21 FRONT ST - BUILDING INSPECTION �1 OV6
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:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
21 Frnnt S rPPr Salo 01970
No.and Street Ci Town
II t} / Zip Code Name of Building(if applicable)
^ SECTION 2:PROPOSED WORK _
(`lVl Edition of MA State Code used IBO 2009 If New Construction check here❑or'check all that apply in the tw®ws bi&w
Existing Building Repair❑ Alteration Addition❑ Demolition ❑ (Please fill out and submit d' )
Change of Use ❑ Change of Occupancy F9 Other ❑ Specify: t —m
Are building plans and/or construction documents being supplied as part of this permit application? Yes A7 Wo ❑ In m
Is an Independent Structural Engineering Peer Review required? Yes ❑ N r—m
Brief Description of Proposed Work: Teunvr h1,11 i D Ja cnv
outper- least Q:ttaehed rn
_ -z"
m
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): g Proposed Use Group(s): $
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)k Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.) 91UO9
SECTION 5:USE GROUP(Check as a plicable)
A: Assembly A-1 13A-2 13 Nightclub-Cl A-3 E3 A4❑ A-5❑ B: Business 13 E: Educational ❑
F: Facto' F-1❑ F2❑ H: Hixh Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional 1-1 ❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ 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 111 HA IIB 13 MA IIIB ❑ rv ❑ TVA E3 VO 13
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 0 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: MA Historic Commission Review Process:
Not Applicable X1 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ ' Yes❑ or No*7 Yes❑ No 13
SECTION#: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
7dbe
Address of Property Owner
• erg Brothers RELLC 7 Rantoul Street Beverly
nt) No.and Street 1 Q 15
City/Town Zip
wner Contact Information:n Goldberg 9789220800 978 423 6344SGoldberg@goldbergprope tiesRE.col
Telephone No. (business) Telephone No. cellle,the property owner hereby authorizes ( ) e-mail address
Name Street Address Ci Town State Zipe roe owner's behalf,in all matters relative to work authorized b/this buildingpermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildin is less than 35,000 cu.ft.of enclosed s ace and/or not under Construction Control then check here 13 and ski Section 10.1
10.1 Re stered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address
Registration Number
Street Address Ci Town
tY/ State Zip Discipline Expiration Date
10.2 General Contractor
Goldberg _
Company Name
Steven J. Goldberg cs - 065097 -3 1
Name of Person Responsible for Construction _ Z
7 Rantoul Street Suite 100B License No. and Type if Applicable
Beverly MA 01915
Street Address
978 922 0800 City/Town State Zi '
978 423 6344 SGoldberg@goldbergpropertpiesRE.com
Tele hone No. usiness 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 issuance of the building permit.
Is a si ed Affidavit submitted with this application? _ Yes O No O
SECTION 12.CONSTRUCTION COSTS AND PER FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building O
2. Electrical $ Building Permit Fee-Total Construction Cost x_(Insert here
appropriate municipal factor)_$
3. Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $
6.Total Cost $ Enclose check payable to
(contact municipality)and write check number here
SECTION 1 :SIGNATURE OF BUILDING PERMIT APPLICANT
By enter'n my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
applica t is true and a est of my knowledge and understanding.
S e dberg Owner 978 423 6344
Please print and signname Title p
7 Rantoul treet Suite 100B Beverly Tele hone
o. Date
MA
Street Address Ci Town
ty/ State Zip
Municipal Inspector to fill out this section upon application approval:'
Name Date
The Commonwealth ofMassachusetts.
.Department oflndustrialAccidents
Office ofInvesWgations
600 Washington Street
Boston,Md 02111
www.masS.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ContractorsMectricians/Plumbers
AlipUcant Information Please Print Legibly
Name(Business/Organizadonindmdual): Goldberg Properties•Management Inc.
Address: 7 Rantoul Street Suite • 100B
City/State/Zip: Beverly, MA. 01915 Phone#: 978.922.0800 .
Are you an employer? Check the appropriate boa: r77.
e of project(required):
1.❑ I am a employer with 4. I am a general contractor andI
employees(full and/or part-time). have hired the sub-contractozs l New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. Remodelingship and have no employees These sub-contractors have 'Demolition
working forme in say capacity. employees and have workers'., 9. Q Building addition
[No workers' comp.insurance comp.fi irance#
required] S. 0 We area corporation and its . 10.❑Flectrical repairs or additions
3.0 I am a homeowner doing all work Officers have exercised their Il.El Plumbing repairs or additions .
myself.[No workers'comp, right of exemption per MGL 12. Roof r
c. 152, §1(4),and we have no ��
insurance required]t ME]Other.
am oyees.[No workers'
w .insurance required]
*Any applicant that obecka box#1 must also&out the section below showing their wo-rkais'compensation pokey htformation.
t Homeowners who submit this affidavit indicating they am doing all work and then him outside contractors must ahbmita new affidavit indicating sach"
tContractors that check this box must attached an additional sheet sbowing the name ofthe Bub-contrscmrsaed state whether or not thoso entities have
employeas. If the subconbactors have empleyea%they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insgrance for my employees. Below is and the o1i
information P c1' job site
'
r
Insurance Company Name: A.I.M. Mutual' Insurance Company "
Policy#orSelfins.Lie.#: policy 11 AWC-400-7026520-2015A F..pirationDate: 5-01-203
Job Site Address: • City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Seadon 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine lip to$1,500.00 and/or oke-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. Be advised that a copy of this statement may be forwarded to the OfEce of
Investigations of the DIA for insurance coverag0.verification.
I do hereby cerfib under the pains and penalties of perjury that the information provided above is true and'rorrect.
Siahature: Date-
Phone M
Official use only. Do not lvrite in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):'
card Health 2.BuilduigDepartment 3. City/TownClerk 4.Electrical Inspector..5.Plumbing Inspector
6.Other
Contect Person: Phone#:
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