78 LEAVITT - BUILDING INSPECTION 71
The Commonwealth of Massachuset -- -..
y Department of Public Safety
` ! '• � \hu>dchu+rlls titatr lluilding Code(7R111,\IR)
1� Building Permit Application for any Building other than a One-or artily Dwelling
(Ihis svdion For Offir ial use C'inh•)
IIuilJiug l'crmit No miter. Date Applied: --_-_-_ Building Official:
SICI ION 1: LOCATION(Please indicate shuck 0 and Lut s fur locations for which a street address is not,
S(e tA` - - - 0 -�f70 - CCc✓e oct�TG to7
— - -
�Gt. and tilrrrt C14 /town /ill Code Nance of I1rulJntg(if applita(de)
SEC HON 2:PROPOSED WORK
F.diliun nl .MA stalk.Code u+ed - . .__ It;Very Construction thctk here Igor check ell that apply in Ilse two row+bolnw --
F\isling Building;❑ Rvimir❑ :\Itcnllion ❑ Addition❑ Ucw 11ition ❑ (Picric lilt"td,uld Submit.\Ppendix 1)
Ch.utgc of Use ❑ Ch,utge of Oetup,utty ❑ Other ❑ y:Specif
:Are budding plans and/ortxntsirtuliun d,ttunlellls being Supplied,vi part of this permit application? Yes A& No, CO] --
Is an 6tdependent Slntcht cal Engineering Peer Review required? Yes No ❑
Brivt Destriptiun of Proposed Work:._-.-- Alok 5 To Ire 4 �/ d t
SECTION J:COMPLE"rE THIS SEC PION IF EXISTING BUILDING UNDERGOING RENOVATION,,1UUl'1'ION,(lit
CHANGE IN USE OR OCCUPANCY
Chetk hew•if an Exisling Building Utvestigation and Evaluation is enclosed (See 780 C\IR.4) ❑
Exisling Use Gnwp(s): Proposed Use Gruup(s$_._______ ._.___
SEC'r10N J: BUILDING IIEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(indu do basement ic%v1s)R Area Per Fluor(Sq. ft.)
total Area(sq. ft)and rutal Height(ft.)
SFCFION 5: USE GROUP(Check asa licable)
A: Assembly:\-1 ❑ A.2❑ Nightclub ❑ :\.1 ❑ :\-f ❑ :\-i❑ 0: Business ❑ E: Educational ❑
F. Fadu F-I ❑ F2❑ I Ili h Hazard If-I ❑ H-2❑ I1.% ❑ 11-4❑ I1-i❑
1: btstitutiunil 1-I ❑ 1.2❑ I-t❑ 1-I❑ ,%I: \fercan tile❑ It: Residential R-10 R-2❑ It-t❑ R-a ❑
S: .Slurage SI ❑ ti•?❑ U: Utility❑ Special Use❑,nod please Jest ribe helow:
Spatial Use
SECTION 6:CONSTRUCrION IYI'F. (Check asa licable)
Lit ❑ IB ❑ II:\ ❑ IIB ❑ MA ❑ 1111i3 IV ❑ VAa \'ll ❑
_-_-__ SEC"r ION 7:Srl'E I.Vf0 Rm,itTION(refer to 7,41)C.\(It I1 Lo fur details on each item)
W.�ler Supply: 19uoJ Lune Infinntatiun: Sewage Uisposa{; rmnth Ferric I)cbris Iteuurval: ----
Public❑ C hock t ou Btdc I local /one❑ Indit,ne tnmtitipal❑ A Ircnth will not he Liteuw�d I\i+povol<in•❑
I'mme13 or indvnlih' /tint or,m +tic+t+lvltt ❑ n•quin'd ❑nr ln•nth nr.prtdt- .
-_- prnnd i+ontlosr'I❑
Itailntad right-uf-way: i 1 I.Vardi tu.\ir.\'.i% galiun:
\ot .\pgdtr.&K.L7 Is'-tnt,ntrrurthin.nrptnl,ypm.nh •�rt','' I+Ihrtr rratrt, „,nq,IrlrJ'
"I t ,v.ont b, IludJ rn,lo.rJ❑ ( 1v, 0 „r.\'o❑ L,C] \n ❑ I
ti1 1. 1 WN 3:CON IINT()F( hlt l 11 -
r I ,I,h,-u,a
It,r. Ihr budJ,ng•„ nl.utt.m�pmn.(Irr tit.Irm' <1,r,,,tl ' Iq•ul.tnon,
-- SIA I[ON 9: 1%0111'it I OWNFR:\U-IIIOIt IZA,I ION
-- --- —
uuc uul \+Id 1n ss nl I n�{n/r^ly lawn r , / 1 /� Q ` `,
Cove yL-c-II . c — ._CIA_\Evu -\ (�-._ __.... __._ /q..7/i
_.... _ _ Lip
-.. Nn and Strcl City/ fawn
N,unr(Print) .
I'mperty Owncr Con Lail Inlormatitm: -- —� ._._ .____.___
'a_ G l`l .i_ _ IZS T WY �t722
eL _._. r-mail address
title releplunte Nu. (business) telephone Nu. (Cell)
II apl+l iiablr, tin properly owner hrrcbV authorizes
Street Adtlr•ss _City/Town State - Zip
Name
to ait In pe I'll the pro rt owner's bt'half• in Al malh•rs rvlativc to work au Ihorized by this buildin iermit a p tlicaliun.
SECTION 10:CONS'I MUCF1ON CONTROL(Please fill out Appendix 2)
If builJin•is It's.+than 1i.ntAl cu.ft of endosa•d c race,u+J or not unJer Cunstmction Control then check here Q,utd vki Srdion 10 1
I0.1 Registered Professional Responsible for Construction Control
P
Nome(Registrant) hone'cic No. a-moil address Registnnion Number
-- 1
"---- Cif Stele Zip Discipline Espimtion Date
9trect Address y/town
10.2 General Contractor p
U Nome of 1'cr."son Responsible fur Construction License No. aml Type if Applicable
Street Address �yJ�"CJ-'q-, i(, ig /�/4N / +a P
?zi t-3 ? Za-1 S 7- bJ11ct�r� 446Q
rvlr phone No. business -rcic+hone No. Cell a-..tail address
SECTION 11: apt R'J K, + r'Mu'l v.t t p+� tx u:.\.M 1 .0 1 B I,',vi I M.C.L.e. 151 25C 0
A Workers'Coot pens.utiun Ittln mnce.\fftdav it from the MA Department of Industrial Acc idenEs must be completed and
subniiiwd 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 a Bunion? Yes❑ No ❑
SECFION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor ,
Item Mid :Materials) total Construction Cost(from Item 6) .
S_._---_—
1. Build in S Building Permit Fee 'Total Construction Cost s_(Insert here
'. Fleelrical S appropriate municipal factor) 5
t. Plumbing; 5 "Intact nttuaici polity
Note', \lininnun (ee' S___( l )
\ 7. \Ice hanii al Olht'r) S Eni lox ihcik jm.vable it. —
///4,\ rip. I*„pal Cost (cnntacl muniiipalihy end write i heck member here
SECr1ON IJ:SIGNAI UIIE OF BUILDING PERMi"r APPLICAN-r
14v rnh•riny, my 11.umc hrloty, 1 hery I,v attest under tilt' pains.utd pvmltics of perjur}' that Al of the inlunu,tlion i,ntLn nrJ in Ibis
epidicatiun is true and.111 Lmde it,the best of nay know Icdgt'and uuder'Lmd iny,.
__ - - lilt' Irlcphone Xo lamr
I'Ir.isr poor on,l ��t;u nomr
. �In,l \J,Irrss
City, I,m❑ titate /Ip
\luniiip.tl Inspeclur to fill out this .e tion upon .application approval:
�' IIIlk' _
1
JUL-16-2012 12:52 SMITHWICK & MARINERS 207 781 5571 P.02
VDAC
TRAVELERS J� WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (7PJU6-027ON26-0-12)
RENEWAL OF (7PJU6-027ON26-0-11 )
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
1.
NCCI CO CODE: 13579
INSURED: PRODUCER:
PALMERS COVE YACHT CLUB INC SMITHWICK & MARINERS INS -
74 LEAVITT ST - 366 U S ROUTE
SALEM MA 01970 FALMOUTH ME 0 05
AN
Insured is A CORPORATION
Other work places and identification numbers are shown In the schedule(s) attached.
2. The policy period is from 03-20-12 to 03-20-1 3 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
m=
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A- The limits of our liability under Part Two are:
a�
Bodily Injury by Accident: $ 500000 Each Accident
Bodily Injury by Disease: S 500000 Policy Limit
Bodily Injury by Disease: $ 500000 Each Employee
a.
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
c -
c D. This policy includes these endorsements hedules:
SEE LISTING OF ENDORSEMENTS - E O NFO PAGE
4. The premium for this policy will be determined by our Manuals*'Rules, Classifications. Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 03-12`12 WC S7 ASSIGN: MA
OFFICE: DIRECT ASSIGNMENT 701
PRODUCER: SMITHWICK & MARINERS INS 28JYL
...... ---.. . ... - TOTAL P.02
��. C['[•YOE S.�LE.1 [, Akss.1CHusErrs
.. BUILDING DEPART>lis—sr
If
120 WASHLNGTON "' FLOOR STREET, }
TEL (978) 745.9595
F.V((97,9) 7{0-9846
�l�l[JE'LEY DRISCOLL
AA YO Z Monti ST.PIE-Us
DIRECTCR OF PCdLIC PROPERTY/RI:R-DINC,COJL%IMIONER
1Vorkers' Compensation rnsurance Affidavit: Builders/Contractorv/Electrlcians/Plumbers
\nnlleant information Cleme Print Len'ihrr
Nam,:Iliusi'v,ol7rgamraliun Indiridu•dl: POA VvL e \^ Cove YA C 4\T C 1 L,6
ddress: e a v t 11 S T
CitylStatc/Zip: Sit\ e FrA. N: "4 l 8 `1 4 4 S 12.2-
'fire you an employer'!Check the appropriate bolt 'rype of prnJect(required):
I.0 I un a employer with 4, ❑ I am a general contractor and 1
anlpinyces(rail and/o art-urine have hired the sub-contractors d• ®Now construction
2.❑ I am a sole proprietor or partner• listed off the uttaehed.�heet t I. ❑Remodeling
.hip and have no employees The"subcontractors have I. C]Demolition
working for me in any capacity, workers'comp,insurance. g. Building addition
[,No workers'comp. insurance 3. ❑ We us a cnrpnrarion and its
rctluired.1 ofncers have axamised their 10-C]Electrical n:psirs or additions
J. lain a homeowner doing all work right of exemplion per MGL I I.C]Plumbing repairs or additions
myself.(No workers'sump. C. 152,,)1(4),and we have no 12.0 Roof rupairs
insurancdrequired.it vmpluyees. (No workers' t),[]Olher
cum p.insurance mquin d.)
-.I,uy appll.:ua nor ch.vk,bait At owl also all uul b,weliuo balaw ahawing chair"it,*.campanwdun puhoy in0'rmanon.
'I1. nVuW'v,a who ruhmil this Undavil indiatllna'hry are doing all kwre and than him oauide Collins,"mml mhmll a new atndavil indlolins.aah.
C�mn,oWn Thal,lawk'hla box mwi jawhod an addator W.heal,hu W as Ile nano af'he ru?aunlncWn and'halt W eAdn•wmp•policy Informadaa.
I urn art rmpluyrr/hubs pruvfdhlX Ivorkus'cumpeurodun huurancefar my ernpluydex Below/a Ju pollry undJub she
informarinn,
Imur:mca Company .Name:
Oa 70 �,O
I'uliey J ar Selr-ins, "L/is d: U 7 g�(l (1- i rli Expiration Data:i'�-dbL-l-tL�
/ub5ila.WJrcxs:�'-1 �GY]\I% tt Si[Q ± CityiState/2ip:La(arn MRn1970
\ttueb a copy of the ttorkers' compensation policy daclarallara poke(Ihowlne the pulley number and aspiration data).
F'.lilure to,ecury vuvera,a us required under Rcclian 21.\of MGL e. 152 can lead to the irrlposilion of criminal penalties of a
fire mp to S 1,SCd.0f)and/ur one-year imprisn"f as well as civil pcnahias in the form of a STOP WORK ORDER and a lima of till to 52 d0-I:0 a day boost Ilse violamr. Ile advised that u copy ur'Ihis,latement may be furwurdvd to Iha OI'tiva of
I.n'c,I i gal iuos„I o1v nb\ Il)r IOturanee en vpmyC Verl liviliun.
/du/rrrrby verr,)y under the puiru mrd ptnu/rlr.r"fgerjury r/rur r/le iuJ'uralullon provided ubava is b9l,I0,j carrree
—t
U.I rv:
011h,vin.e.mly. 17,1"of ,rita,in 1/1ra:1rea, ro�d cumplar Sy city ur mrvn.,/J)riu[
City or I'o,rn• ,
I. !,oanl of Ilcuhh d. Iln Hdlm� Depth ln'cul I. 1 icy,'runn Clerk I. Iil.etric.11 fn,pccb'r i. PlnmDin;; In,pxncr
6. t)II'af
l.nnlait i'r non: I hone It
CITY UE S,l[.E, i ti . ,
, �tiL155.1CH(,SETTS
3LMDLNC DEP.1mms r
I'O TUHNGTON SrXW, }'4 FLOOAt
K11®F Rt gy ORlSCOLL FkX(973) 74&994
.tiL1Y0l! rROS4u ST.Pm"A
01"cro4 OP PL atic PROP msel at:QpLNC cO.%Ltrtss,ON Eft
Construction Debris Disposal At'fidavit
(required for ill demolition and renovation work)
In sccardance with the.sixth edition of the Stats
Debris and the p
Building Cade, 780 C��iR section 111.1
throvisions of MCL a 40, S J4;
Building Permit AI is issued with the condition that the debris resulting from
I 11, S 1 JOA.
this work shall be disposed of in a properly licemed waste disposal facility as defined by,%,IGL c
The debris will be transported by:
Ala c-T 4 Sc d e
C4�r
(n,+me ut'hauler)
The debris will be disposed of in :
(iddreu or r riL�y)
C%
� °rn�n+ren(permit i .� .
pplic�nt