54 MARGIN ST - BUILDING INSPECTION 1 ,
---------------- -- ----- --- ---- ----- - ------- -
„A� , The Commonwealth of Massachusetts
Department of Public Safety
-sr 2 :Massdchusvtis State Building Code(780CMR)
Building Permit Application for any Building other than a One-or Two-Family Dv clli
('Phis Section For Official Use Only)
IIu ilJiug I'ennit Number: ____ Date Applied: Building Official: _
SECTION 1:LOCATION(please indicate Block p and Lot p for locations for which a street add r s is not available)
No. and Street City/rown Zip Code Name of Building(if al+plicable)
SECTION 2:PROPOSED WORK
Ldition of MA Stale Code used — If New Construction check here❑or check all that apple• in the two rows below I
Iaisting Building❑ Repair ff-I Alteration ❑ Addition❑ Dcnn+lih011 ❑ (Please fill out And Submit Appendix 1)
Change of Use Cl Change of Occupancy ❑ Other ❑ Specify:__.
Are building plans and/or construction dtWUHIetll9 being supplied as part of this permit application? Yes ❑ No 0— _—
le an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: A Z�: z tt74'G�%
SECTION 1-CONIPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here Ban Existing Building Investigation and Evaluation is enclosed (See 78)CMR.14) ❑
Existing Use Group(s): --- Proposed Use Group(s):____ _--
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)8r Area Per Floor(sq. ft.)
Total Area(sq, ft.)and Total Height(ft.)
SECTION So USE CROUP(Check as a livable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-1 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ - If: Hi h Hazard H-1 ❑ H-2❑ 11-3 ❑ 11-4❑ 11-5❑
1: Institutional I.1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ It. Residential R-10 R 2❑ R-1❑ R-4❑
S: Storage SI ❑ 5-1--❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION rYPF. (Check as applicable)
IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ [[III ❑ I IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMA"FION(refer to 780 CAIR 111.0 for details on each item)
Water Supply: Flood Zone Information: I Sewage Disposal: Trench Pennih Debris Removal:
Public❑ Check if outside Road Zone❑ Indicate municipal ❑ A trench %kill not be Licensed Disposal Silt,❑
required ❑nr trench or,pecif}'.-__-_._._.
I'm ate❑ or indentifv Ions; or on site system ❑
permit isenclosed ❑ _ _
Railroad right-of-way: Il/ards to .Air „ir Navigation: V \ .r . ,.,,,.. �. I y,
.Not Applicable❑ Is Structure%vithin airport approach arc,%? Is their o.% rnnydoted'
Of Con+ent to Budd 111110101113 \es❑ or No❑ Yes❑ No O
SEC HON 8:CONTENT OF(TIt I IFICA IT 01:OCCUPANCY
Ldition, t Code: -" - L'se Cr of(s): I\I % Ili nsl nii lii n: l!ccuPaut I,1ad par I loor
DI es the butldm),c,nnam in tiprmkl r ti\stunt.' 1;p%c1a1 Stipulations
SIX IION 9: PRO111(I1 I'Y OWNER AU'r11ORIZA'T ION
Name,md Address ut 1roperty Owner --
Name(Print) No..unlStreet City/Town Zip "
Property Owner Contact Information:
Title rclephone No.(business) Telephone No. (cell) a-mail address
If,ipplicable, the property owner hereby authorizes
Name Street Address City/Town State Zip It,act on the property owner's behalf, in all matters relative towork authorized bV this buildin permit a p IicatioiP.'
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if budding is less than 15,000 cu.ft.of enclosed s pace and or not wader Constnaction Control then check here❑and ski p s ctioa 10,t
10.1 Registered Professional Responsible for Construction Control
Nance(Registrant) - Telephone No e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
S fi9vc4
Company Name
1�ao,9a/i2 ��ri/�•r-a C Dol�3tr
Name of Person Responsible fur Construction License No. and Type if Applicable
22ta _0/7-4/
Street Address City/Town State Zip
Tcie phone No. business Telephone No. cell a-nail address
SECTION 11:wru:r.it;:, ruatrrN�,:�rh?Nt.��air..�Nc'r.vru�,1�'ll M.G.L.c. 152.1 25C6
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
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6) -S—,/
1. Building S 90'9 10� Building Permit Fee a Total Constntction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=S
1. Thumbing $
4. :Mechanical (I-iVAC) S Note: Minimum fee'S_—(contact municipality)
S. Mechanical (Other) S Enclose rhack payable to
(I total Cost $ (contact municipalitN')and write check number here --_--
SECTION 13:SIGNAI'URE OF BUILDING PERMIT APPLICANT
Ile entering my name below, I herebv attest under the pains and penalties of perjury that all of the information cont.iincd in this
.application is true and dccurate to the b0t Of nw know ledge,md understanding.
L ocr i� la ulr� ---dzP .-- -- _OC—.4 r --
I'le se print and 11t;n name Title 11 h phone No. Date
'rvet Addrevs City i roam Shiite Zip
v G vri, l
Municipal hupector to fill out this section upon application approval:
Name Dale
CITY OF S.1L&Nf, AUSACHUSETTS
f31.'tLOLVC DEP.1RTtE\T
I'0 V7.1.immTON STXW, 1'6 FtOOIt
1*EL k973) 74S.9S99
FAX(973) 1449846
,'UJtBERLfiY DIILSCOLL
MAYOR 1}tov u Sr.Ftartts
01"Crott Or PL SLIC PIIOPEATY/Stan m co.%nlrS3roNER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
to, and the pro e P with
Debris, and t the sixth edition ottha State Building Code, 730 CUR section I 11.f
visions of UGL a 40. 3 54;
Buiidiny Permit!/ is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licerued waste disposal facility as defined by,bIGL e
I 11, S I30A.
The debris will be transported by:
(name 0(hauler)
The debris will be disposed orin :
(name or ramlily)
1�ddrea of f�,ihly)
iynamreorpermitrpphunt —
Commonwealth of Massilchusetts
r Massachusetts-Department of Public Safety DeNaranent or Labor Standards
Board of Building Regulations' tions and Standards HeadwrE Rowe Doctor >tj,
Sip`"" ` Deleader SupervisorI�Bf
License: CS-,;F; 8
� �,�! -� ¢ LEOCADIO PAUUNO
_ g Ef..Date 0527111 "
%. LLOCADIOPAULINO — n
ILAVdMNCF MA 01843 .I DSOM1 a 05JJ2`A1d12 Grid J`{ ,r41yr
�ot1m
fkmbwdC0.N.ES.T. x
Be
Expiration `. e, jy
Commissioner 12J0912013
{�1 ✓-c (fJ109fYJliMt[OPR���O ✓��JlffthfldCQJ
. �•+= e•�!O-7'C•oU9Umee'fi09ds�'B�C65"HCgalA44'0
i - s HOME IMPROVEMENT CONTRACTOR
, Registration 1145522,e �,It Type: i
��. I 2 Expiration 2=013�r„j . ,IndlvlduaL.
f. LEOCADI0 PAULINO
.ern ' `0, -
LEOCAD10 PAULINO
`41.BOURGUFST
(Le -LAYMMIMMA4184.3'..;,:._'A . Undeheeretary
OCM� "
T.&eatiinuicimCOL.
4l 9WR OMST
y� �►ouim - -"
I g-
05/27/2011 09:25 978794857E TA SIMRIVAN PAGE 05/05
��.., OP iv.KN
CERTIFICATE OF LIABILITY INSURANCE
°"; ,'"' '
THIS CERTIFICATE 15 MUM AS A MATTER OF DWO ATION OILY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CENtMCATE DOES I= AFFOOIATIVELY OR NEGATIVELY MOO. EXTEND OR ALTER THE COVERAGE AFFORDED Of THE POL9=
BELOW. THIS CERTIPICATE OF DSURRNCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUROWL AUTHORIZED
REPRESENTATIVE OR PRODUCER ANO THE CERTIFICATE HOLDER
IMPORTANT: S the a:MRaER holder Is an ADDITIONAL SSURED.On PoNcyges)MUK be endorsed d SUBROGATION IS WAIVED.subw to
the tame and cDndNknm CIUM poky.o:bb pondan Rlg mqulre an ondomment. A ablrna'on V&codMc b styles ISO abler dghb to Sn
anMeab holder In Saw ofarch ondersewmaltsL
PRODUCER
T.A.Sullivan km Any.bt:
3M S.Union SL
Lawrana.,MA 01643
LACON-1
AAppora covorAm MAICA
POORM LeOeadloPaWtne NsamLA:SUr MAUrAwWrlwm
OBA 1.A A CosubDatlon LAwaBTe:
41 Bourque at .-. e:
Lawrence.MASIM o IIaIYQII a-c:
VINaB1E:
mmom
COVERAGES CERiFICATENUUMMOL, NUM
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE 04URED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. morwriNSTANOM ANY REOUIREIN UIT.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 POUCIEB DESCRIBED HEREIN 19 SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN WAY HAVE BEEN REDUCED BY PAID CAIM&
1YL4 oFfa1p1ANIXDan Pa1CTOPP B AM= omwowrym ROVED
GENERALLWLRY PAWOGWRREMLE f 1,000.001
A X CO%VERCVLGENBNLLIAB%J" PNG E 00747S•22 0~1 eumN2 sEe PA c f 300,
CIANaMADE ❑OCCUR vEuEXP1Ama Pmmm S 5.0E
PERSONAL S AOv IUURY f 1.000A0
GFWB AGGREGATE s 2A00A0
SENL AGGREGATE LOM APPLIES PER- PRODUCTS-CDMPAOPAGG s 2A66
POLICY P LOC S
AUIONOMLUM Lfm COMBINED SINGLE LAW s
IEeeodJeml
ANY AM cocky f Rw(POPw=* S
ALL OWNED AUTOS BOdLYINANN(PALicLNntl a
SCHEDULED AUTOS PROPERTY DAMAGE
f
HRED AUTOS lPiraoddwAl
NON-01M;wAUTOS S
f
UNINIMIAWa OCCUR EACH OCCUW*xcF. s
OIDISSLm CLAIUS.MAOE AGGREGATE i
DEDUCTIBLE s
: f
iLOPI{Ep6aASPNOAT1oN WCSTATU- OTN-
ANDeMPLC"MLLMD1TY YIN
AAIYPfiDPRETORPARTLaRIEINIXTINE NTA Fi EACH ACCIDENT f
(ecM�dllalDELUDEe! u LL DISEASE-eA 2n2nd f
D uder
TONS inff EL 06GAEH•PWCY n 12
p onlnerdal Applio IN
PRC E001W6}2 1041mll
0611ca1PTIaI OF OPERATIONS LOCATIONS I VIRun"PsNCA AC01w1-1 Wall, dR-mlft9dwdANffmmspmf&
Gerpentry and dabadiog
CERTIFICATFHOLDER CANCELLATION
CITY0FP
SHOULD ANY OF 11EABOVE OE6CMED POLICIES BE CANCELLED BEFORE
THE WIRATION DATE THEREOF, KMCE
CHy of Peabody ACCORDANCE WF U E POUC:Y OML WILL BE OEIJVERED IN
Peabody,MA
AIn1OLANDREPF40 TATME
��tr �0IN84 MA*= ION T . A2 fthta mserved.
ACORD 26(MOa0p) TM ACORD a"Sad logo are TTgfalswd ITlafb of AC0RO
r C['IY OF 5.1LE.� (, N L1SS:\CHl 5E-ITS
1 BUILDING DEPAWTMFENT
120 WASHINGTON STREET 3"'FLOOR
T'EL (978) M-9595
F.�c(978) 7 W846
`i\IBERLEY DRISCOLL
Am"t n4o.n L%S ST.PIERR8
DIRELToa OF PUBLIC PROPERTY/BUI1.Dt\G COS11MISSIONER
1Vorkers' Compensation insurance Affidavit: builders/Contractors/Electricians/Plumbers
limlicant information Pieese Print Le�ihly
Nalne tnusines.aUrgamralian lndividuall: L% I (_�ni r /'� r�
Address:_ll/�oyrrQ/.�
CityiStatc/Zip: Phone N: /7Sl 7
Arc you an employer.'Check the appropriate boas FrElElecrric,41
ct(required):
I.(] lain a employer with 4. ❑ I an a general contractor and 1a. nsrtutian
entpinyeea(tLll and/or part-lime).• have hind the sub•comnctars 6.
2.❑ I am a sole proprietor or partner. listed on the attached sheet t ling
ship and have no employees These subcontractors have tion
working tier me in any capacity. workers'comp.insurance, addition
(. o workers'.comp, insurance J. ❑ We are a corporation and its
required.) ofllcers have exercised their . al repairs or additions
7.❑ I mn a homeowner doing all work right of axempliun per MGL I I.Q Plumbing repairs or additions
myself.(\o workers'sump, a 1 J2, 11(4),and we have no 12.0 Roof repairs
insurance required.) t - empluyees. (No workers'
sump.insurance mquircd.) 12.❑Other
vay appllaww Jim rlwaka boa At mime alwr all our the meliva balm chewing their wodaa'eomiwnudun policy tnnumutiom
'1 h.nauwft"wild,uhnril this atndavis indicating ihey an doing all,wrt and then him aWride eomeerote Mimi auilmll arm alndavil indleting ouch,
$\mnwtun that chcsk this box mime nuchud an a"flurud.heel ahuwing the nine arthe will r rimtons and their wnhen'wmP,pulley In(ummnae,
fain on eurpluyer ibur/s prov/dlnX workers'eumprusadun hrmruneo jar my emp/uyees Below It JrePolley and jub silo
inj'orrtruNon,
I nsurmce Company Vain e: 6L1foe __....-
Policy d or Self-ins. Lie,d: Ad Z41 z,i_=2 Z Expiration Dale: .L/' Zk-/ Z
ear
Job SittsAdtlress:Sl�"/1//.G1/��i✓ r CitylStatr/2ip: ��L�%1/' iL.�
Attach x copy of the Workrn'cempemulos policy declarallen pigs(showing the policy number and expiration data).
F.liluru m wcuru coverage as required under.Section 21A of SIGL c. 152 can lead to the imposirian of criminal penalties of a
tire UP to i I,S00 00 and/or one-year imprisonment as Well as civil penalties in the form of a STOP WORK ORDER and a ilia
of IT ua S2A 110 s day against the viulamr. Ile advised that a copy of this statement may be furwardcd to ilia 011iue of
Inrrstigutiunv ufthe DIA 1;)r indurmcc coverage vcrilicaliun.
/du herrby rnr'y ruder der pains oat pertaide.r.j1 perjury r/tut the rn�unnuduu pruviJaJ uGuve Lr frog ruaJ carrrae
,r
F
dy, /7�a nor ror...Lrlrrru hr(unrplrreJ 6y airy ur ruin njflriu!
nr l't,lnc. i'crmitil.lcenrenpAtolnarity (circle one)thh ' lluildlm, I)cporhncnl I ( ityi Ibw❑ Clark !. ENC1rlca) htglcctnr i. 1'lumbtn;; httpdctarher
—_ _. ______.-. I
I'n ni.11r V ri,,m
PROPOSAL
PROPOSALHO. --
SHEETNO.
DATE
PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT:
NAME 3 ADDRESS
ADDRESS
DATE OF PLANS
PHONE NO. ARCHITECT
We hereby propose to furnish the materials and perform the labor necessary for the completion of
All material is guaranteed to be as specified,and the above work to be perfommd in accordance with the drawings and spedficall
submitted for a work and comp) ina substantial worvaanike manner for fie sum of f
Dollars
with payments to be made as fofbvts:
Respectfully submitted
Any aiMedai Or dBAMM UM abase spetlftBOr b.m* eWa m
ant he Al a nrow wImtls so-WW Per
adwK w delays briar av carnal
(dote -This proposal may be withdr
by us if not accepted within - d
ACCEPTANCE OF PROPOSAL
'The above prices,specifications and conditions are satisfactory and are hereby accepted.You are authorized to do the.work
as specified. Payments drill be made as outlined above.
Signature
Date_ J l f C— Stgnat