITY INSURANCE 12/11/2013 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 Linda Gallant NAME: FAX EA Stevens Company, Inc. PHONE Far. (781)322_2324 CNol(781)397-7672 369 Main St. AIL ADDRESS,lindag@eastevensins.com P. O. BOX 166 INSURERS AFFORDING COVERAGE "ICA Malden MA 02146 INSURERAAcadla Insurance Company INSURED INSURER B JOHN PANTAPAS INSURER C: PO BOX 4065 INSURER D: INSURER E: PEABODY MA 01961 1 INSURER F: COVERAGES CERTIFICATE NUMBERCL139304655 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 DDL SUBR POLICY EFF POLICY EXP LTR TYPEOFINSURANCE POLICY NUMBER MMIOpIYYYY MWD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 50,000 FXIOCCUR A5114194-10 /18/2013 /18/2014 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LS $ TCLAIMS-MADE AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY HIREDAUTO AUTOS (Per $ 8 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAS CLAIMS-MADE AGGREGATE $ DELI I RETENTION$ $ —TEWORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMSER EXCLUDED? NIA (Mandatory In NH) EL DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (AUach ACORD 101,Additional Remarks Schedule,if more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Miroslaw )Cantorosinski 17 Leavitt St. Salem, MA 01970 AUTHORIZED REPRESENTATIVE /+ Thomas Cares, Jr/LG 6`-_'Oa . ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. 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