80 WHARF ST - BUILDING INSPECTION (2) tt� CK -709 ,)
REGE IS
The Commonweal o sakhs �ts
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Department 1 sty hlassachusetts State Building Code(780 CMR)
_ Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Onl )
p Building Permit Number: Date Applied: Building Official:
I SECTION 1:LOCATION(Please indicate Block 0 and Lot M for locations for which a street address is
No.and Street City/Town Zip Code Name of Building(A applicable)
SECTION 2:PROPOSED WORK
Edition of NIA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Alteration ❑ 1 Addition E37 Demolition ❑ (Please fill out and submit Appendix l)
Change of Use ❑ Change Of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes Cl No ❑
Is an Independent Structural Engineertn Peer Review reyuired? \ Yes ❑ No ❑
Brief Descri plion of Pro used Work cl n S IGP
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n� �Jt lr v.a C.).r� clSyn�rCCxSa
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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) O
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.) `3
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-t❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E., Educational ❑
F: Facto F-I❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-I❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile ClR: Residential R-l❑ R-2❑ R•3❑ R-4❑
S: Storage S-t ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ ILA Cl HB Cl 1 HIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
waters upply:/ Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 6 Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required ❑or trench or specify:
Private O or indemify Zone: or on site system❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: MA I I. t"ri Cgirypn,si .,it._.� . I pot...:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes Cl or NO❑ 1 Yes O No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): type of Construction: _ (kcupain Load per Floor:
Uoes the builJiny,con lain an Sprinkler System?: _ Special Stipulations:
lM Al L- Tn OFFICE
SECTION 9. PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Ate -[ L& r- 5
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
-
Title Telephone No.(business) Telephone No. (ceR) a-mail address
If applicable,the property owner hereby authorizes
Mine 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 building is less than 35,0M cu.ft.of enclosed space and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. c mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
'A 1
Compan Name
tl ` 1 /'1
Name of Pierson Responsible for Construction License No. and Type if Applicable
-)
Street Address City/Town State Zip
G .
ll2-0-&HO
Telephone No. business Telephone No. cell a--mad address
SECTION 11:WORKERS'COMPVNSA'rION INSURANCY..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 issuance of the building permit.
Is a signed,Affidavit submitted with this application? Yes 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor l0 r-)o
and Materials) Total Construction Cost(from Item 6)_$ t
t. Building $ Building Permit Fee=Total Construction Cost x—(insert here
2.Electrical $ appropriate municipal factor)=$
3. Plumbing $
d.Mechanical (HVAC) $ Note:Minimum feem$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ `0 cjci (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By 7" n
r ame below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this _
app is t re and accurate to the best of my knowledge and �understanding.F2skrJ e o- [
Pleas print and sign name Title Telephone No. Date
r� S) �1r1Z17
Street Address City/Town State Zip
Municipal inspector to fill out this section upon application approval•
Na to Ll Date
The Commonwealth of Massachusetts
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Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(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 Building(if applicable)
SECTION 1 PROPOSED WORK
Edition of MA State Code used_ If New Construction cheek here Cl or check all that apply in the Iwo rows below
Existing Building❑ Repair❑ 1 Alteration ❑ I Addition❑ 1 Demolition O (Please fill out and submit Appendix I)
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 IndependentStructuml Engineering Peer Review required? Yes ❑ No O
Brief Description of Proposed Work:
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 ClvIR 34) 0
Existing Use Group(s): IProposed Use Group(s):
SECTION4: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 S.USE GROUP(Check as applicable)
A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑
R Facto F-I❑ F2❑ If: High Hazard H4❑. H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional 1-1❑ I-2❑ 1-3❑ 14❑ 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) -
fA ❑ too HA ❑ 111) 0 ILIA ❑ IIIB ❑ 1 IV 1 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 i] Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify, required❑or trench or specify:Zane: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: %I_\I Boon, Nevi.!..
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No O 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition al Cade: Use Group(s): Type of Constriction: Occupant Load per Floor:
Dnes the building nmtain an Sprinkler System?: Special Stipulations: _
The Commonwealth ofMassaehusetls
Department oflndustrialAccidents
I Congress Street, Suite 100
Boston,MA 02II410I7
UW www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Avvileant Information Please Print JA 'bl
Name(Business/organization/Individual): I \\ f \e
Address:
City/State/Zip: SG2��1n) Q��C��97d Phone#: 97i� 1LIQ (0`RC)
Are you an employer?Check the appropriate box:
T7'Pa of project(required):
1.❑I am a employer with employees(full and/or part-time). 7. New Construction
2.Q I am a.sole propriew or partnership and have no employees worl®g forme in 8. Q Remodeling
my capacity.INo workers'comp,insurance required.]
3.Q I son a homeowner doing all work myself.[No workers'comp.in required.)t 9. Q Demolition
4.O Imo a homeowner and will be hiring contractors to conduct all work on my property. I will ]0 Building addition.
ensure that all connactm3 either have workers'compensation insurance or are sole I LE]Electrical repairs or additions
proprietors with uo employees.
12.�Plumbing repairs or additions
5.Q I am a general contractor and I have hired the sub-bontiactm listed on the attached sheet. -
These subcontractors have employers and have workers'eomp.msurnoms 13.❑Roof repairs
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. er 1\p.i 5
I5z§1(4),and we have no employees.[No workers'donW.insurance requited.]
Any appliiem that checks box#]must also fill out the section below ahowurg theirworkers'compensation polity infdrmatioa.-
t Homeowners who submit this affidavit and catmg they ere domg all work and then hue outside contractors most submit a new affidavit indicating such
iContrach s that check this box must attached an additional sheet showing the more of the sub-cohowars and state whether or not those entities have
employees. If the sub-comractoss have employees,they must provide their worker s'.romp.polity,number... -
I am an employer that is providing workers'compensation insurance for my employees.:Below is-the poliey and jobsile
information. /� r
Insurance Company Name: A55c1c i Ae-X r IM9`in( er 5 -I-vim,,)r4H[ P_ C 6 .
Policy#or Self-ins.Lic.M U-X -SCn-`5CO�- LA Z- LG I&A Expiration Date: Is III q
Job Site Address: i)r, S T City/State/Zip: S=12 r^, /t Ala U
Attach a copy of the workers'compensation policy declaration page(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 may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby c u er the pains and penalties ofperjury that the information provided above is true and correct
ig nature: Date: I I U I Co
Phone#• �1� 1 w - k ck c n
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF SALEA4 MASSAcHus s
r BuiLDudG DEPAR7wmr
120 WASMNGTONSTREET,3"FLOOR
TI L(978)745-9595
FAX(978)740-9846
RIIv18ERL.EYDRISQ'�LL
MAYOR THOMAS ST P ERRE
DmECroROFPUBLICPROPERTY/Bu[LDmoomm SS1o7�n
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
�� 1 1
(name of hauler)
The debris will be disposed of in:
(name of facility)
�CQS bUf- a LA tAA-
(address of faci ity)
Signature of applicant
��\1l0 \lro
Date
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. I WCC-500-5001342-2016A
PRIOR NO. I 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 OV Deposit Premium $898
STATE CLASS
MA 42 State Assessments/Surcharges
$559.00 x 5.7500% $32
This policy, including all endorsements, is hereby countersigned by 4 _ &-E;-a 01/08/2016
Authorized signature Date
Service Office: B 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.