72 LORING AVE - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
/ ff Department of Public Safety
��� V�1\➢Y/1 Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One or Two-Family Dwelling
(ThisPection For,Official Use Only) '„ _
BuildirigPenruPNumber., Date Applied ,- °.BuddtngOffrctalF••` `' ¢ '"�
SECTION 1:.LOCATION,(Plle�ase indicate Block.#and Loth#for locations for'which a.street.address is not available)
7 .2 7e/� AUZ• d197Fwt pf 77c, QgrylG,
No.and Street City/Town - Zip Code Name of Building(if applicable)
SECTION2: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 ❑ 1 Addition❑ 1 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
Is an Independent Structural Engineering Peer Review required? Yes ❑ N91-0
Brief Description of PrSoposed Work:
Z C..acir CO1JC/LO'Urc /1 2vN Tsre.i 21anire9_ 7- D.411€2t
SECTION 3:COMPLETE':THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,AD_DITION"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):
ix SECTION'4:'BUILDINGHEIGHT ANo 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) '' "
A: Assembly A-1'13 A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B% Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2 O H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ 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 fi:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB-❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION�7i SITE INFORMATION (refer to 780.,CMR:111.0 focdeta*Is 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 Connnission P.eview 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.00CUPANCY'
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
4';y.; e 4 , •a „' ;,,;, � SECTION;9: PROPERTY OWNER AUTHORIZATION'a ri', , • s r ,.�� , , _
Name and Address of Property Owner
Naive(Print) No.and Street City/Town Zip
Property Owner Contact Information:
OWAIGA 9 2f- /Y36 - -
Title Telephone No. (business) Telephone No. (cell) e-mail address
If pplicabl�e1the property owner hereby authorizes
M( LL. l.Jl�b m4lLD lSS (. P-L. Sr. ",t 01907
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.
a „, , , : SECTIO 10 CONSTRUCTION,CONTROL(Please frll out-Appendix 2) ,,,,,, , -
Ifbuildin is less than 35,000 cu.tt:of enclosed s ace and/or not under'Constructiou Control th6nrcheck here q`and ski Section 10.1
10A Re iste id Professional Responsible for Coins-truct on Control=°i .�i:'..,,�. . . , ':` '- "^ '•t '` -•`-
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 Generale:Contractor'":, t•. ,. ,..:d_l x, '
r///� Co
, bO ///'�P,ki AA l 0, s-TAyvc_r,yt•.+ W ` "•fry
Co/m�pany Name
( A-xw wltlle GS o6ly4 J
Name of Person Responsible for Construction License No. and Type if Applicable
/A RVALrt11" ST- 4 0 )5a
Street Address City/Town State Zip
Telephone No. business Telephone No. cell V e-mail address
:, SECTION 11:VVORKCRS".COMPENSATION INSURANCE AFFIDAVIT'M:G.L.c.152. , C 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 E
°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 $ Enclose check payable to
6.Total Cost $ 12-0v 0, n (contact municipality)and write check number here
SECTION 13:i 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 my knowledge and understanding. i
��vnn un-n � w�st uc�* ►— 7�I_�yL_ 3 �1 s P i
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section' upon application approval
Date Name-.
' I
,. CITY OF S,UzN,f, NLSSACHUSETTS
11� t Bt:(LDLYGDEP.IRTJLEYT
\ I A C ASULNGTON STREET V FLOOR
T EL (978) 745-9595
F.U((978) 7-W-93-S
KIJ[DE.4LEY DRISCOIl.
NLAYOR TXIOAU ST.PIEMS
MxECTOA OF PL auc PROPERTY/8t:11.DLN<;COSOn55tONEA
Construction Debris Disposal Aff7davit
(required for all demolition and renovation work)
In accordance with the sixth edition orthe State Building Code, 7s0 CNIR section l 11.5
Debris, and the provisions of I&ML c 40, S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal racility as defincd by bIGL c
l 11, S 150A.
The debris will be transported by:
612
(namc of hauler)
The debris will be disposed of in
(name of facility)
(Address of rigidity)
�W
signature of perm t Ipplicant
Mate --
i
i
Y
° CITY OF S:1LE,),I NLilSSACHUSETTS
aL' mwc;DEPAMLF.NT
120\V.1SNL;IGTON STREET, 3so FLOOR
•' TEL (978) 745-9595
`- FACC(973) 740.9844
(v3f3FRi FY DR)SCOLL osUSST.Pt&aR8
,MAYOR
DIRECTOR OF PUBLIC PROPERTY/OIaIDNG COS06IISSIONER
' Coin en ation insurance f Mdavit: Duildert/ContracturflElectr)cians/Plumbers
Aimlicant informatinn Please Print Legibly
Nan10 I11usiness.Orytnpiiruiomindividual): CA o"
Address:_1 S Juwa uk 51 -
CitylStatcalp: Phone If:
Are you an employer?Check the appropriate boat 'type of project(required):
I. I am a umployer with I D 4. ❑ 1 am a general contractor and 1 6. ❑Now construction
°nlployees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner. listed on the attached.Sheet 1 7. ❑Remodeling
whip and have no employees These sub-contractars have il. Cl Demolition
working ter me in any capacity. workers'camp.insurance. 9, 0 Building addition
(No workers'comp,insurance 5. C] We are a corporation and its
required.)
oitkcn have exerolsed their 10.0 Electrical repairs or additions
J.C] 1 am a homeowner doing all work right of exemption per MGL I I.C]Plumbing repairs or udditions
myself.[No workers'cump. c. 152,y 1(4),and we have no 12.❑Roof repairs
insurance required.jt omployees.[No workers, IJ.�Other�ue c l�t4
comp.insurance requlmd.)
-Any opplk,wa duo,chucks boa at must also,lilt out the secliuo belowahaw(ng their w l a sl compsnudon pulley inji,mallam
'I1,, uuwmts who,ubmil this aindavit indicadny they am doing all work and then hire"164si antmYnera mint sahtnit a new ailldavit indicating such.
:Contractors that check this box must auachod an addtdutwt wheal showing the name of the IutrY•antrastan and their workers'cump.policy fnfamadon.
/urn an enrployar thuN.r provldln!<workers'romprnradorr fierurunee jar my amp/users: Below/s IAe Polley andtub site
injarenurlon.
Insurance Company Name: C-rhJo"C'"a J l�lt"'�L.C`
' n
Policy 9 or Self-itn. Lic. N: 1Zt/C t}L�/]j(.1 7�y' /Vl.l+ Expiration Data• /��,��// '
Job Site Address: 7 X Z of-joc 4yF- CilylStatr12ip: �✓IZ_M A i o)°eZ o
Attach a copy of the woriters'compensation policy declaratlen pugs(showing the policy numbor and expiration data).
Failure to sucuru coverage as required under Section 25A t)fMGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a find
of up to 5250.00 a Jay against the violator. Ile advised that a copy of thisstaremunt may be forwarded to the Oh ice of
Investiguliume ofilic DIA fur insurance covcrago wrificatiun
/da hereby typdfy under I alnr mad penuldes ufper/elry r/1af the Lejunnurlmr provide/d'/{bwe;at died correct
Sig_nature: � Data• J /�/�]
Phone rJ: !' • f —
i 011tr•iul use only. Ors not wrile in dill urro; !o be cuueplefed by city ur lawn ayJ/clud I
I
Ciryor'I'uwn: ., _ Permlt/i.lcense.4 i
Issulag Authurity (circle one): -- -_—
I. Iloard of livallh L Iluildlmg- Deparnnent I.Cityrfuwn Clerk 1. Electrical hupectur 5. Plumbing inspector
6.Other _ _ _
Contact I'rrsn is ... . . Phone iJ•
OP ID: LR
CERTIFICATE OF LIABILITY INSURANCE DATE 5112)
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 endorsements .
NT
PRODUCER 781-935.8480 NAMEACT
PHONE
DeSanctis Insurance Agcy,Inc. 781-933-5645 (" Na Es : Fax
ac Nor,
100 Unicorn Park Drive E-MAIL
ADDRESS:
Woburn, MA 01801 PRODUCER CAPON-2
CUSTOMER ID is
INSURERS AFFORDING COVERAGE NAIC p
INSURED Caponigro Construction Co.,Inc INsuRERA.Selective Insurance Co of SC 12572
159 Burrill Street INSURER 8:TechnologyInsurance Company 42376
Swampscott,MA 01907 INSURER 0:
INSURER D
INSURER E:
INSURER r-:
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.
INSR ADVE SUPER TYPE OF INSURANCE
LTR POLICY NUMBER MM DDI YY MPM pC P LIMBS
LT
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
A X COMMERCIAL GENERAL LIABILITY S19164830 11121/12- 11/21/13 PREMISES fEa occurrence $ 100,00
CLAIMS-MADE OCCUR MED EXP(Any one parson) $ 10,00
PERSONAL$ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 3,000,00
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 3,000,00
POUCYFx-1
PRO- LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00
(Ea amident)
ANY AUTO BODILY INJURY(Par person) $
ALL OWNED AUTOS BODILY INJURY(Per accident) $
A X SCHEDULED AUTOS A9092896 06106112 06106/13 PROPERTY DAMAGE
X HIRED AUTOS (Per accitlenq $
X NON-OWNEDAUTOS $
$
X UMBRELLA Me X OCCUR EACH OCCURRENCE $ 2,000,00
EXCESS UAB CLAIMS-MADE AGGREGATE $ 2,000,00
A 51916483 11/21112 11/21/13
DEDUCTIBLE $
X RETENTION $ NONE $
WORKERS COMPENSATION X I WCSTATU- OTH-
gY
AND EMPLOYERS'LIABILITY
ER
B ANY PROPRIETOR/PARTNERIEXECUTIVE YIN NIA TWC3326129 09/15/12 09/15113 E.L.EACH ACCIDENT $ 1,000,00
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) MA E.L.DISEASE-EA EMPLOYEE $ 1,000,00
ILyes,desaihe under 1,000,00
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
A Misc Tools S19164830 11/21/12 11121/13 Limit 15,00
Deduct 50
DESCRIPTION OF OPERATIONSI LOCATIONS/VEHICLES (Attach ACORD 101,Addillonal Remarks Schedule,N more space Is mqulmd)
Illustration of Coverage
CERTIFICATE HOLDER - CANCELLATION
ILLUS-1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ILLUSTRATION OF COVERAGE ACCORDANCE WITH THE POLICY PROVISIONS
AUTHORIZED REPRESENTATIVE I
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
-T1. /C/ ,�fo /u ** MassachusMts- Dcp:u tment of Public Sat'ch'
Office of Consumer Affairs&B sines Regulation lugBoard or Building Regulations and Standards
q� HOME IMPROVEMENT CONTRACTOR Construction Supervisor License
Registration i&1999 Type:
ff Expiration: 729@Q14 DBA License: CS 61061
C NIGRO CO(�1 r.R ONT,
F � CARLO E CAPONIGRO
CARLO CAPONICi ���' °' 159 BURRILL ST
159 BURRILL ST ��:E //s SWAMPSCOTT, MA 01907
SWAMPSCOTT,MA O'P,9�0 �„��
�{y Undersecretary
itf Expiration: 712MG13'
Commissioner Tr#: 17390