0055 FEDERAL ST - B. P. APP B-15-1233 �c>✓� -r--� 3�cel 3 5
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The Commonwealth of MaMhr dPiW SERVICES
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Department of Public Safe
Massachusetts State Building Code(7s�p KOV _q A 11: 1 1
Building Permit Application for any Building other than a One-or Two-Family Dwelling
t - (This Section For Official Use Only)—
Budding
nl )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)
:!Tr ) e jd "R X st 546ewr mA• o (t10
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 a6 that apply in the two rows below
I Existing Building❑ Repair le I Alteration ❑ 1 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 gil—
ls an Independent Structural Engineering Peer Review required? // Yes ❑ No 5?3
Brief Description of Proposed Work:_le Me V e d L b S'N---� 4 p Q x
Ero41 cu4LL S t C ; e c 1ilJtq 3 2 (14+1t, A000„ c
y- -P 4Lan to 4" i *k hl)e4y
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(R.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1❑ A-2 13Nightclub [3A-3 [3A=1 C3 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 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ - R: Residential R-113 R-2 fd' R-3❑ R-4❑
S: Storage S-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 111 IIA 13 JIB 13 1111A 1110 13 1 IV 13 1 VA E3 VB 13
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)'
Wafer Supply: Flood Zone Information: Sewage-Disposal:
Trench Permit. Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicatemunicipal 13A trench willnot be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required 13 or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA I listoricCummiuiun Hegwy_Pnxc=s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ or No❑ 1 Yes Cl No Cl
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 Property Owner
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Name(Print) No.and Street - City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
04 Li 064cX?7,1W / "?/ Zo�OL L -5t 6157,1- 0
None Street Address City/Town State Zip
to act on the property owners 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 s ace 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. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
- 10.2 General Contractor
50 eh I102,4AI C'�u, st PGvs
Company Name
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Name of Person Responsible for Construction Q Licen�'see�nNo. and Type if Applicable
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Street Address City/Town State Zip
q-K7-,_053j 1:32? 13
Telephone No, business Telephone No. celle-mail address
SECTION 11:W'ORKER.5'C'OMPENSA'TION INSURANCE AFFIDAVV' 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 O
SECTION 12.CONSTRUCTION COSTS.AND PERMIT.FEE
Item Estimated Costs:(Libor
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)
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 name below,1 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 knowledgeand understanding.
Please print and sign:;me( - Title Telephone No. Date
c sf- i'-e�y-�?i� o
Street Address City/Town / '^ State Zip �9
Municipal Inspector to fill out this section upon application approval: �// v �
Name Date
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Suliervisor
License: CS-073832
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Jv` FiFti
JOHN M SII
6 DANIEL TE12R� s
PFA80DY MA
r
,r1s?a Expiration
Comimnussioner
� scion 12/19/2016
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t°onxa�ionhirs& ..�aa add ella
Ottiiee of Conanaer Affairs&8dineas Reguiatlox
HOMEIMPROVEMENT CONTRACTOR
RapIstranon y#180809 Type;
ExpinUon f7l2017 Individual
4 ! i) ]
JOHN SIUVA
6 DANIEL TERRACE' s
PEAEODY,MA 0196b - Undersecretery.-
CITY OF SALEA MASSAMUSEM
Dm Dm DEPARn Ew
120 WASHINGTOONSMtEFT,3dDFLOOR
AL(978)745-9595.
KIMBERLEYDRiSQ7LL FAX(978)740-9846
MAYOR TCAs STAEW
DntEcrox of maucrRorERTr/BunDmc oamisslomit
Construction Debris Disposa/A}fidavit
(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:
u �l L
(name of hauler)
The debris will be disposed of in:
name of facility)
(address of facility)'
Signature of applicant
Date
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.masxgov/iia
Wworkers'Compens2tion Insurance Affidavit:Builders/Contractors/Electricians/Piumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibiv
Name(BusinessiOfgani?ationilndividual): Buc—ha�a nA) CnAj%tr ur,�18&) ..
Address: I
City/State/Zip: GjUXj Phone#:
Are you an employer?Check the appropr(ate box:
1. 1 am
et a employer with .3 emyktyecs(full and/mpad-timType of project(rei(uired):e).' 7. ❑New construction
2.Q I am asole proprietmor partnership and have no employees woriFmg-frame in
S. 0 Remodeling
any oaPacity.[No Workers,comp,inamatee required) rrxr�v,,��''
3.0 I=a homeowner doing all work myself.[No workers'comp.romance required.]t 9. LtsUemolitiaa
4.E]I am a homeowner and will be hiring contractors to conduct all,work on my property. I will 10 O Building addition.
ensure that all contractors eitherhave workers'compensation insurance or are sole I LEJ Electrical repairs or additions
propaietors with no employees.
5-El I am a general contractor cad I have hired the subcon6acton listed on the ausched sheet. 12. Plumbing 1'epBirS m addltiODS
]hese sub-contnchas have employees and have workers'compmsuua t 13.01toofreptilrS.
6.0 We are a corporation and its otlicashave exercised their right of exemption per MOL o. 14.Q Other
152,§1(4),and we have no employees.[No workers'coidp:ensu noee regioned.) - -
"Any applicant that checks box C must also fill out the section below,showing thei workers'compmsetion policy information:
t Homeowners who sulmat&in affidavit indicating they are doing as work and then hie outside contractors must submit a new,affidavit iodinating such
1Contracum that check this hos must attached an additional about showing the tutee of the sub-contractors and state whethei or not those entities have
employees. If the sub-conoaaors have employees,they must provide thei.workers'.comp.policy.m®ber. -
I air an employer that is providing lvorhers'compensation insurance for my emplgpees.:Below isthepolicy andjobsite
information. �I
Insurance Company Name: r O�YI/rt'C/'C t �.NS � rp�ar C d�JI
Policy#or Self-ins.Lic.#: 7 100A—g75T P&7–7 Expiration Date:
Job Site Address: a83 Den(Q4 s-G. . .. City/State/Zip: so,l`o,- V Ga cuG,(p7
Attach a copy of the workers'comps section poBcy 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 ce der the p - and penalties ofperjury that the information provided above is true and correct
Sitmanre• c Daft,
Phone#: 97B'a S7–Ga/3
Ojjceial use only. Do not write in this area,to be completed by city or town oTwiaL
City or Town: PermitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Conrad Person: Phone M