1 SEWALL ST - BPA-15-1134 BUILD WALL FOR SECURITY -e q H 2 Z.
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The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(this Section For Official Use Only)
I.
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK
` l Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ 1 Repair❑ Alteration 2'� 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
P Change of Use ❑ 1 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? A Yes ❑ No ❑
Brief Description of Proposed Work: (3uiL6,hlc /� wAc.t— trot Ai>Dc- S€GU2�T�I
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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) ❑
Existing Use Group(s): Proposed Use Group(s):
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.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I❑ F2❑ I H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ I-2❑ I-3❑ I4
El 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 6.CONSTRUCTION TYPE(Check as applicable)
IA E3 IB0 IIA 13 IIB [3 111A IIIB ❑ 1 IV 1 VA 13 VB 13
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details 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 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 ❑
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:
S cr r 1 p co"-v . ! o zo
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner 2 ,1
JAV4 or-T-06doRrt4 SINCE Z4,5l'A&7- SVrg— UFUL�d2C / . Ari GI l5
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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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 owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(Ifbuildin is less than 35,000 cu.ft of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip - Discipline Expiration Date
10.2 General Contractor
Company Name ,1
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Name of Person Responsible for Construction License No. and Type if Applicable -
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Street Address City/Town State Zip
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Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ S'CO
2 Electrical $ �� Building Permit Fee=Total Construction Cost x_(Insert here
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appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 500•�o (contact municipality)and write check number here O ZZ
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 est my bknowledge and understanding.
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Please
lSPlease print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
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Name Date
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The Commonwealth of Massachusetts
Deparbnent oflndustridlAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
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Workers'Compensation Insurance Affidavit:Builders/Contractors/Elechicians/Plumbers.
TO BE FILED WITH THE PERNDT JNG AUTHORITY.
AvvlJcant Information Please Print Ledbly
Name(Business/om.anizationandividual): C-- Vj L
Address: 3G Cl t/LC— r�Z yCTi
City/State/Zip: �l/ C ILM U( /SPhone#: 7S' 'S %S Gz `}
Are you an employer?Check the appropriate box: -'
Type of project(rei]uired):
I.❑I am a employee wAh .employees(fill ed/mpart ikne).' 7. 0 New COI1atrnC[lon
2.&am a sole proprietor er partnership and have no employees working for me in 8. 01temodeling
any eapaeiry.[No workeis''comp.insurance required] .
3.Q I am a homeowner doing all work myseH.[No workers'comp.insurermce requ.tell 1 9. Q Demolition'
4.M I aen a homeownerand wifl be hiring eommutors to coma all work on my property. twill 10 Q Blilldnig addition.
emme that all conmams either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
Iaapeie[ms with no employees. 12.0Plwnbmg repairs or additions
5.a I am a general cohemenor and I have hired the sub-eom s ams listed on the anached skeet,
7bese sub-contracton have employees and have worker's'comp.mmmocg3 13.Q Roofiepaira.
6.E]We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other
152,§1(4),and we bave no employees.[No workers'coop:insurance regained.) -
'Any applicant that cheeks box#1 must also fill our the sedan helow showing thefr workers'compmsare Policy i�uimNim.. -
t Homeowners who submit this affidavitifi irafing they are doing all work and thin hive outside comractors must submit a new affidavit indicating such
1Conracters that check this box must athwhed an additional shed showing the—oflhe sub-contractors and state whether or not those entities have
employees If the aubcomnctors have employees,theymmutprvvidetheir workers'comp.polirym®ber.. .-..
law an employer that is providing workerscompensation insa raneefor my emjiJoyees. Below is thepoliryrad' b site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.M - Expiration Date: -
Job Site Address, City/State/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 pmalties m 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 tern airs pen res ofperjury that the information provided
- - o ' dd lcoSrrc.
/ (Signature: 1 eS
Phone M
Qijieial use only. Do not write in this area,to be completed by pity or town gfflkint
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.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 corrmmorweahh 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(IJ.P)with no employees other then 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-insuredcompanies 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 permittlicense 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 eacb
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. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
: OTY OF SALEA MASSAC HUSEM
B[&IDm DEPAR7mEw
120 WA9MCTONS7REET,3HD ROOR
L(978)745.9595.
FAX(978)740-9846
KIIv18ERLEYDRISOOLL
MAYOR 7}MAS STREW
DutEcrOR OF FM1JCPROPERTr/BUMDRc amsmoNER
Construction Debris Disposa/Affidavit
(required for all demolition and,renovation worki
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 d 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/d/ebris will be transported by:
H 1L 7'Z
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
—� Date
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