57 WHARF ST - BUILDING INSPECTION (5) •• 1 ti: II
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(730CMR)
Building.Permit Application for any Building other than a One-or Two-Family Dwelling
O (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)
No.and Street City/Town Zip Code Name of Bufl ' g(if applicable)
® SECTION 2 PROPOSED WORK
iEdition of MA State Code used_ If New Construction check here❑or check all that apply in the two roses below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit AppendN l)
Change of Use ❑ Change of Occupancy ❑ 1 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? \ 1(es ❑ �No E7�
Brief Description of Proposed Work: yeQO ftC l.�l�(1!1(Yi1�,Q�Q'�r GYI(1_ 1 IYlC
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 CNIR 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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Factory F-I❑ F2❑ H: Hi h Hazard H-1 ❑. H-2❑ H-3 ❑ H-4❑ H-5 CI
1: Institutional I-I❑ 1-2❑ 1-3❑ 1-4 CIM:.Mercatittle❑ R: Residential R-10 R-2❑ R-3❑ 1140
S: Storage S-I ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ Ill ❑ HA ❑ If6 ❑ IIIA ❑ [fill ❑ 1 IV ❑ 1 VA ❑ V13 ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Su`p—pI Flood Zone Information: Swage Disposal: Trench Permit Debris Removal:
Public[� Check if outside FlooJ�Zone❑ Indicate municipal A trench will not be Licensed Disposal Site
required❑or trench or specify:
Private❑ or indentify 1--I�L Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \I\ l .,t i i „nm�i,u n It vi,n. I'rrC
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 Cade Use Group(s): Type of Cun.stnuction:" Occupant Load per Hooc
Dues the building contain an Sprinkler Systend; Special Stipulations:
MA1L�p 12��
SECTION9: PROPERTY OWNER AUTHORIZATION
nr
r.an i .\ddnss 1 I'roprrty Usvner
Name(font) No.and Street City/Town Lip
Pro)rrty Owner Canto.•t Inform itfon:
�+ra�l`�sk���� -i h9n 9� �\cxs �rfx�4�k mr�rr�.
Title Telephone No.(busme s) Telephone No. (cell) e-mail address
If a >>licable,the property m ner hereby authorizes
l-1 L6 cos is �(fc4. -
Name Street Adders, . - -ciwl town Stale Zip
to act on the +ro+ert% owner's behalf, m all matters relative In work authorized by this buildin• permit a r rlica Lion.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If buildin•is Iris than 35.(Wcu.tt.of ena'losW s wcu and/or not under COMAnietion Control then check here O and ski !kmiun I0.1)
10.1 Regis ered Professional Responsible for Construction Control
�'M�\c1-�ae� 1��(a�-� ��. IIbSc I�IraJ4'�Jfnrra_u,�ua
Name(Registrant�` Tele+h ne No. e-mail a dress Registration Number
l�s.,v, U
Street Address �— City/Town State Zip Discipline Expiration Date
10.2 General Contractor
U\\Vvc e caal k( igir.
N,me of Person Responsible for Construction License No. and Type ff A licable
� Wl�v���trenl,�ieo�-Grp\
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.352. 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 3ust be completed and
submitted with this application. Failure to provide this affidavit will result In the denial of he f anceof the building permit.
Is a signed Affidavit submitted with this application? Yes No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=SLCQ (�
1. Building Sce,i,noo Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical S appropriate municipal factor)=S
3. Plumbing $
4. Mechanical (HVAC) S Note:Minimum fee=S (contact municipality)
flew,5. Mechanical (Other) S Enclose check payable to Q C
6.Total Cost S Co.00C) '— (contact munfcf alit )and write check number here
SECTIO 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the rams and penalties of perjury that all of the information contained in this
application is true and accurate to the best if my knowledge and understanding.
A J1Q� 3r
I'lea.c print.cod sign name ride Tale phone No. Date
ULW
l ;Irevt .lddress ('ity;'Torun ,S1.1te Zip
!J
Municipal Inspector to till out this section upon application approval: `4^'I
OTYOF SALEA MASSACHUSEM
BI.QIDINGDEPARTMENr
120 WASIMNU nMaSTREET,3'DFiooR
7LL(978)745-9595
FAX(978)740.9846
' KIIvIBERLEYDRIS�LL
MAYOR THOMAS ST.PMERBE
DIRECTOR OF PUBLicPROPERTY/BUIIAING ocmussOMR
Construction Debris Disposa/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 00, S 54; Building Permit p 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 debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
s V
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
UV www.mass.gov/dia
NVorkers'Compensation Insurance Affidavit:Builders/Contradors/Electricians/Plumbers.
TO BE FH.ED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Iezfblv
Name(Business/oigam7ation`/I-ndividual):
r
Address: �> lti��r�0.�F PP� �� h�2 Q—F—
City/State/Zip: Phone#:
Are you so player?Check the appropriate box:
Type of project(required):
I. am a employer with employees(fall and/or part-time).' 7. �❑�New' construction
2.01 am e.sole proprietor or partnership and have no employees working for me in g• ly^cmOdehng
an capacity.[No workers'comp.insurance required] - u�3.❑I am a homeowner doing all work myself.[No wodmrs'comp.insurance required.]t 9. El Demolition
4.n Iran a homeowner atd will be hiring contractors toconduct all work on my property. I will 10 0 Building addition,
ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet.Tbesesn b-contractors have employees and have workers'comp..a ro 13.mmo t ❑ROOfT- epnits
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§](4),and we have no employees.[No workers'rip.insurance regtmed.] - -
•Any applicant that checks box#1 must also fill our the erection below workers competrsetion pohry mformation.
t Homeowners who submit this affidavit indicating they are doing all work and than him outside contractors now submit a new affidavit indicating such
tContractors that check this box must attached an additional sheet showing the music of the sub-cautractors and state whether or not those entities have
employees. If the sub-contrarturs have employees;they must provide their workers'.comp.polity.number. _
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job sue
information. n
Insurance Company Name:' `�,, M r' •'� -7
Policy#or Self-ins.Lic.M' \\�\\A��X �l l 1'�OD-,3`',Io�'r O Expiration Date: y r�7(� 1
Job SiteAddresa:5-1UJ ckf-V c, eel �\IC�tYKCA city/State/Zip: M / 01
Attach a copy of the workers'compensation policy declaration age(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 penalties in 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 rosy be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains penalt' jperjury that the information provided a4 ove#trur and correct
Signature: T G Date:
Phone#i'
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
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#:
li
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. WCC-500-5001342-2016A
PRIOR NO. WCC-500-5001342-2015A
ITEM
1. The Insured: Village Construction Inc
DBA:
Mailing address: 196 B Pleasant Street FEIN:"-"'1709
Marblehead, MA 01945
Legal Entity Type: Corporation
Other workplaces not shown above: See Location
2. The policy period is from 03/11/2016 to 03/11/2017 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 B
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
Code Estimated Per$100 Estimated
No. -Total Annual Of Annual
Remuneration Remuneration - Premium
INTRA 137531
INTER SEE CLASS CODE SCHEDU E
Minimum Premium $550 Total Estimated Annual Premium $866
GOV GOV Deposit Premium $898
STATE CLASS
MA 1 42 State Assessments/Surcharges
$559.00 x 5.7500% $32
This policy,including all endorsements, is hereby countersigned by C � C'.p 01/08/2016
Authorized Signature Date
Service Office: 8 R Alexander
54 Third Avenue 50 Congress Street Suite 530
Burlington MA 01803 Boston, MA 02109
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
A.I.M. Mutual A.I.M Mutual Insurance Company
Massachusetts Employers Insurance Company
Y P Y
New Hampshire Employers Insurance Company
INSURANCE COMPANIES Associated Employers Insurance Company
• CERTIFICATE OF INSURANCE
To better service your needs and help you process your request for a Certificate of Insurance
for this policy, fax in your request directly or call the following members of our service team. We
look forward to helping you process your request promptly and accurately.
Certificate of Insurance Fax Request: 1-781-270-5690
Fax anytime, 24 hours/7days
Or call us at 1-800-876-2765:
Debbie Cox ext. 8740 dcox@aimmutual.com
Debbie Gargano ext. 8975 dgargano@aimmutual.com
54 Third Avenue • P.O. Box 4070 • Burlington, MA 01803-0970 • Tel: 781.221.1600/ 800.876.2765 • Fax: 781.270.5599
BRIDGEWATER• BURLINGTON • CONCORD, NH • HOLYOKE• MARLBOROUGH
sponsored by Associated Industries of Massachusetts