96 SWAMPSCOTT RD - BUILDING INSPECTION (33) The Commonwealth of Massachusetts
Departmentof Public Safety
Massachusetts State
Building Code(780 CM2)
Building Permit Application for any Building other than a One-or Two-Faraily Dwelling
(This Section For Official Use Only)
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)
�f: Swa„n�pycmtf � 5ade.nt SAeq�<e:r.,.-'s coax '
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED.WORK.
Edition of MA State COLIC used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix'1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: 4-
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? 7 f �, Yes ❑ No el�
Brief Description of Proposed Work: �62m pc"Ati I=' X ZS-f G'.0+u'C-1LC44 d41�
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): I
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 El A-3 ElA-4❑ A-5❑ B: Business ❑ E: Educational Cl
F: Facto F-L F2❑ H: Ili h Hazard H-1 ❑ H-2❑ H-3 ❑ FI-4❑ H-5❑
I: Institutional I-1 ❑ 1-2❑ I-3❑ 14❑ 1 M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
So Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a plicable)
IA ❑ Ill ❑ I[A ❑ lip ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
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:
A trench will nut be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify:
Private❑ _ or indentify Zone: y or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ 1 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 Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
CEo q76 -7ff-15673 017_g0l- 5-3'I,7
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes r
�itim�s wca!-r q3 a�clfs ur�(g1e Rr� Ckes .� AM- o3oix
Name T 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)- -
If building is less than 35,000 cu.It.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Res onsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
l7 nt duo a ffc y7` �2 rtkcu br� peed, 144 all S4,
Street Address City/Town State Zip Discipline Expiration Date
10:2 General Contractor
Company Name
a?!-1vtCS
Name of Person Responsible for Construction License No. and Type if Applicable
tiff 6303/6
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:1VOKKIiIS'COMPENSAI ION INSURANCE AFFIDAVI I 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❑ No ❑
SECTION 12:CONSTRUCTIONS COSTS AND PERMIT FEE: -
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(insert here
2. Electrical $ appropriate municipal factor)=
3. Plumbing $
4. Mechanical (HVAC) $ Note:blininmm fee=$ (contact nimuci iiitty)
5. hlechanical Other $ Enclose check payable to
6.Total Cost $ al
.GOD,d0 (contact municipality)and write check number 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.
Please print and sign name Title Telephone No. Date
Gf 3 wzl/s uillrne iZ.Q. G�.ts� � 0303�.
Street Address City/Town State Zip )
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF S'UE,l,t, Ni LkSSACHUSETTS
* B[:Im=DEP.kRn1&NT
, �+ 120 W-ASHC IGTON STREET, 3" FLOOR.
TF.L (978) 745-9595
FRix(978) 740-9846
K1\tBERLBY DRISCOLL
,NLaYOR THo.%w ST.PiERRB
DIRECTOR OF PUBLIC PROPERTY/BCILDNG CONNISSIONER
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 It 1.5
Debris, and die provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
its
(name of hauler)
The debris wi11 be disposed of in
(name of facility)
(address of facility)
signature a permit ap 'cant
(late
4dm Saii.l,x
!° CITY OF a7a1I . -NM, . L1SSACHi SETTS
BUILDL\G DEPARrNlF_NT -
120 WASHINGTON STREET, 3a°FLOOR
\� TEL. (978) 745-9595
FA'c(978) 740-9846
KyNBER F.Y DRISCOLL THONLJLS STTIERM
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUMDDZG COhLiISSIONER
Workers' Compensation Insurance Affidavit: Builders/contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Na tile (13usiocss;organization.'Individual): —�aM��)IKA�+� —!!l(� GvFr47xan[ •fWi�l
Address: C13 V111AIt
City/State/Zip: Q�.e7-�eR ..-NH Phone ii: 978 6-9 7 Sl'1
Are you an employer?Check the appropriate box: 'rype of project(required):
I.21 am a employer with_.._ 4. ❑ 1 am a general contractor and 1 6. Q'Rew construction
employees(full and/or part-time),* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t �• Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9 ❑ Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per MGL I I.[] Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. (No workers'
comp.insurance required.l 13.❑ Other
•Any applican that checks bos#1 mull also nil out the section below showing their workers'compensation policy inib oration.
t I lomeowM"who submit this affidavit indicating they am doing all work and then hire outside contractors must submit a new affidavit indicating such
:Comncuori that check this box must anach xi an additiun:al shut showing the mmne of the sub-contractors and their workers'comp.policy information.
I ant an employer that is providin/{workers'contpensaNun insurance for my employees. Below is the policy andfob site
information.
Insurance Company
Policy #or Self-ins. Lic. 0: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I In hereby c tijy nder the u'ts an penalries a perjury that the injonnallon provided above is true and correct
.SSi'mi it Date: V�30 /•j
Phone :
Official use only. Do not write in this area,to be completed by city or town offfc•iuf
City or
Issuing Authority(circle one):
1. Board of health 2, Building Department 3.Cityffnwn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: __ _.... . . .. _._...._....� Phone#:
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_ WENTWORTH NEWBURYPORT,MA 01950 SKml
PARTNERS&ASSOCIATES V:978.462.5822 F:978.462.5823
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PROJECT NAME, PROJECT ADDRESS, PROJECT NUMBER, DATE,
JACQUELINE'S 96 SWAMPSCOTT RD. 099-13 09-23-13
GOURMET COOKIES SALEM, MA
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