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14 RICE ST - BUILDING INSPECTION (3) frs� The Commonwealth of Department of Public S4fety cES r Massachusetts State Building Cods($Jf9 Fw N Building Permit Application for any Building other than a O or'�vv&:)Fa;li% welling (This.Section For Official Use Only):. ( Building Permit Number: Date Applied: Building Official: SECTION 'LOCATION(Please indicate Block i!and Lot It for locations for which a street address is not available) _ I to c� 1 No.and treet City/Town Zip Code Name of Building(if applicable) SECTION 7-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 I Repair Alteration Addition❑ Demolifion ❑ (Please fill out and submit Appendix 1) Change of Use d I 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 ❑ No ❑ Brief Description of Proposed Work:- a J fb —r C-ti SECTION 3:COMPLETE THIS SECTION 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)k Area Per Floor(sq. ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a plfcable) - - A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Factory F-1❑ F2❑ 1 M:: H-5❑M 4 I: Institutional I-1❑ 1-2❑ I-3❑ 14 cantile Cl R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) - IA ❑ IB ❑ IIA ❑ I11) O ILIA ❑ IIIB ❑ I IV O 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details.on each item)- Water Sup Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: Licensed Disposal Site❑ Publi^�,�'"(1- Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P Private❑ or indentify,Zone: or on site system❑ required O or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: i.,toric Cu.nmisiun t'n_c_s: 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: SECTION 9: PROPERTY OWNER AUTHORIZATION Name-and A tress of Property Own r / Name(Print) No.and Street City/Town Zip Property Owner onC/Y formation: Za.VeN�c. ) Tele - Title Teleph (Wsmessphone No. (cell) e-mail address [f a lic le,theroperty'oy+nerereby authorizes J J _ l �n �/]/7 Name Street Address City/own State Zip to act on the property owners behalf,in all matters relative to work authorized b this building permit application. SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2). _ f b ilding is less than 35,006 cu.ft:of enclosed space and/or not under Construction Control then check here O and ski' Section 10.1 10.1 Registered Professional Responsible for Construction Control - o� Name(Registrant) Telephone No. e-mail address -Registration umber Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:W0RKER.13'COA41'FNSA'110N INSU RANCF AFFIDAWI YLG.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 I] No O SECTION 12.CONSTRUC ION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ I.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ t 4.Mechanical (HVAC) $ Note:Minimum fee=$ (c � ) 5.Mechanical Other $ E k a to s En check payable _ 6.Total Cost $ - (contact municipality)and write check num er 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. lj , T/'atif u?Sr 0 all Please pr76 int �� , JD r Titl Te hone N Date Street Address / "J - C Town State Zip Municipal Inspector to fill out this section upon application approval: _=r+2" `"Z✓ / / Name Date Details Page 1 of 1 M Qtneia_Wetsi of tic 6cecm,--Off Co of PWb! 'a-ety and ScCv.ltj(hopss) Mass.Govf Iowa Stetc-Pgendes ensee Details ull ame: `' ' JOHN J GAUVAIN ender: er Name: ti dress: ddress 2: i ity: Salem tate: MA ipcode: 01970 o nt : Urtted. tates icense o: S- 6 76 License Type Construction Supervisor Profession: Building Licenses Date of Last Renewal: 8/13/2015 Issue Date: Expiration Date: 8/15/2016 License Status: Active Today's Date: 11/5/2015 Secondary License: Doing Business As: atus Chan e: Lic se Renew I o rere uisite Information No Disci line Information ocumen um I Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=258716& 11/5/2015 The Commonwea/t/t ofMassachuseM Department oflndustdidAccidents I Congress Street,Sutte 100 Boston,MA 02114-2017 www.maxsgov/dia WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Pinmbers. TO BE FILED WITH THE PMWFrING AUMORITY. Applicant h&Mation. Name(Business/Oigem ationandiv dusl): I ) _ Address: / ZeYV City/state/Zip: Shone M .C� / e /. Are you m empbyerr CBetk the ppproprfak boz: Type Of project(required): I.�Ian a employer wk -empbyees(full eod/orpart-Lme).� 7. O Xew COnSI<7lellon 2yG�9ie,ma,sok pmpricforor partnership and Lave oo eempbyam wodang formeio $: bug �yy capacity•[blc wakem'comy.::w•�,••,egnved,l 9. V Demolition.' 3.p,m a homeowner doing all wodr myself:[No worker comp;insmaDm 7T'ku dJ i ]0 Q Bmltling addition. 4.p lam a hoomcoweer®a mT be bumg contactors to coodtm all work on MY proPerty. Iwo] - ensme that all contactors either have workers'compeamhon msum ee m are Sole 11.0 Electrical repairs or additions Pe no,msloyees. 12:�Plumbng repe've or additions 5.O I a general camactm and l have hued the sob-coomm m s listed on the nlached sheet i E]Roofrepaif8.. . These sub;comtperomhave employees end have wcelmo'comp.;mromzeYs r .Q - . 6.0 We are a corporation and its officmS Lore exercised ihearitM of exempton per MGL c. 14. Otb . e IS2,§1(4),and we harem employees [No wor](ms'camp iDamana reguued] •Anyepphaotthatcheckstmax lmust also fdl out thereitiunbeknrdiSaiagtbmwor]ran poheym(arttnmon. t Homec w who submit thb adm&e bfaffi g they arc doing all work mud d=bLe outside e0>mactwa must aultndt i new alrldavit i"Camig OWL: lContactom that check this boa must attached Onsdditonal sheet showing�name of the sub- ma and state wtelterm Dot those amities have employees Bthemb•coatatmshayeemployers,they must pavvidelheu wmkm'..omPPolicYnunD*. IamanemployerdWisprovidingwor*='Co pkon ceformyearplpyees IBetowisthepoliryemdJobsile - lnformaBon. Q �If/ Insurance Company Name: 1'gt"✓i 7 `�J� Policy#or Self-ins.I,ic:W. �/ 4 V 1 MP�tion�- Job Site Address: City/Stete/Zrr: m Attach a copy of the workers' ompeosation policy declaration page(showing the Polley n er and erybration _ate. coverage _ Failure to secure as required under MG.L c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 as well as civil allies in the form of a STOP WORK ORDER and a fine of up to$250.00 a it and/or one-year imprisonment, Pen 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 hereb opakier o perjury that the informadan provided above' true and eo U!/ Phone Off4wa l am only. Do not write in this area,to be completed by city or town o,B"rciaL City or Town: PermWMcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Pets Phone#• Information and Instructions m Massachusetts General Laws chapter 152 requires all employers to provide workers'eon pensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, 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 apsrbnents 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 certificates)of insurance. Limited Liability Companies(LLQ 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-msured'companies should enter their self-insurance license number on the appropriate lime. 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 pernat/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 ofthe 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 commnermal 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. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia CITY OF SALEA MASSAMUSE M 1 Bu7.nnvG DEPAR7MENT 120 WA$HINGWNSTREMT,3'OFiooR 7kL(978)745-9595. KIIv18 FAX(978)740-9846 MAYOR 11ECMMS ST.PfBR M DntEcroR of PUBLicPROPERTY/BurLDm ociamomR 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 00, S 54; Building Permit g i 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: (name of hauler) The debris will be disposed of in: (namt4of facility) EzR -� 4 (address of acility) e of plicant to