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57 WHARF ST - BUILDING INSPECTION (3) Ta- -7 Z-q(,, 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 ">(11us Section Por:OfficialUse Only)" ,;: - �\ Building Permit Number " """""Date Applied `" "$iiil3ing Official. d SECTION 1::LOCATION(Please indicate Block=#and Lot#.for locations for which a street address is not available) 51 UJhc '�S� . �c�\2r� c`N� o\oil o No.and Street 2 City/Town Zip Code Name of Building d applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building 91 Repair❑ Alteration ❑ 1 Addition❑ 1 Demolition (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No — / Is an Independent Structural Enginee?q g Peer Review required? Yes ❑ No UI Brief Description of Proposed Work: 1�2m��r \ 0�- (,�Q�c�c I hC7n' SECTION 3:.COMPLETE THIS SECTION IF EXISTING BUILDINGDNDERGOING:RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY -' Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): - - a - SECTION 4:',$UILDING-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.) e,SECTION5:-USE.GRO,UP(Check as.applicable) c A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ - H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 El 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: CONSTRUCTION TYPE(Check as applicable) IA ❑ - IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ I VA VB ❑ SECTION 7:SITE,INFORMATION.(refer3o�780 CMRld1.O for details on each item) Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public Check ifoutside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site IV " 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 Cl 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: CA Lt_ S'�1-lam ,eJ � t �Lf�vt�' 11 71 }EY I SEt�ID TD Z E SECTIONI9: PROPERTY OWNER AUTHORIZATION r' Name and Address of Property Owner - P( J Cc cy-N V x�—L 511�J\ti c& , E ��\e c (VA O\C—1 C� Name(Print) No.and Street City/Town Zip Property Owner Contact Information: _ - Chloc\'VQ\\-DM'C'(cice , Title - - Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes �' C\,t:,Q\ cr��b\a�or cr\ o\g�S 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) If buildin is less tlian35,000 cu.ft of enclosed'-'s ace and/or not under Construction Control then check here 0 and skip Section 10.1 10.1 Registered Professional Responsiblep for.Construction Control Nam e�Re�' trant Telephone No. e-mail address Registration Number _ Street Address - - City/Town State Zip Discipline Expiration Date 10.2General Contiactor- - - - Company NaAe Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip - TeIe hone 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 ust be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the' ance of the building permit. Is a signed Affidavit submitted with this application? Yes No ❑ 'SE CTION11 CONSTRUCTION COSTS,AND_fP,ERMITFEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ S "' 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 C,- OYsA C\QM 6.Total Cost $ — (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. - \ .m;cl�cal� Kru - mr . 101 - 1 l at t Please print and si name Title 1 Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approvals. Name -- Date i CITY OF &UENI, NWSACHUSETTS BL'BDING DEPAR-MW..NT 120 WASHINGTON STREET,r FLOOR o* TEL(978)745-9595 FAX(978)740-9846 KI\tBERLE'Y DRISCOLL ,MAYOR THOMAS ST.PIERME, DiRECi'OR OF PI:BLIc PROPERTY/BUILDING COdLNISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business lorgauiradomodividual): Address: City/State/Zip:C(c.-Ib\a)r)-&e\ �C r\/�O\g� l� Phone#: Are yo employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).• have hired the subcontractor 2.❑ 1 am a sole proprietor or partner- listed on the ottaehed shccL t 7. ❑ ling ship and have no employees These sub-contractors have. 8. Demolitioa working for me in any capacity. workers'comp.insureoce. 9, ❑Building addition [No workers'comp.insurance S. ❑ We are a corporation and its 10.❑Electrical airs or additions officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑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' comp.insurance required.] ME]Otber •Any apparent ttnteheds box al most also fill our the section belowshnwing their woken'compensation policy inrunnaden. *I Immowtten who submit this aftidava indicating they ate doing all work and then hire anside cwwacton must submit a raw affidavit indicating root. . :Cuntracton that check this box must attached an additional suet showing the none ortln ad,.aamawton and their woken'comp.policy information. I rem on employer that leProvidhrg uvorkers'compensation Insuratrce for sty employees. Below IS the polley and Job site information.Insurance Company CNQa Ec*,, �C ��rS J Policy#or Self-ins.Lic.#: �3C- - 1-c U\�jya-�O\ Expitntloa Date; 2SU\ -k Job Site Address: 5D,\n�k �J�- . City/State/Zip:_`- G Ocn AQV(K) ) 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 of the DIA for insurance coverage verification. I do hereby er th a $ an tcualtles afperfnry that the lnformadon provided above Is true and correm Sienallfre:_ / Date: ��a,\\ Phone#: 1cb\- (o�5\— »l� OJJicial use only. Do not write In this area,to be completed by city or town o 1clal City or Town: Permitll.iecuse# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.C)tyirown Clerk 4.Electrical inspector S.Plumbing Inspector 6.Other Contact Person- Phone X. CITY OF SmF.m, i%Ic sAcHU$ETTS BuR DING DEPARTMENT 120 WASHINGTON STREET, r FLOOR TEL (978) 745-9595 FAX(978)740-9846 1QJIBERLEY DRISCOLL MAYOR THoms ST.PmRRB. DIRECTOR OF PUBLIC PROPERLY/BUILDING COAL MIONFR 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. The debris wilt be transported by: (name of hauler) The debris will be disposed of in CGt �n�T1C . (name of facility) (address of facility) signature of permit applicant date Jcbrisafr.Ja . Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot#for locations for which a street address is not available) No. and Street City /Town Zip . Name of Building applicc le) For the above described property the following action was taken: Water Shut Off? Yes ❑ No CAI Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No El-"- Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? .Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) wm WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE 4_ Associated Employers Insurance Company 54 Third Avenue, Burlington,Massachusetts'01803=0970 (800)876-2765 NCCI NO 40959 POLICY NO. I WCC-500-50C 42-2013Ai PRIOR NO. WCC5001342012012 ITEM 1. The Insured: Village Construction Inc DBA: Mailing.address: Mr Michael Rockett 190 Pleasant Street FEIN:"-""1709 Marblehead,MA 01945 Legal Entity Type: Corporation Other workplaces not shown.above: See Location 2. The policy period is from _03/11/2013 to 03/11/2014 12:01 a:m..standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Partone of the:policy applies to the Workers.Compensation Law of the states listed here: MA B. Employers'.Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A The limits of liability under Part Two are: Bodilyinjury'by Accident $ Bodily Injury by Disease $ 500,000 each accident Bodily.Injury by Disease $ - 500,000 policy limit _ 50O,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC2003 06 A D. This Policy includes these Endorsements and.Schedules: SEE SCHEDULE 4. The premium for this policy will be determined.by our Manuals.of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. - Classlticatio— n- g----- -- —..__... remiumBasis ..._._ _ _ Rates ­ '- — T Code I Bshmated Per$700 No. Total gnnual Of j Estimated ---------- No I Remuneration PremAnnium I 1 INTEA 137531 i — i INTER I I iSEEi CLASS CODE SCHEDUI E Minimum Premium $550 ------ -� t GOV GOVV� Total Estimated Annual Premium $550 I Deposit Premium STATE CLASS $138 _ 42_,� MA Assessment Chg. [$$..OQ�x 4C2b0 o%(,- $ This policy,including all endorsements, is hereby countersigned by "�-'��`"-"'c-��` ' ------- __ 01/18/2013 Authodzetl SignaWre ------------ Date Service Office: 54 Third Avenue Boston Insurance Brokerage Inc Burlington MA 01803 24 Federal Street,4th Floor Boston,MA 02110 WC-00 00 01 A(7-11) - Includes copyrighted material or the National council on Compensation Insurance, used with its permission.