57 WHARF ST - BUILDING INSPECTION (2) The Commonwealth of Ma SERVICES
Department of Public Safety
Massachusetts State Building Code(780 CMR) pp ((���
Building Permit Application for any Building other than'awleWI2,aFSmil�y'JUjIing
(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)
51 HA O\9- 0
No.and Street City/Town Zip Code Name of Building tf applicable
SECTION 2: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❑ Repair Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
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? tc� ` Yes ❑ No ®�
Brief Description of Proposed Work: Tle,-l\r.r O w.2v� O t <'X\4r s Qr (\r r
l\cicFrh-f v.� O� 2 r\ p� by Q c An ,5
n rey Q a r\ anln oQ \-
t
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❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ M: 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 IB ❑ IIA ❑ II13 IIIA ❑ IIIB ❑ 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:
Public Check if outside Flood Zone❑ Indicate municipal veA trench will not be Licensed Disposal Site
Private❑ or indentify Zone:�1 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❑ 1 ❑
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:
C4>Ut-t--p Li P .O . q/ �
�I
SECTION 9: PROPERTY OWNER AUTHORIZATION
` Name and Address of Property Owner
PW C_0l"n\ex 57 0)orF S't, Ske ZE 5cr\em KA ORName— (Print) � No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
TI 1iChUe aocke_T* 51 Lu&rt ��y��e aF Sm�Yv� �} \Q Q
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)
f building is less than 35,000 cu.ft.of enclosed space ace and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
TktAnnol Roc "ek- q- c aRG `\q 5_q
ame Reg�strant) T ]ephone No. e-mail address Registration Number
9ln p12a0.a�} SN "' QC A �y� �q y I0
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
\'
11\rin1 C_ �C GV c
Comps Name
1-�c k QV�- CS -,`T 4 J( I d
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:WORKERS COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C fi
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 budding permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
1.Building $
ao Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to Ct y' A O�
6.Total Cost 1 $ Z�a (contact municipality)and write check number here _ 1694
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
51 l lhar�C 5� tS\ e aE �o\e_w tL\� okg-io
Street Address City/Town State Zip
A-�
Municipal Inspector to fill out this section upon application approval:. YC7"'^ i,Gfrn.
Name Dat
i CITY OF S�UEN4 MASSACHUS=S
• • B1:B.DINGDEPkmiENT
r 120 WASHINGTON STREET,r FLOOR
TEL.(978)745-9595
FAX(978)740-98"
KINfBERLEY DRISCOLL
MAYOR TkoMAs ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO3-MUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electiicians/Plumbers
Applicant Information _ `I \ Please Print Leeibly
Name(BusinessiorganizatioMlndividual): 't 1 I1Glq P C_OYES IlcsiCTd C,n ,L,r^
v
Address: 19lo6 V\2oscknlr ��V
City/State/Zip: "4rb\e h xa Phone#: Th - (li 31 - 30-7 )
Are your°employer?Check the appropriate box: Type of project(required):
1.10'(am a employer with 4. (] 1 am a general contractor and I 6. 0 New construction
employees(full and/or part-time).• have hired the subcontractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet t 7. remodeling
ship and have no employees Then sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp.insurance, g, 0 Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing a6 work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
comp.insurance required.]
Any applicant not chocks loos rl must also all out the sectim below showing their waken'compensation policy intumution
t IInmeownen who submit this affidavit indicating they me doing all work and thm hie outside commoton must submit a new affidavit indicating sud,
:Cuntracton that chuck this box must attached on additional shot showing The name of tho atbKoenrsctors tutA their workers'comp.policy intomutim.
ION an employer that Is providing workers'compel rarian insurance for my employees. Below!s the policy and Job site
information.
Insurance Company Name,_.Ass O CI CtV Tr n c
Policy#or Self-ins.Lie.#: W CC 50Q &00 VNt-4 Z.- 7 Cd q R Expiration Date: it 1
Job Site Address: _J li� � City/Stamaip: H4 �G-70
Attach a copy of the workers'compensation policy 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 S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations orthe DIA for insurance covcmge verification.
l do hereby ccrt er the sins and pealtien of perJary that the information provided above it true and correct
11 t ; 8
Phone#
OJJicial use only. Do not write in this area,to he completed by city or town aJJicIal
City or Town: Permit/License#
Issuing Authority(circle one):
L Board of Health L Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person- Phone#:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Emptgyers Insurance Company
54 Third Avenue, Buffington, Massachusetts 01803-0570
(800)876-2765 NCCI NO 40959
POLICY NO. WCC-500-5001- 342-2014A
PRIOR NO. I WCC-500-5001342-2013A
ITEM
1. The insured: Village Construction Inc
DBA:
Mailing,address: Mr Michael Rockett FEIN:`-"`1709
100 Pleasant Street
Marblehead,MA 01945
Legal Entity Type: Corporation
Other workplaces not shown above: See Location
2. The policy period.ls from 03/11/2014 to 03111/2015 12:01 a.m.standard time at the insured's mailing address.
3. A. Workers'Compensation Insurance:Part One of the policy applies to the Workers Compensation Law W.the
states listed here: MA -
B. Employers'Llability Insurance:Fait Two of the policy applies to work in each state listed In Item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 50%000 each accident
Bodily Injury.by Disease $ 500,000.policy limit
Bodily Injury by Disease $ 500,000 each employee
C: Other States insurance: Coverage Replaced by Endorsement WC 20 03 06 A
D. This Policy includesahese Endorsements and Schedules: SEE'SCHEDULE
4. The premlum for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.
All II rmation required below is subject to verification and change byaudit.
Classifications Premium Basia Rates
Code Estimated Per$160 Estimated
No:. Total Annual of Annual
Remuneration Remuneration Premium
INTEA 137531
INTER SE CLASS CODE SCHEDU
Minimum Premium;$560 r Total Estimated Annual Premium $550
GOV I GOV Deposit Premium $138
STATE 1CLASS
MA 1 42 MA Assessment Chg.
($99.00�x 33.4000-0%/�- $
This policy,including all endorsements,is hereby countersigned by - -`- 01/15/2014
Authomed.Signature Date
Service:Office: Boston Insurance Brokerage Inc
54 Third Avenue 24 Federal Street,4th Floor
Burlington MA 01809 Boston,MA 02110
WC 00 0001 A(7,11)
Includes copyrighted material of the National council on compensation insurance,
used with Its permisslon.
CITY OF SM-EN1, UNSSACHUSETTS
BumDLNG DEPkRT.%tEr7
120 W.ksHiOGTON STREET, 3"D FLOOR
TEL (978) 745-9595
FAx(978) 740-9946
KI,\tBERLEY DRISCOLL
MAYOR T HomAs ST.PtEM
DIRECTOR OF PUBLIC PROPERTY/BVILDING CO\LMSIONER
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 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.
`1T`he debris will be transported by:
UGryh 5AQ CjCX0 \"Cj Zvi L
(name of haul
The debris will be disposed of in :
NocrhSiC}�e Crvr �\v.a TYNC.
(name of facility)
TCAV'V-ex-5 \--14 \ern HOr
(address of facility) r
signature of permit applicant
date T-
d.brisafLdoc