40 LEGGS HILL RD - BUILDING INSPECTION (4) rE5 -iq-$ zi i
The Commonwealth of Massachusetts
O•• bo�3 _ ((__ Department of Public Safety
V Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or T 1 y In
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building ieial
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a s a ress is not available)
40 1.M5 A-11 Rd MA61tl &A hk OALis (n]h of U01-} 56fit
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❑ Alteration ❑ Addition Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other X Specify: c4tn-o- -
Are building plans and/or construction documents being supplied as part of this permit application? Yes 1< No ❑
Is an Independent Structural Engineering Peer Review req Yes ❑ No ❑
Brief Description of Proposed Work: '-'t;1�? uired?o �- l - Ortt W:\k
�g-i1O�ie P-0 terl� SSCc A 6u \\ be- an {one &(4 � d64 r we,
I.l:kk bA mct i4 vC 44. tl dY6rpon?oS,�6R k"6erjS 645 5C(A}nn9
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.) I p oq (0� a ® do
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ 1-2❑ 1-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
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 ❑ 1 IIIA ❑ IIIB ❑ IV ❑ VA 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❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ 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:
�( S E—W C JQ l t,-t___ dA
A Smith �1
Business Development Manager- Groom
smit m ccnsbvn
11,617,817.1541 _J
Tel 781.592.592.31353135
Fax 781.593.1480
www.groomco.com
j www.groomenergy.com
III 96 Swampscott Road
Salem,MA 01970 build green
Better Building Through Better Thinking
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
EX4e O;foc 7Q i _Iqo _7ca h;3th(ockS��r3kKMreyrvta r
Title 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 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 10.1
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
Company Name
'_LbmnS Groan^ ? G O 3-7 4
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
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Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'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? Yes❑ No ❑
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building go,G p p
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 $ (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.
-Thymnc 791 . 542. ilk
PP/�llease[print
,and
sign name Title M Telephone No. Date
-1 G j,aw&o4-?A Sotltw. Ink O Q 0
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: o 2 /
Name Date
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen isor
License: CS-040379
,Il\
THOMAS GROOr_W
96SWAMPSCOTTRD _
Salem MA 019707 "
" W Expiration
Commissioner 04/1 912 01 5
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organizadooilndividuaq: Groom Construction Co. , Inc.
Address: 96 Swampscott Road
Salem, MA 781 -592-3135
City/State/Zip: . Phone.#:
Are you an employer?Check the appropriate box: Type of project(required):
1.[3 I am a employer with 7 5 4. ❑ I am a general contractor and I 6. ®New construction
employees(full and/or part-time)■ have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
(No workers'comp.insurance comp.insurance.
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 1 1.❑Plumbing repairs or additions
myself.(No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance deg]t c. 152,§1(4),and we have no
employees.(No workers' I3.❑Other
comp.insurance required.]
'Any applicant that checks box N must aim fill out the section below showing their woriras'conVonsation policy inforination.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lcontractors that check this box must attached an additional sheet showing ttw name of the rubconnctors and state whether or not those entities have
employees. If the subcontractors have ariployces,they must provide their workas'comp.policy number. - .lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site j
Information.
Insurance Company Name: Zurich" American Insurance Co.
i
Policy#of Self-ins.Lic.#: .5821749 Expiration Dg t e: 3—1 0—1 5 I
Job Site Address: City/State/Zip:
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 i
fine tip to$1,500.00 and/or one=year imprisonment,as wetl 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 coverage'verification j
I do hereby certify under thepains and penakfes of perjury that the information provided above,is true and correct
Signature, Date,
Phone C
i
F
onlyr Do not wrUe tittr area,to a eampleled y city or town official
n: Permit/License#
hority(circle one):
Health 2.Building Department 3.City/fown Clerk 4.Electrical Inspector 5.Plumbing Inspector
rson: Phone#:
Client#:237796 GROOMCONST
ACORD, CERTIFICATE OF LIABILITY INSURANCEATE(MD/Y
O3/14/204014yyy)
/14/
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 poliey(les)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 RTACT
NAME: Certificate Desk
HUB International New England PHONE g78 657.5100 FAX 866-475-7959
A/C No Ext: A/C No
299 Ballarcivale St EMAIL
Wilmington, MA 01887 ADDRESS: nee.certificates@hubinternational.com
INSURER(S)AFFORDING COVERAGE NAIC If
978 657-5100 INSURER A:Zurich American Insurance Co
INSURED Groom Construction Co., Inc. INSURER B:Colony Insurance Company
96 Swampscott Road,Suite 6 INSURERC:Navigators.Specialty Insurance
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 CONTRACTOR 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,
LTHR TYPE OFINSURANCE ADDLSUBF POLICY EFF POLICY EXP
POLICY NUMBER MM/DDNYV MWDDNYY LIMITS
A I GENERAL LIABILITY GLOS821748 3/10/2014 03/10/2016 EpAqCry1Hq GOECCTURRENCE $1 OOO ODO
X COMMERCIAL GENERAL LIABILITY _ PREM SES RENTED
5 Ea occurrence 000,000
CLAIMS-MADE ly OCCUR MED EXP(My one person) $1 O 000
PERSONAL&ADV INJURY $1 000000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: .PRODUCTS-COMP/OP AGG $2,000,000
POLICY FXJ PRO- 7 LOC $
A AUTOMOSILELIABILITY BAP5821747 3/10/2014 03/10/201 COMBINED SINGLE LIMIT 1,000,000
Ea accident
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident $
AUTOS AUTOS )
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS Per accidem
B UMBRELLA LIAR X OCCUR AR3461192 3/10/2014 03/10/2015 EACH OCCURRENCE $5 000 000
C X EXCESS LIAR I CLAIMS-MADE NYI 4EXC724671 IV 3/10/2014 03/1012015 AGGREGATE $5 OOO 000
OEO I I RETENTIONS $
A WORKERS COMPENSATION 5821749 3/10/2014 03/10/2015 X WC STATU- orH-
AND EMPLOYERS'LIABILITY TORY LIMIT
ANY PROPRIETOR/PARTNEWEXECUTIVE Y/N OFFICEWMEMBER EXCLUDED? ERI N/A Item 3A: MA,MN, E.L.EACH ACCIDENT $BOO OOO
(Mandatory In NH) FL,NC,WV E.L.DISEASE-EA EMPLOYEE $BOO OOIf yes,descrbe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000
A Equipment CPP5821734 3/10/2014 03/10/201 $150,000 max item
Leased/Rented $700,000 total limit
$2 500 deductible
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ANach 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
by written contract,all as respects Auto, Liability and Excess Liability.Waiver of Subrogation included
as respects Workers Compensation/Employers Liability. Policy forms available upon request.
CERTIFICATE HOLDER CANCELLATION
Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Groom Construction ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
O 1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S1097085/M1095991 DKO04