59 WHARF ST - BUILDING INSPECTION The Commonwealth of Massach setts
® Department of Public Safety,
,Massachusetts State Building Code(7,KCMRI
Building Permit Application for any Building other tha a One or 6-FamV Dwe ling
. (Phis Section For Official Use Only)
Building Permit Number:.. Date Applied: BuIIding al:
SECTION 1:LOCATION(_Please indicate Block#and Lot#for locations for wh'\h a street address is not available)
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No.and Street City/Town Zip Code Name of Building(if 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 ❑ 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? pp Yes ❑ No 2-1,Brief Description of Proposed Work: ria 'Cl C e. .f Ut-
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: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ 1 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:
- SECTION 6:CONSTRUCTION TYPE(Check as applicable) -
IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ . I VA ❑ VB ❑
- SECTION 7:SITE INFORMATION(refer to 780CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public A trench will not be Licensed Disposal Site
d Check ff outside Flood Zone❑ Indicate municipal Private❑ or indentify Zone: A0`i 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 thew 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 Sprinkler System?: Special Stipulations:
SECTION9: PROPERTY OWNER AUTHORIZATION A -
Name and Address of Property Owner
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. .- Name(Print)" - No.and.SMeet City/Town Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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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 buildingis less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control - -
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Name(I;egrstrant) Telephone No. e-mail address Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor`
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Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
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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 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 ji suance of the building permit.
Is a signed Affidavit submitted with this application? Yes IY No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor •�s.�
and Materials) Total Construction Cost(from Item 6)_$qJ� —
1. Building $ 'a50CJ^ —
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, A-y U t-
6.Total Cost $aZ — (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT -
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
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Please pri t and sign name Title - Telephone No. Date
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Street Address City/Town State Zip
rmllicipllellspector to fill out this section upon application approval:
Name Date
i CITY OF S�U.Ebt, MASSACHUSETTS
• BUILDING DEPAR11EENf
120 W ASHINGTON STREET,3sa FLOOR
\ TEL (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
,MAYOR T3IOMAS ST.PWIM
DiRECTOR OF PUBLIC PROPERTY/BUILDING CO%MUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contratstor3mlectriciaiWPlumben
.Applicant information Please Print Legibly
Name(Business,Organiufion/Individual): V• ,\Qa.L+ ��•-t t t �� ni{1
Address:
City/$tate/Zip:Math\eY,aad MAU\g`+:pPhonc M -A8\- Qbcg- a\-J \
Are YAu an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 4. 1 am a general contractor and 1 6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or patu=- listed on the attached sheet.t 7. 0 Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp. insurance 5. We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
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' ME]
comp.insurance required.]
•Any applicant that checka box al must also fill out the section tnelowshnwing their workers'compensation policy infotmaaon.
t I lnnteowtcs who summit this affidavit indicating they arc doing all wink and then him outside eontmeson must submit a now affidavit indicating such.
:Comrawn that cheek this box must attached an additional ahaet showing the mate of as a,b,,ar usoM and thek workors•comp,policy infomution.
l am an employer that is providing workers'compensation hisarance for my employee& Below is the policy and Job sloe
information. //�
Insurance Company dame:' (—), �- C.C.VQA ErrOL\ g� T• -s C—C-1 .
Policy N or Self-ins.Lic.is V3gC- aJ�-'r ram\aO\� Expiration Date:_4.k\\rb
Job Site Address: 5- v1�ec��J�t • City/State/Zip: C f\A
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 bet forwarded to the Office Of
Investigations of the DIA for insurance coverage verification.
l do hereby certify under the pains and penaltles of perjury that the information provided above is true and correct
Simai trea Dam6 \ k \
Phone q;
OJJfciai use only. Do not write in this area,to be completed by city or town ofiklet
City or Town: Permit/I.Icense q
Issuing Authority(circle one):
1.Board of Stealth 2.Building Department 3.Cilyifown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#
CITY OF SM 11, NLkssAa-iuSETTS
• BuU DLNG DEPART%mN T
130 WAsHtNGTON STREET, 340 FLOOR
bT TEL (978) 745-9595
FAX(978) 740-9846
KI,\fBERLEY DRISCOLL
MAYOR THoatas ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%UISSIONER
Co6struction 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 will be transported by:
t1�rc � caeca<�;r�
(name of hauler)
The debris will be dispo�sed of in :
-5 nc>AN 'CAQ- \/ a-"L���-
(na(m�e of facility)
(address of facility)
signature of permit applicant
date
debrisAff.0c
From:ROCKET REALTY 7816392290 05/11/2012 C9:55 #392 P.001/001
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
64 Third Avenue,Burlington,Massachusetts 01111103
(600)676-Y7e5 NOCI NO 40959
POLICY NO. WCC 5001342012012
PRIOR NO. WE 5001342012011
ITEM
1. The insured vipage Construction Inc
Mail Address: Mr Michael Rocketl Marblehead MA 01945
190 Pleasant Street
Street No. Town or City County State Zip Code
FEIN nmor1709
Olndlvidual [3PadnwshiP 000MOM oA OJoinl Venture El asociellon (]Other
Other vorkplacea not shown above:
2. The polity period is from Q'�]12012 to OY112013 12:01 a.m.standard IMe at the Imuied's malting address.
3. A. Workers Compensation Ineurenee:Pen One of the policy applies,to the Workere Compensation law of the stales Haled here;
MA
6. Employers Liability Insurance:Pat Two of the policy apples to wok in each state listed in item S.A.
The limits of our fiabaity under Pad Two ere: Bodily Injury by Accident S 500,000 each accident
Bodily Irdury by Disease 6 ___§Qg,lgQpodcy limit
Wily Injury by Disease 8 500.ODD each employee
C. Other States Inaurenw:Coverege Replaced By Endorsement WC 20 03 06A _
D. This policy Includes these endorsements and schedules:SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Gassiricallons.Rates and Rating plans.
All information required below is subject to"Akdon and change by audit
Clessihcallons Premium Stake Rates
Coo. E� Perahaa EmTbua
ft. TOW meal a Amue
Renwnw.am RarwRr.fim PrenNrm
INTRA 137531
SEE (TENSION OF INFORMATIC N PACE
Minimum premium$ 500.00 Total Estlmeted Annual Premium $ 550.00
As indicated iltertn adjustments of premium shall be me": Deposit Premium $ 138.00
❑ Annually O Semd Annually ® Quarterly ❑ Monthly
MA Aaseesment Chg.
S291.00 x 5.9000% S0.OD
Gl_.¢-'Lila.
This policy,Including all endorsements,is hereby couttemi2ned by 01279012 _
AWvuad Slv. bee
Boston Inaturance
T'OVATE CUSS A1101T OFFIIE OFFICE CG CLAIM HECK NAME
ROUP 24 Federal Street B41hFlooe Inc
IAA I 5022 I 26 WO Boston,MA 02110
WC 00 00 O1 A(7-11)
w.m.s W hwd.w.d.I of me N.son.l Ceenw.n cerrR.ewa,Manta,
chat oiN its e.rma.KK'.