224-228 NORTH ST - BUILDING INSPECTION (2) q `i OD- Cf, t Z-7 H
The Commonwealth of Mass L SERVICES
Department of Public Safety
Massachusetts State Building Code(780 CNR Ff 4 Building Permit Application for any Building other than a One-or o y&Mng
__ _ _ _ _
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, ._;� V C (This Section For Official Use Only) �iC E !"- 3 wx . . .
Building:Permit Number u iPateApplied °�=': Building:'Ofhcial = " - 'I -
N SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not av able
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1 8 _ _ so e
—g No.and Street City/Town Zip Code Name of Building(if applicable)
t-j,_; ,.. , , ,('s. . , .,._ _,._s '¢,SECTION 2:PROPOSED WORK ' :<< . . .. �, tG,.
y .� ., m..:,.,M,. ,....
_^ Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building 1L Repair❑ 1 Alteration K I 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 IN No ❑
Is an Independent Structural Engmeerin Peer Review required? ,/ / Ye ❑ No
Brief Desch tion of��pp��oposed Work: 2. /
SECTION 3 COMPLETE THIS SECTION IF.EXISTING'BUILDING UNDERGOING RENOVATION,ADDITION,OR u
E
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):
NO 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.)
• v - w $_` ;" SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ 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❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
...., ._.. ., �....._.. 4 SECTION fi:-CONSTRUCTION TYPE(Check asapplrcable)-:-1--
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
` SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) F,
Water Supply: Flood Zone Information: Sewage Disposal: TrenAtrench c Permiill t:
be Licensed rs Remo Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench orspecify:
Private❑ or mdentify Zone: or on site system❑ 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 ❑
..r ' SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY.e�
.. . ,
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
D0
es the building contain an Sprinkler System?: Special Stipulations:
`.SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address s of P op��y Owner
Name(Print)fl W �'"' ��ny �C� d55.Street Ctty/Town Zip
Property Owner Contact Info ti.on:
j
R-T N f *eLtt i ffffl
Title Telephone No.(business) Telephone No. (cell) e-mail address
If app 'cable,the pro erty owner hereby authorizes
Name Street Address City/Ttlwn State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECT ( PPION 10.CONSTRUCTION CONTROL of enclosed m10-
Please fill out A end 2
) z
u"�''e `s birildvi is less than 35,000 eo:ft. s ace and or not i der Construction Control then check here O and ski Section 10.1)
10.1 Registered Professional Responsible for:Construction Control(
Qennis J (swat. Q � 31/SS
Name(Registc t) leghone No. e-mail a r ss Regi tr ti Number
9.4 hoe '�ar uaie. /e g �}(4y0 e S d O /6
Street Addres City/Town State Zip Discipline E pirati n Date
10.2 General:Contractor:. .._.. "En n.,u�.: .. .... .. _
IA � G
Company Name
Name of Person Responsible fop Construction License No. and Type if Applicable
Street Address City/'lfown State Zip
Telephone No. (business) Telephone No. (cell) a-mail a ess
-4.. ._ - =:4..-.�_•SECTION lli WORKERS'COWFNSATION INSURANCE AFFIDAVIT .G.L:c.15 . 25C 6 ....c_',..,
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 17
SECTIONI2:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Cam
4�.
Item and Materials Total Construction Cost(from Item 6)_$ l'7 11=0�0
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ tj'�-t/ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost I $ Lt (contact municipality)and write check number here
2'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 "bes of ledge and und>erstan ing.
Please rint and sign natlye� Title Telephone N o� Date
Street Address City own State Zip
3wi,
Municipal Inspector to fill out this section upon application approval
r __ - -Name .,,.:Date,
Initial Construction Control Document
UTTo be submitted with the building permit application by a
Registered Design Professional
for work per the 81h edition of the
*
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: xxxxxxxxxxxxx Date:02-03-2016
Property Address: MARGIN STREET
Project: Check(x) one or both as applicable: New construction x Existing Construction
Project description: ST.THOMAS CHURCH REAR ENTRY ENCOSURE
I Dennis J. Gray MA Registration Number: 5185 Expiration date: 08-20-16 ,am a registered design professional, and I
have prepared or directly supervised the preparation of all design plans, computations and specifications concerning':
x Architectural x Structural Mechanical
Fire Protection x Electrical Other:
for the above named project and that to the best of my knowledge, information,and belief such plans, computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted
engineering practices for the proposed project. I understand and agree that I(or my designee) shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17, as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, I shall submit field/progress reports(see item 3.) together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'.
Enter in the space to the right a"wet"or
G\S�EBED Alley
^o No.51a5
sosrow
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electronic signature and seal:-
Phone number: 978 745 4404 Email: dennisgray@verizon.net
Building Official Use Only
Building Official Name: Permit No.: Date:
Note 1. Indicate with an 'x'project design plans,computations and specifications that you prepared or directly supervised.If`other' is chosen,
provide a description.
Version 06 11 2013
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, MA 0211 4-2 01 7
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FMED WITH THE PERNUTTING AUTHORITY.
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): 7.
Address: Gt 4
City/State/Zip: �`/¢ 151%) phone#:
Are you an employer?Check the appropri a box:
FRemodeling
oject(required):
1.Al am a employer with__employees(full and/or part-time).' construction
2.❑I am a sole proprietor or partnership and have no employees working for me in odelingany capacity.[No workers"comp.insurance required.]3. I am a homeowner doin all work m elf. olition❑ g ys [No workers'comp.insurance required.]t4.�I am a homeowner and will be hiring contractors to conduct all work on m ding addition
Y Property. I willensure that all contractors either have workers'compensation insurance or are sole rical repairs or additions
proprietors with no employees.
. bing repairs or additions
5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheep
These subcontractors have employees and have workers'comp.insurance.t 13.❑Roof repairs
&❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
Information.
Insurance Company Name: ' ,/fQ![.Lr,I1pRlJ/ TT1��llsstt .( 6tll.�-�ply/C
Policy#or Self-ins.Lire. W cL Expiration Date:
Q
Job Site Address: IYA City/State/Zip:_ Y/�J�JR
Attach a copy of the workers'compensation policy declarati n 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 cert' n rthej#aS agar9ftTfies
)ofperjury that the information provided ab ve is uee and correct.
Si ature: ✓ Date: 4
Phone#:
O
fficial use only. Do not write in this area,to be completed by city or town official
or Town: Permit/License#
ing Authority(circle one):
oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
thertact 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 written."
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 dwellinghouse
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 appr2Lnate 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 pemutilicense 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 dog 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
Massachusetts' Department of Public Safety,
Board of Building Regulations and Standards' -
License: CS-05333o
r' Construction Supervisor
' JOHN A STUEVE., IZ,.
62 ABORN STREET ,
PEABODY MA 0196
l
C11- , Expiration:
commissioner 16/02/2617