8 NORTH ST - BUILDING INSPECTION (2) The Commonwealth of Mass4n �CEIVED'
T Department of Public Safety h� AL SERVICES.'
r ry4y@ Massachusetts State Building Code(780��JJ
Building Permit Application for any Building other than a ONL+roRivo-5inp g
�J (This Section For Official Use Only)
I Building Permit Number. Dane Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not avaBabte
S A/oi -SA- a1�7, �/ntI 6,'/C17U w.dr7 da, - ./'!•�/ �ie�
No.and Street City/Town Zip Code Name of Budding(if applicable) _
SECTION 2:PROPOSED WORK
Edition of MA Stale Cude used_ if New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Wi Alteration O I Addition❑ 1 Demolition O (Please fill out and submit Appendix t)
Change of Use E3 Change of Occupancy O I Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes O No ❑
Is an Independent Structural Engineering Feer Review required? Le Yes O / No O
Brief Description of Proposed Work:. 9e r s e/n e r O+r t 110 rvt/oar /'Ul�✓� w� t'5
A/cw t✓SSzr� /d6Srr, /a „ /r/r �rrru.v 14 Z14 A tv_
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) O
Existing Use Group(s): Proposal Use Group(s):
SECTION 4,BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(sq.it.)
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 O A-5 Cl 1 B: Business ❑ E: Educational ❑
F: Facto F-1 O F2❑ If: High Hazard H=1 O. H-2❑ H-3 O H-4❑ H-5 O
1: Institutional I-1❑ I-2❑ 1-3 O f-1❑ M: Mercantile❑ R: Residential R-t❑ R-2 O R-3❑ R-4❑
S: Storage 5-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable) -
[A ❑ IDO (IAO 11813 HIA ❑ 1118E3 1 IV C3 I VA V8E3
SECTION 7:SITE INFORMATION(refer to 780 Cb1R 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit- Debris Removal:
Public❑ Check if outsiale Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required O or trench or specify:
Priva to O or indentify,Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: 1,-\
Not Applicable O Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed O 1 Yes 17 or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:. O cupant Load per Flour:
Does the building contain an Sprinkler System?:_ Special St ipu laliuns:
�SED\�T_ tOVN
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner �,/ � �j �
N/<JTls7 C, �idii (j 8 Alo✓/r� -01 JA/o'�. .® /66r
Name(Print) No.and Street - City/Town Zip
Property Owner Contact Information:
MJ V&fflt /f.rl,-114( _
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 owners 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 ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
'7,a/yr( ivy In G/� 293
Name
�t s(ReJr lrra/n)G TeJh mail address( ol�i N/ Registration Numbe
ziNe
ra J r
Street Address - City/Town State Zip Discipline Expiration Date
10.2 General Contractor P
Company Name
T4r•f uV _f4rA
Name of Perso Responsible for Construction License No. and Type if Applicable
Po oit, a /2 _4 /f/7 177. OQ?G
Street Address all? Z93- yo ff6 City/Town State Zip .
Telephone No. business Telephone No. cell e-mail address
SECTION 11:1VORKEF&COMtPENSA IION INSUIZANCT AFFIUAVrr M.C.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 0 No 0
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE -
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building S Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)-$
3. Plumbing $
d.Mechanical (HVAC) S 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 any name below, 1 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.
4-/ ,
Please print and sign a Title ,y Telephone No. Date
Street Address 11 City/Town State Zip
Municipal Inspector to fill out this section upon application approvaL• �
Name Date
The Commonwealth of Massorhusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
rkers'Compensation Insurance A}Ldavit:Builders/Contractors/Electr]cians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le 'bl
Name(Business/Orsmizattiion/Individual): I-Al EG1-a o- ' G At ( G iii A-4, ,. . .
Address: eG 13 -A 2 6 2
City/State/Zip: Z74 'alMeJV Phone M Q7 71
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑I am a employer with employees(full and/orpart-time).• 7. ❑New construction
2.Q Into a sole proprietor or partnership and have no employees working for me in g. Q Remodeling
any capacity.[No workers'comp.insmance required] .
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t - 9. Demolition
4.0m 1 a a,homeowner and will be hiring contractors to conduct all work on my property. ]will 10❑Building 8ddition. '
emu I that all cbritiactors either bave workers'compensation insurance or are sole 1 LEJ Electrical repairs or additions
proprietors with on employees.
12.n Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-conaractors listed on the attached sheet. 13.L61 oofr airs
These subcontractors have employees and have workers'comp.insurance.[
6.Q We are a corporation and its officers have exercised their right of exemption per MGL a 14.Q Other
152,§](4),and we have no employees.[No workers'dump.insurance required.)
_._ .. _. _... ........ _. _ ..._. ._. . I L
*Any applicant that checks box fl l must also fin out the seen=below showing their workers'compensation policy bil'ormation: ..
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
lContmctors that check this box must attached an additional sheet showing the more,of are sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their.wmkers'.comp.policy number
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job-site
information.
Insurance Company Name: 7✓-/6 L% A,Policy#or Self-ins.Lic.#: (/-a 0y,r61416&j-lj Expiration Date: .rll /f,y/ -
Job Site Address: 8 /7 J� GStylstate/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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify nder thepains and penalties ofperjury tthhat the inforiadon provideed above is true and correct
i ature: � Date: t P iT/lU
P
O11u:ial use only. Do not write in this area,to be completed by city or tows offWal
City or Town: PernflbUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or writtep."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017.
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CITY OF SALEA MASSAaR SE M
B[LAWG DEPA1trau4T
120 WASFmvGroNS=ET,3IDFLOOR
7kL(978)745-9595.
FAX(978)740-9846
B.IIvIBERLEYDRIS�LL
MAYOR 1HOMAS STAIEM
DntEcroROFPLaucPRommy/Bu=mOONAgS oiaA
Construction Debris Disposal Affidavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
6e
(name of hauler)
The debris will be disposed of in:
YLIA111 11117,1�.A 4 z r7.0
(name of facility)
(address of facility)
Signature of applicant
iv/ill.-
Date
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Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License:.CS-019729.
Construction Supervisor
a:I t.
JAMES W SHEA - l
45 DEARBORN S1 L
_ SALEM MA 0180
CA, Expiration:
"Mioner 10/16/2017
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