37 WINTER ISLAND RD - BUILDING INSPECTION (2) tr
The Commonwealth of Massachusetts
yA� V➢u I Department of Public Safety Nlassachusetts 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)
p
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 4� 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 X. No ❑
Is an Independent Structural Engineering Peer Review4 quired? r _ ,i ? Yes ❑ Nc, (
Brief Description of Proposed Work: FS Il(G� /Y�17 g `/� l� K I(:41ty ZCi�✓ ']J� l
r i
s
419 be
D oG 1
S CT ON 3:COMPLETE THIS SECTION If EXISTING BUILDING UNDERG16ING REN VATION,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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
--------------
1: Institutional I-1 ❑ 1-2❑ 1-3 El14❑ 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 IB EI IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 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❑ Check if outside Flood Zonc❑ Indicate municipal❑ A trench will not be Licensed Disposal Site
required❑or trench or specify: '
Private❑ or indentify,Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: 1 lntoric Cgnmu.si_h Rea.-n I r ce, s:
Not Applicable❑ - Is Structure within airport ap oach area? Is their review completed?
es or Consent to Build enclosed❑ Y ❑ or No7 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:
SECTION 9:.PROPERTY OWNER AUTHORIZATION
Name and Address of Pr perry Owner
Name(Print) No.and St eet City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
None 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 35,000 cu.ft.of enclosed space and/or/ not under Constriction Control then check here❑and skip.Section 101
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor " ' -
���TOA!
Company Name C
1 C/ (ho004�-sue �ST �/d� un�e�I�.f�c�i
Name o erson Responsible for Construction License No. and Type if Applicable
_� 'l
t is et Address City/ wn State Zi
Telephone No. business Telephone No. cell a-mail address
SECTION 11:.bVONKFIZ6'COkIPFNSAeKri IN:SURANKT.APFIOAVi Y 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❑ No ❑
SECTION 12:CONSTRUCTION:COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ V Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact mu ieipality
5. Mechanical Other $
Enclose check payable to
6.Total Cost (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my none below,I hereby attest under the pains and penalties of perjury that the information contained in this
application is true and accur.to to the best of my knowledge and understanding.
Pleas prurt and sign e e T ephone No. Date
Street Address Cit /Town to Zip (�
Municipal Inspector to fill out this section upon application approval: - [
`. Name Date
CITY OF SiUEII, NLUSACHL SETTS
Buami:lc;DEPARTMENT
� � �• l'_O\nbSHLNGTON STREET, J"FLOOR
TEL (978)745-9595
FA.e(978) 740.9846
ICI.\BFRi FY DRISCOLL
MAYORT1i06lAS ST.PIEARB
DiltELTOROF PUBLIC PROPERTY/BUILDING CObLIISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant information �Please
� Print Legibly
V;tI11C l0usiaxy�Urganizaltio vindividual): � 1' 44UL 4 LC
Address: ( � )A�(A 004? i�
City/State/Zip: Phone#: �_�V
Are ou an employer?Check t e appropriate box: Type of project(required):
1.Are
a employer with 4. Cl I am a general contractor and 1 6. ❑New construction
employees(floll and/or pa -time).•-� have hind the sub contractor
2.0 I am a solo proprietor or pars cr- * Iisttidon the attached shau't l 7• ❑Remodeling
ship and have no employees These subcontractors have S. []Demolition
working for r;a in;iny capacity. workers'camp.insurance. 9, 0 Building addition
(No workers comp.insurance 5. 0 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 I I.❑Plumbing repairs or additions
myself.(No workers'camp. c. 152,§1(4),and we have no 12.[] Roof repairs
insurance required.)r employees.(No workers'
camp.insurance required.) !J.❑Other
•Any appllcum dwl vilml a boa el mutt alto fill uut The seclim below showing Chair worker'compensation p°If�y inromaalfoo.
'lhwnuuwm"who submit this affidavit indicting They ant doing ell wOr#and than hint Mnlide contrctaa most submil a new amdavil indicating ruck
!Caneroclun that check This box must anachodan a Wiuurwi,hrrt showing Tho name of the aubs-goo nl and Ihalr worked'mmP.policy infornution.
lain un employer that is providing worker'comprnradon Laurance jar my employees: Below is 111e policy end Job site
information.
Insurunce Company Name:. Q
tulles it ur Self-lets.Lire/.H: J( l��® ( — ExpimtTion Date:lLO—ZJ
Job Site Address:ant ! lr �.Sl lJ City/S12t1!JZip:
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 ot'41GL a 152 can lead to the imposition of criminal penalties of a
tine 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. Ile advised that a copy of this statement may be forwarded to the Office of
Investigtuimts tifthe DIA for insurance coverage vcritiealiun.
/doherebyterllj aderthepal endpenukles ejperfury t/rat the LajoreruNon provided above is true mr,/l correc6
,. ., Dure• A /�� 1
phone
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oJJlrial use only. Do not wrire in rids urea,robe contplered by city or town a lela2
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City oe 7usvn: __-_ - Pcrm(tR.lccnse x _` ---_------
Issuing Auiburily(circle one):
1. Ruard of Iivulth 2. Building Deparbnent J.City/fown Clerk 4. Electrical inspector 5. plumbing Inspector
6.Other
Contact Person: _... . . . --- _ Phone It'
CITY OF SA1LEM3 ,NL WSACHUSET'I'S
�� .
BI:tI.DL�iG DEP.►R-I1lEYT
120 CV.•1SHLNrTON STREET, 3"�Room
TEL (973) 745-9595
(CIJ[0ERL EY DRISCOLL FAx(978) 7-J0.9345
.NILLYOR Dtomm ST.PIEILU
DMECTOR OF PLELIC PROPERTY/EILIML%1G COJp(15SIOYER
Construction Debris Disposal AftIdavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Coda, 730 CMR section l 11.5
Debris, and the provisions of tbiGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall ba disposed of in a properly licensed waste disposal facility as defined by tMGL c
(11, S 150A.
The debris will be transported by:
(name of haulur)
The debris will be disposed of in :
(name oP acdity)
(aldrcss u ratihty)
sign re of Pcrmil applicant
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13 Windsor Road
MOw w ' ® � Beverly,MA 01915
.Y�'SJ` K 978-927-2005 w
REMODELING & REPAIRS LLC - 976-927-2005f
- - - - www.morYisonremodeling.com
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