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40 LEGGS HILL RD - BUILDING INSPECTION (3) �6 I The Commonwealth of Massachusetts Department of o Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Tvvmielli Fir (This Section For Official Use Only) Building Permit Number: Date Applied. Buflding fici. SECTION 1:LOCATION(Please indicate Block#and Lot-#for local. ns for w ich gfret&ddress is not available) L 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❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) `';Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No M Is an Independent Structural Engineering Peer Review required? Yes ❑ Nokl Brief Description of Proposed Work: 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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ I H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2❑ I-3❑ 14❑ 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 ❑ Ill IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item): ' Debris Removal:i h Pe rmit:ermt: Water Supply: Flood Zone Information: Sewage Disposal: Trench Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p required O or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: btt\I Iwlonc Cnmmi sion 1 0,w,,1 m-ess: Not Applicable❑ Is Structure within airport approach area? Is their:review completed? or Consent to Build enclosed ❑'% Yes 0 or No❑ 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: SECTION 9:,PROPERTY OWNER AUTHORIZATION- - Name and Address of Property Owner � L/O 1�B6S lJ/ �� p, YMCA Old ,T Ir Akal /� Slla?e/ ��a ion ,zr3/cE/d2lq Name(Print) No.and Street City/Town Zip ` „ P perry Owl qr Contact f formation: I�/[\ Title K'•7/-fL/, ` Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this Iwilding 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 101 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 C mpan Name t XG°a-n/a..vzi Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:4VOI'KFRS'CCNvIt hNSA[ION INSURANC f .4FFID,\VTf 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 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=$_I�(contttact Y• municipality) 5. Mechanical Other $ Enclose check payable able to Cr y OleAh4t l 6.Total Cost $ �Q.,D (contact municipality)and write chd7k n tber here SECTI N 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. PleaseleBse�infj me / i f�� r� Titl / Telephone ate Street Address " City/Town sf/�rwL'•y'"J-� !'Stt4atteFJr1--Ziipp(� Municipal Inspector to fill out this section upon application approval: Name Date "x ` s u i. r 1" .n y +1 '� ? e ksF��y'"Ya7'"'W""''`.`a°r ir•s` p as ,.,,; .g.d `^;.' "'" T, Ors CITY OF S.-1LLN , NIASS'ACHUSETTS '+ BL'ILOING.DEpAR'LStEVT a. 120 WASHINGTON STREET;r FLOOR TEL (978)745=9595. AkX(978)740-9846 KINMERLEY DRISCOLL i1TtiYOR' Timlib AS.ST.PiFRRB DIRECTOR OF PUBLIC PROPERTY/BUILDING CO.MISSIONER Workers' Compensation Insurance Affidavit: BuildersieontractovVElectricians7Plumb'ers A ifcnnt Information Plcase print Le 1bt GG» y�Nettle(Busitttss:Organiratiorulndividual): V ® v// . - Address: �m L "Q,6l City/State/Zip: Z � hone hl: 78�' 931 — g�2Z ,%re you an employer?Check the appropriate box: Typo of project(required): 1. I am a employer with+ 4. 0 1 am a general contractor ands 6. 0 New construction employees(iLll and/or part nine).• have hired the sub-conaactors 2.0 1 am a sole propnetor or partner listed on the attached shcet t ?• R, emodeling ship and have no employees •• These subcontractors have 8. 0 Demolition m working,for e in"y capacity.:. workers'comp insurance` 9, C]Builiiing addition (No workers co np:,insuranca S. 0 We are a corporation and.itm; -- required.]", officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homcuwner doing all work right of exemption per MOL 11.0 Plumbing relimirs or additions myself..(No workers'comp. c..152,§1(4j,and we have no ; 12.0 Rao m f ropamil suranceregwV,red- employees..(No Workers':, ' compAnsurancercquiicd.J' 13.�]Other` •Any appiicuu duo chimka beret trust also fill uullhe seattoo below showing their Watkins'compenurtun policy mlermattom.` !I hvneownera who submit this a idavh indleaing they ne doing all work and thco hum outside canuaetou must submit a new amdavil indicating such, Cuntractan that chack this box most attached an addiduwa shell showing me name ofthin sub ffiruton and Iho4'wurkes'comp:polity infotmadcn,. fain an empidyer that 1s provlJing worker'rompeeradon lnrurancejor m1.y emplayeet Below Is the policy gpdJob site 17 fsurance Company dame: w��Q V I-�•v�sv ljj(� /,fir,Q Policy 4 or Self-ins. Lic. N: Expiration Date:.. Tub Site Address: City/State/Zip: Attaeb 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 ofMGL`c 752 can lead to the impositiortofcriminal penalties of a tine up to S1,500.00 And/or one-year impri'sonmcn%as wellas civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be adviscd'that a copy of this statement may be forwardt;d.io the Office of Investigulions ul'the DIA for insurance coverageZX vcriti�atton. Ida hereby certify ruder thr puine and penugfer ofperfury that eke injornreNais provider/ubuve is true and cornet Sienttnre• Data' . pbnnc d: _. . F se only. Oo notwrite in this urea,to be completed by city ar town o flclaGwn' Permit/License 4 ulhorily(circle one): f health 2. Building Department 3.Cilyffown Clerk 4. Electrical Inspector 3. Plumbing Inspector erson: Phone 8: 1. . -. .. ..... . . ........_� ..._._......._.__ ._.. _., .. _..._.___ ._ _. _. .. . _...._ .. .__. . . . . CITY OF S41L.trti[, jt\,W wHUSETTS "� Bt:tLDLvc DEP.tR'I1tEDir 120 C((.131iLYGT0V S-MEEr, 3i°Ftcort TEL (978) 745-9595 ximoE4LEY DRISCOLL Ftic(�78) 7.10-934,5 N ckyoR TFl0SN3 Sr.P1EAU DMECTOIt OF PULIC PROPERTY/ELMDLNC CONNISSIGNER Construction Debris Disposal Alf7davit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Coda, 730 Cj%JR section I 11.5 Debris, mid the provisions of MOL a 40, S 54; Building Permit hi is issued with the condition that the debris resulting from this work shall be disposed of F-in a properly licensed waste disposal tactility as defined by 1tiICL e I 11, S ISOA. The debris will be tr wsportcd by: (nJI11C Urtl QlJtpO The debris will be disposed of in (manic or rulliry) i Pf llJnrfC nrpermit Jpplic.mt d 1( I /"'1 OP ID:5X C.A "MLX -GATE CERTIFICATE OF LIABILITY INSURANCE 06121113 .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 ORPRODUCER,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 endorsements . CONTACT PRODUCER .. 617-723-7775 '. 'NAME: Hays Companies 617423-5155 PHOO.No...Fr 133 Federal Street,2nd FloorADOREss E MAIL Boston,MA 02110 "PRODUCER YMCAO-1 _ Owen Callaghan cllsT4 ID - " _ MSURER(SI AFFORDING COVERAGE ,y__ NAICk INSURED YMCA of the North Shore _^ wsuneRA:New"Hampshire InsuranceCo. 23841 Diane Linehan "INSVRERe:New Hampshire Em Jloyers ins Co _ 23841 245 Cabot Street WsuRERc:National Union Fire Ins.Co. 19445 Beverly,MA O1915 _.. _._._. .. ._.....................:.._..�.-- _ INSURER D '.INSURER E:I-_ _.. ........ - .. 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 W.._. ADBLSD�.-........._._�__._._ ._-......_� e : .. ___ ..m.� PDLICY EF INTR TYPE OF INSURANCE POLICY NUMBER M/OOR'YYY MMIDDIYYYY _.LIMITS GENERAL LIABRITY EACH OCCURRENCE $ 1,000,00 bAMAOEYO'REYITEO-"" A X�COMMERCIAL GENERAL LIABILITY 01-LX-004258427-8: 12129N2 12129%3 PREM)SE�S Lea xwpenw $ 10000 CLAIMS-MADE lX OCCUR MED.EXP�Myone Persanj) SOD I. - _ - PERSONALBADVJNJ_URV—y(�5-- 1000,00 GENERAL AGGREGATE I$ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: f PRODUCTS COMP/OP AGO $ 2000,00 PRO- A I LOG $ POLICY I AUTOMOBILE LIABILITY ) I COMBINED SINGLE LIMB $ 1,000,000 A my AUTO I �01-MH-005123218-2 12129112 - 12129N3 $ (Ed acciden0 BODILY INJURY(P.,pereon) ALL OWNED AUTO$ -BODILY INJURY(P.,e.,denl). $ X SCHEDULED AUTOS I PROPERTY DAMAGE $ X HIRED AUTOS ( (Peracadmd) X'..NON-OWNEDAUTOS -----t$ X Physical Damage - 1$ X)UMBRELLA DAB I X JOCCUR EACH OCCURRENCE _ $ 10,000,000 EXCESS LAB ClA1MS-MADE AGGREGATE S 10 000,000 C --- 1`129-UD-004659306.8 L2I29N2 12129113 '- DEDUCTIBLE RETENTION $ I WORKER$COMPENSATION X WL$TATU i` -OTH AND EMPLOYERS'LIABILITY .. 9RYLIb1LT$_i.�.�.ELL.�..... _... B ANY PROPRIETORIPARTNER/EXECUTIVE YIN NIA IECC 4000620012013 01101H3 01101/14 EL EACH ACCIDENT $ ., , _ 500,00 OFFICERNEMBER EXCLUDED? (Mandatory in NH) EL.DISEASE EA EMPLOYEE'S mm500.00 If yea,describe under �_ _ DESCRIPTION OF OPERATIONS below - •- -- .. E,L.DISEASE-POLICY LIMIT $ 500.00 A Property 01-LX-004268427-8 12129/12 12129113 Blanket — 86,312.00 5,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (A ch ACORD 101,AdEleonal Remade SCMdule,K more space M required)' Evidence of insurance. - li "CERTIFICATE HOLDER'- .-CANCELLATION SHOULD ANY OFTHE'ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE; EXPIRATION DATE THEREOF, .NOTICE WILL BE DELIVERED IN City of Salem: ACCORDANCE WITH THE POLICY PROVISIONS- 120 Washington Street;3rd FI;. - Salem,MA 01970- AUTHORREDREPRESENTATIVE Owen Callaghan ©1988-2009'ACORD CORPORATION. All rights reserved. ACORD.25-(2009/09). The'ACORD;name and'logo are:registered marks ofACORD 1 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction supen'isor ` License. CS-052872 ROBERTAPANUfYZ10Vt - BEVERLY '-- 1 PINE RD - MA 01915 Expiration 01131/2015 commissioner ,�•.....^,,-.�___,,,.,-,,,.,.mum-.a.,�-�-.w...w..�-.-^^^^:."e....-- ..��_...: