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40 LEGGS HILL RD - 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 o- m'ly el ' g hi-s Section For,Official Use Onl .,,.Cl Y) Building�Permit Number: Date Applied , ',Building Official: SECTION 1:LOCATION.(Please.indicate Block.#and Lot#for locations for which a stre,: m is not available) 'r 4/0 I -0 , ' No.and Street City/Town Zip Code 04Name of Buildi4(' 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❑ Repair❑ 1 Alteration ❑ Addition Demolition Cl (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other KSpecify: Ow 501 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*_� Brief Description of Proposed Work: nv SECTION 3:COMPLETETHIS�SECTION IF EXISTING.BUILDING.UNDERGOING RENOVATION;ADDITION,OR CHANGE IN USE OR OCCUPANCY . " Check here if an Existing Building Investigation and Evaluation is enclosed(See780 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'asapplicable)r� A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business' ❑ - - Ei Educational ❑ F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-S❑ I: Institutional [-1 I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 - R-2 ElR-3❑ R-4❑ S: Storage S-1 S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: ' (ChSECTION 6:CONSTRUCTION-TYPEeck as applicable) .i IA ❑ IB ❑ HK ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7.SITE INFORMATION (refer to-780 CMR 111.0 for details on each item) w":''.. • ' ' 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❑ Private❑ or indentify Zone: or on site system❑ required❑ or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: NIA Historic Cormnission Review Prue ess: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes O or No❑ Yes❑ No ❑ t . . 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: o � G �`: $ ' <;'° „ ,,, °: ,SECTIO15'9' PROPE[tTYOWNERAUTI-IORIZATION „ ;, ; Name and Address of Property Owner Nang—(Print) No.a Street City/Town Zips F. Pro erty Owner Contac Infor�ation: g I.�V� �,hat1 c�1,4C�1�-�- MCI-, Title :-..` '" '�� '- ,Telephone No. (business) Telephone No. (cell) e-mail ad ress [�✓ If ap2licable, the p erty owns hereby authorizes 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'CON_STRUCTION CONTROL(Please frll out Appendix 2) .y °: If b'uildin is less thane 35,000 cu.ft.of encloseB s• ace and jor not imdeG Co'nstruction.Cbiit<olaheri ctieck tieie d skip Section 10.1 - 10:1 Registered Professional Rest-msible for Construction Control^:�' Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline - - Expiration Date 16.2 General Contractor -`. :„'x . , • £ `<.e :�_ DA-lbto At-` R Company Name 2 Cc Name of Person R sponsible-for Cons License No. and Type if Applicable_ Inq- Street Address - - ' City/Town State Zip dM Telephone No. business Telephone No. cell e-mail acidress ..'SECTION 11:WORKERS`COMPENSATION INSURANCE AFFIDAVIT.. M.G1L 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 and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 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 $ E close check payable to 6.Total Cost $ (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. PJease print.gnd sign name T. le Telephone No. Date Str Address �,/ City/Town State Zip Municipal Inspector�to'fill out this.section upon application approval:, ' - ;i Name.' Date 1 ' SECTION Y.PROPERTY 04yNER AUTHORIZATION" ,•: - '_ . Name and Address of Property Owner - Nam (Print) No.aWStreet City/Town Zip Property Owner Contac Infor tiom / u al Title Telephone No.(business) Telephone No. (cell) a-mail ad Tess If apalicable,the proRerty own,r hereby authorizes Name Street Address City/Town State Zip to act on the prop owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10 CONSTRUCTION CONTROL(Please fill'out Appendix If buildui is'less than 35,000 cu fGo of enclosed s ate and(oi'notunder Construction Control:tlieii check tlei'e d ski-`:Section 10J -,10:1 Re 'sfered Professional Res-bnsible for Construction Control_ - -Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 Genial Contractor, " ... . . , - • Company Name - �d5 i Q�C i idr NnS Uo +Q1CS12C E� C'S Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip oc�1E 69 17,6A--L( 64 Cay'tcf !STAJ�U Telephone No. usiness Tel hone No. cell e-mail address e-mail address -`.SECTION 11 WORKERS,COMPENSATIOMIN ISUR aNCE AM- DAV IT M:G.L.c:15Z§t25C 6 t- 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 13 No O- SECTION 12 CONSTRUCTION COSTS AND PERMIT Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ -� Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ - appropriate municipal factor)_$ 3.Plumbing $ ..Mechanical (HVAC). _ __$ _ Note:Minimum fee=$ (contact municipality)_ - 5.Mechanical Other $- E close check payable to 6.Total Cost $ - (contact municipality)and write check number here SECTION 13.SIONATURB OF BUILDING PERMrr 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. Please print end sign name , T' e , Telephone No. Date �rv�c �pl Li��� � y�► 1{��c ��4 AZi,I� Ste- Address _ _ City/Town State Zip lnsMunicipal- pectorao'filI out this section upon applicahonapproval - , _.. .;" ,• ,'- Naine Date i CITY OF &UXIN1 'NLXSSACHLSETTS • BUILDING DEPARTMENT 130 WASHINGTON STREET,3m FLOOR �j TEL (978) 745-9595 FAX(978)740-9946 1u5IBFRT RY DRISCOLL THOMAS ST.PIERRE MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busin cis�OrganizatioNlndividual): fr_, Hr-� Address:/City/State/Zip: ��'SG6—cTI/AOt-�6-7 Phone if: 701 62) 607 Are you an employer?Check the appropriate box: Type of project(required): 1.04 am a employer with �2_ 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time)." have hired the sib-contractors 2. 1 am a sol eproprietor or artner- listed on the attached sheet.t �• Remodeling ❑ P ship and have no employees These sub-contractors have Il. 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 LEI Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12•❑ Roof repairs insurance required.)t employees. [No workers' 13.❑Otha� comp.insurance required.] •Any applicant dust checks box 81 must also fill out the section below showing their workpa'eompensad.policy infumsdon. *I loinutwoen who submit this affidavit indicating they are doing all work and then hire outside cusumcnom oust submit a now affidavit indicating such 'Contractors that check this box must anached an additional sheet showing the nume of the suboonract m and their worl.'comp.policy inforttedon. I um an employer that is providing workers'compensation insurance for my employees. Below Is the polley and jab site information. :� ,�I Insurance Company Name: '_ I� FG(�•t (�f Policy 4 or Self-ins.Lic.H: -4� 7 tJ-+�' ti� L+ �✓`— Expiration Date: Job Site Address: `Lt�•C3�tSI 't({t j City/StatetZip:5"^1 r14 a t YO 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 S1,500.00 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. l do hereby certify under tthe pains and penalties of perjury that the information provided above Is true and correct Si1.3ttre• �-`�C Date: Phone M Official use only. Do not write in this area,to be completed by city or town oJrciat City or Town: Permit/License# Issuing Authority(circle one): I.Board of 1leallh 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 1 RightFax C2-2 6/26/2012 6: 21 : 43 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MI619nig YY) TWAIZERTIFICATE 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(iss)must be endorsed. If SUBROGATION IS WANED,subject to he terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to he certificate holder in lieu of such endorsemen s . PRODUCER CONTACT NAME: PHONE —VAX THOMAS GREGORY ASSOC INS (A/C,No,Eid: 401 EDGEWATER DR EMO PRODUCER WAKEFIELD,MA 01880 CUSTOMERII #: 73DJJ INSUREMS)AFFORDING COVERAGE NAIC# INSURER A: TRAVELERS INDEMNITY CO_ INSURED DOW,ETHAN DBA ETHAN DOW GENERAL CONTRACTING INSURER B: INSURER C: INSURER D: 95 ROCKLAND STREET INSURER E: SWAMPSCOTT,MA 01907 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: --THIS IS TO CERTIFY THAT THE POUCESOF INSURANCETED WHAVESEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREHENN T,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. LWTSSHOWNMAY HAVE BEEN REDUCED BY PAM CLAM. Nyy ADO SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLCY NUMBER (MMV]D1YYY'/) p,ILTDOtlYYYI LIMBS GENERAL LIABILITY ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE f7 OCCUR. EMISES(Ea occurrence) ED EXP(Any one person) $ RSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER-. ENERAL AGGREGATE $ POLICY C]PROJECT LOC RODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY 30MBINFD SINGLE $ ANY AUTO — — _ - - --'- - -- IMIT(Eaaccident) ALL OWNED AUTOS ODILY INJURY $ Per person) SCHEDULE AUTOS ODILY INJURY $ HIRED AUTOS Per accident) NON-OWNED AUTOS ROPERTYDAMAGE $ Per accident) UMBRELLA LIAR Ej OCCUR EACH OCCURRENCE $ REXCESSLIAB CLAIMS-MADE AGGREGATE $ $. DEDUCTIBLE $ r RETENTION $ A WORKERS COMPENSATION AND WC STATUTORY OTHER 05/18/2013 X EMPLOYER'S LIABILITY Y/N UB-58264199-12 05/18/2012 uMIIS ANY PROPERITORrPARTNEWEXECUTIVE E L.EACH ACCIDENT $ 100,000 OFF ERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 100,000;>A" (Mandatory in NHI If yes,describe under E.L.DISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONSILOCATIONSNERICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE, THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR DOW,ETHAN. }` ASSACHUSETTS,n" RC RS GCENSE r 1 rS39798864 y 05.29-2014 05-29-1 Iti M fuss nesr ssr C S 5-06 Ia i DOW 95 ROE' CKLANDI. 1 '" SWAMPSCOTf,MA �<.„,.�� 01907-2523 39'�k 11M Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supenisor 1 License: CS-066844 EIIIAN E DOW 95 RC CAAND Si if SWAMPSCOTTMA 0190Y % 'Expiration - Commissioner 05/29/2015 \ J . � - .V/rc`�pnariuurrcnnrzl/�nfC�/��aU:rzr.�rrlr-!t - Office of Consumer Affairs&Business Regulation , ME IMPROVEMENT CONTRACTOR. e9istration 132456 Type: xpiration 2l8/2015 DBA ETHAN DOW GENERALGONTRQCTING ETHAN DOW .- 95 ROCKLAND ST. � SWAMPSCOTT,MA 01907 .Undersecretary y BMS 8700 FRONT VIEW rA TOTAL VOLUME Interior: 378.3 cu ft TAM . Exterior: 416.9 cu ft HEIGHT SQUARE FOOTAGE O Interior: 52.3 sq ft ODP OR Exterior. 55.9 sq ft m �I � DOOR OPBdWG 1 1JALLTOW ALL -►� OUTSIDE DIMI- g- ROOF T ROOF OIRSIDID E Dlfvt c . - Y 7-1 3/4" ROOF DEPTH BMS 8700 SIDE VIEW 6-11 1/P' EXTERIOR WALL DEPTH We EXTERIOR FLOOR DEPTH BMS 8700 TOP VIEW o 0 0 ]'9 INSIDE W OTH O O O s-s- � WSIDE DEPTH ' 4 BMS 8700 A SECTION VIEW INS A�— Q ® ®g O Y o s`4 1/2' NSIDE ROOT O < 6-1)IT PEAK INSIDE WALL O HEIGHT � O + �I � O0 o. 980 SECTION A-A SCALE 1:20