57 WHARF ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
Department of Public Safety
L Massachusetts State Building Code(780 C
WIT Jl Building Permit Application for any Building other than a O -or T o amily elling
- .'- - � '(This;Section ForOffrctal Use-Drily) r ,-'
Bmliliiig Pernrit,lVumbet '=' "'`'--Date Applied '" '" "' :Building Of cial: - -
i
SECTION 1`..LOCATION(Please indicate Block#and Lot'#for locations for whiAka,.e6A address is riot available)"
51�`3-r--A- S*. O\Q�1C -'2�1\d
No.and Sheet City/Town Zip Code Nblne of Bud g(if applicable)
SECTION 2::PROPOSED WORI: ..
Edition of MA Mate 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 ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and./or construction documents being supplied as part of this permit application? Yes ❑ No UK
Is an Independent Structural Engineennng Peer Review required? Yes ❑ No a-�,
Brief Description of Proposed Work: \-Z \Qc 0 aC)LJ- C'`CjtOk7o 0/�.anC ��CYrC` a`CIQ� �X�-2�t�cSK'
SECTION 3:COMPLETE THIS SECTION IF EXISTING.BUILDING UNDERGOING RENOVATION,ADDITION;OR
..;! CHANGE IN USE OROCCUPANCY_
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.)
i
SECTION 5:,iUSE GROUP.(Check as applicable) /
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Factory F-1 ❑ F2❑ H: High Hazard__ _H-1❑ _ H-2❑ H-3 ❑ H-4❑ H-5❑
Institutional i-1 ❑ 1-2❑ i-3 ❑ I-4❑ M: Mercantile O Residential R-10 R-2❑ R-3❑ R-4❑
5: Storage .Sl ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Cfieck as applicable).
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
...
SECTION 7:SITE;INFORM?.TION(iefer:fo 780'CMR111.0 for details on each item)
Water Suppll Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public C3 Check if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site
Private❑ or indentify Zone: NO- �k 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 pSprinkler System?: Special Stipulations(: /
�. CITY OF S<UEN% iMASSACHUSETTS
BUHMING DEPARTaIENT
r I zo WASHINGTON STREET,3'FLOOR
sac Tat (978)745-9595
FAx(978)740-98"
KIN
iBERLEY DRISCOLL THOMAS ST.PIFRRB
MAYOR
DIRECCOR OF PI:BUC PROPERTY/lil;iLDING CON51ISSIONER
Workers'Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
_4pnlicant Information I Please PrintLealbiv
Name(Busktesslorganizatiorvindividuap:
Address:
City/State/Zip:C�S)Dg.2,cI(�f\AO\O�Ar D Phone li lEst-Cab\-'JO�Ib _
Are an employer?Check the appropriate box: Type of project(required):
I. 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance, 9, [:]Building addition
[No workers comp.insurance 5. ❑ We are a corporation and its
officers have exercised their 10.❑ Electrical repairs or additions
required.]
3.0 1 am a homeowner doing all 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. therR aQ�,q S
comp.insurance required.]
*An y appacam that checks box rrl must also nil uut the sectiao below slnwing their souks)'compensation policy infurmadoa
t tlnmeowntas who submit this affidavit indicating they x doing all work and then him outside comractors most submit a new affidavit indicating such.
=Cuntra•tors that shirk this box must att wheel an additional shst showing the come of fin aub-euntratam and their wotken'ramp.paiicy infommtion.
l am an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and joh slte
information. ^ _
Insurance Company dame:
Expiration Date:
Job Site Addn:ss: rJ1 � GZ F G— City/Statcaip: \ _Cn,cYyNQ) g�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration slate).
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 thyheettt(((DIA for insurance coverage verification.
l do hereby certify der tl alns and penalties ofperiary that the information provided above Is true and correct
Sientture. Date: 1��\
Phone q: _1 S\- Co'D bl Y)Q
Oirieial use onty. Do not write in this area,to be completed by city or town of vial
City or Town: PermitiUcense k
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#.
CITY OF SM E11% tiLASSACHUSETTS
• BL'II.DLNG DEPARTMENT
+ 120 W.\SHINGTON STREET,r FLOOR
TEt- (978) 745-9595
FAx(978)740-9846
yjx{BE1tLEY DRISCOLI
MAYOR 21tOMAs ST.P>ERRB
DIRECTOR OF Pt:BLIG PROPERTY/BCIIAING co%L\IISSIONER
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 a 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:
2�-Tr a cc,- \;ranZ'nc
(name of hauler)
The debris will be disposed of in
c ik'S;S Q Q� -'mac
(� (name of facility)
(address of facility)
signature of permit applicant
date
Jcbris�Ir.Joc
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington,Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. WC p 01342-20 3
PRIOR NO. WCC5001342012012_
ITEM.
1. The Insured: Village Construction Inc
DBA:
Mailing address: Mr MichaelRockett FEIN:"-**'1.709
190 Pleasant Street
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: Part One 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: Bodily Injury by Accident $ 500,000 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 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.
-'---
Classifications Premium Basis Rates 7
.Code Estimated I Per$100 Estimated
No. Total Annual Of Annual
-_ Remuneration Remuneration II Premium
INTRA 137531
3
INTER SEEICLASS CODE SCHEDULE i
Minimum Premium $550 Total Estimated Annual Premium $550
COV IE GOYSS Deposit Premium $138
STAT
MA 42 MA Assessment Chg.
_�._.-_- .c$/J0J0 x 4.2000% $
This policy, including all endorsements,is hereby countersigned.by `~�!r &fiea 0_U_18/201.3___
Authorized Signature Date
Service Office: Boston Insurance Brokerage Inc
54 Third Avenue 24 Federal.Street,4th Floor
Burlington MA 01803 Boston, MA02110
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on compensation Insurance,
used with its permission'.
SECTION9 -PROPERTY OWNER AUTHORIZATION.
_._. ..
Name and Address of Property Owner
PC3 Corn Pl 0, Z. a":' ,Cc <Q I ` o\q U
Name(Print) No.and Street' City/Town Zip
Property Owner Contact Information:
i \ m;C Q.�sh.'. `�1614�- GggO. 10LCo"�\-- "�'J'l0 crltoc`FA!\-c�nccacY-C\1'.ccaM
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
\ III,
-r- an- � \GC3P\2czzA(*
Name Street Address City/Town State Zip
to act zn the property owner's behalf,in all matters relative to work authorized by this budding permit application.
s:w" SECTION 10:CONSTRUCTION CONTROL(Please:fill out Appendix;2)
f bmldin is less than35,000 cu;ft of enclosed s ace and/pr not under Construction Control theh check here Band ski Section 101
10.1 Re istered Professional Rcs 3 onsible for'
' p ' �:C6nstrucfion Control
Name(Re istrant) Telephone No. e-mail address Registration Number
\5o (VIA 0\Z,I5 to
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
\/ \\Q conSAKCACV•oyv C0 . 1<lG.
Company N nRl
\. c`rrn.C\b�\�c�t, t cS- os1\O
Name of Person Responsible for Construction License No. and Type if Applicable
\go P�Qas��! c <b�QN-V_.ia \ o\CkI
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION lli:WORKER.S'-�COMPENSATIONINSURANCE,AFFIDAVIT M.G:Lt:c 152. 25C6
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, I ance of the building permit.
Is a signed Affidavit submitted with this application? Yes No ❑
FSECTION 12:CONSTRUCTION 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:Minimum fee=$ (contact municipality)
S.Mechanical Other $ Enclose check payable to
6.Total Cost $ aCS-Sa- (contact mmicipality)and write check number here I\
.... ...
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains mid penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
-IaX K.N - W10 _\ \3
Please pr' and sign name Title Telephone No. Date
\qo �
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval .
,. ...,:. , w ..
Name; " Date"