0055 - 0057 FEDERAL STREET - BPA-16-935 _ Z
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The Commonwealth of Massachusetts
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:
_nECCTTIION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)ON
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Meq
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 ❑ 1 Alteration ❑ 1 Addition❑ Demolition lease fill out and submit Appendix'I)
Change of Use El 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? Yes ❑ No ❑
Brief Description of Proposed Work:
C ELECC�� gjerit 0 f {SP SIL �J
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 Totat Height(ft.)
SECTION 5: USE GROUP(Check asapplicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ FH.-High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ FI-5❑
I: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
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 ❑ IIA ❑ IIB ❑ IIIA ❑ 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 ❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required ❑ or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: Y1;1 Historic c:oouni_-slt-�n Rev icw_Pro g:+_+:
Not Applicable❑ Is Sh uchue within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Yes ❑ or No❑ Yes❑ No ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Cocle: _ 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
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 ermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
[f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skie Section 10.7
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
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Company Name
�rn Pie�3t N CSS _ 0/ q-4s
Name of Person Responsible or Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WOPKERti 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 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 $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor) _$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
S. Mechanical Otherl $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
S TION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By enterin my name below, I h eby attest under the pains and penalties of perjury that all of the information contained in this
app
lication is anti accura to the best of my knowledge and understanding.
Please pr it and si nam Title Telephone No. Date
Street \dd ress City/Town State Zip
oMunicipal Inspector to fill out this section upon application approval: A J'
Name V Date
. � The CommonweaJlh ojMnssachxsetu
DeparYrnenjr oflnduslridfAr 9dents
I lCongressSAW4 Suite 100
Boston,M-4 Q21I0 2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Eleebicians/ lumbers.
TO BE FH.FA WITH THE PERMTTING AUTHORITY.
Anelcant Lormation Please Prfat l.edbly
Name(Basioe�onfudividual):
Address: C�n9C� �� pry cyr�q
Citylstatemp: )q' Phone# / l Q [.T( 2Z
Are you an employer?Ckeek the apprapalate box: of rb eci .
1.�a employer w7Po V -empbyees(fiill�d/mP�• )•' 7. 0 NeW consmsehon
2.01ame,sok pmrarparmaship and havem erapkyaro R"°?>�a f�rmem g; ORtmodelinB
ray wry•[hIo wafins •io&cautt rrgnkedl 9: giZZ;;Z
3.01am a homeowner dobg an wmk myse161No workers•txanp.dnemaace Mquie&l l .
4.Q 7 am a bomeowaer and mg be hfrwg ewusama m amdm all work m my popery. Iwo
1�Q Buildingaddition,
emm that all conbactas eahahave workers'compemauon iosmavee erm sok 11.0 Electrical repairs or additions
�'� lz.pPhmt d;eaa„i�s
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5. Int a geunul cohmeaWand l hmtheiubl
•twase ee ieteade sesheaf:
❑ d the
ILpeaubcaatraUagbavesmpkenyand bgve oa
wmd 'a® 13.oRoofrepairs.
p.iosmaomt - -
6.0WemamMomfiCianaits of6cesheresaercieeddwkiedofexemptimpeaMUc. - 14.000tier
152.¢1(4),and uvebavero employmn.pto woikeis'coup mmrenu asepmedl ..
•Airy g0ustif'hm eheeta be*sl mum akti Liu ovt the ere on kebwaka vfngtihefrwvktis mpahey m.
t xomeownes who idiit iiEbaoubideconhadmsmust aolenft amv affidwhia�suc3
tContmetors dot of9W sub' ® stma and sWe iubeaem no moue amities hwo .
employees.Ifmesuh-wt! a4nTunPloyw4.0 .-majumidoilk wanizz oamp•policymm�- -
lamanaoployer4uat+isprnvldingwarkors'eompumaa!ivniwarmecejornyBd0wis0ep0Hry011/Iobs#e .
tnjormatton.
Insurance Company Name L1�G� �n1��✓LAIJ� l —
Policy#or Self-ins.I.ic.A C-J F11 is Eapirstion Date:
Job Site Address: Cay��p.
Attach a copy of the warkeis'compensation policy declaration page(showing the policy number and ezpk sdon date).
Failure to seatre coverage as u' under MGI c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or oue-ye�impeis ss well civil penalties m the form of a STOP WORK ORDER and a fate of up to X50.00 a
day against the violptoi A copy ofthi t maybe fory eTded to$ere Office oflnvestigaL ora ofthe DIA flat insurance
coverage verification: , .. . .
I do hereby terrify nn thep ' and penahles ojpajury that the information provided above is cru and earrea
signsture: Daft:
a
Pbcme#
Official we only. Do not write In this area,to be completed by rltY or town oflPeial
City or Tom: PermunAcense#
Issuing Authority(circle one):
1.Board of Health 2.Bugdiug Department 3.City/Town Clerk 4.Electrical hnspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employeea.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or writtep."
An employer is defined as"an individual,partnership,associaticor corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwe"for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required
Additionally,MGL chapter 152,§25C(7)agates"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checlmrg the boxes that apply to your situation and,if
necessary.supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(I.I.P)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Departrnent of Industrial
Accidents for confirmation of insurance coverage. Also be mare to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Deportment of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insuredcompanies should enter their
self-insurance license number on the appropriate lime.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permiYlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to die
applicant as proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venire
(i.e.a dqg license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017,
Tel. 4 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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STi�A1BYDdttS(>Jd.L
MAYOR 7ts�aAsS7`.P�
t�'PtBilCP140PEXTY/Bim
Construction Debris DisposaiAffidw t
(required forall demolition and.renovation work)
In w wrdance with the sbcth edition of the State Building code, 780 CMR, Section 111.5 Debrk,
and the pffAi ms of MGL c4D,S 54; Building Permit B Is isww with the
condition that the debris resulting from this work shah be disposed of in a properly likened
waste deposit facility as defined by MGL c 111,S 15t A
The debris will be transported by:
(name of hauler)
Ther( debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
DESIGN BUILD
I I I I ® ® I OUR HOUSE design+build
59 High St.
Reading, MA 01867
PHONE: 781-944-8489
I FAX: 781-872-1742
— — WEBSITE:
ourhousedesignbuild.com
IPLEASE NOTE:
I MUST CONFIRM ALL MEASUREMENTS ON
SITE PRIOR TO WORK STARTING. BE SURE
TO BE WORKING OFF MOST UP TO DATE
IPLANS BEFORE BEGINNING WORK.
r PROJECT NAME&ADDRESS:
I O O
I O ® 59 OCE Y RESIDENCE
n 59 OCEAN AVE.
I m SALEM, MA
L - - SCALE:
1/4" = 1'_O".& 1/2"=1'_O"
FINISH DIMENSIONS UNLESS
OTHERWISE NOTED
PLAN SET:
PRELIMINARY DESIGN
DATE ISSUED:
8/16/2016
EXISTING KITCHEN PLAN SHEET TITLE
SCALE: 1/2"=l'-O"
A - 1
I
n
�`��- I �� •. ..I _ . •.� J _• ` �•1 ' • - • • � 1. e , • • - � + .
s s s
o DESIGN BUILD
W15421- W3024 V41242R I 'i L42R
P I OUR HOUSE design+build
,p r
c ry
0
815E 3DB30 I 5B33 Dishwasher 59 High St.
(R ® 1 I I Reading,MA 01867
> cld — — —y
w m
Elevation 7 PHONE: 781-944-8489
-- FAX: 781-872-1742
WEBSITE:
v
Elevation 1 r+ I ourhousedesignbuild.com
PLEASE NOTE:
Elevation3MUST CONFIRM ALL MEASUREMENTS ON
W W I ry SITE PRIOR TO WORK STARTING. BE SURE
o TO BE WORKING OFF MOST UP TO DATE
M PLANS BEFORE BEGINNING WORK.
PROJECT NAME&ADDRESS:
DOHERTY RESIDENCE
B18R I 830I F 59 OCEAN AVE.
—� — — — J-- SALEM, MA
j Elevation 5
SCALE:
1/4" = 1'-0" & 1/2"=V-0„
FINISH DIMENSIONS UNLESS
CJD OTHERWISE NOTED
PLAN SET:
PRELIMINARY DESIGN
U151254R
DATE ISSUED:
8/16/2016
PROPOSED KITCHEN REMODEL PLAN SHEETTITLE
SCALE: 1/2"=V-0"
I-0"
A - 2