1 MASSEY WAY - BUILDING INSPECTION (2) 1D5 G(L iy2�
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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)'. ti a
Building Permit Number. Date Applied: Buildiiig Official
SECTION 1:LOCATION(Please Indicate Block 0 and Lot►for locations for tvhiich-a street address is naav ble) n
1 Mk sScre "W S4�1wt 011Z 3 _ o�
N No.and Street City/Town Zip Code Name of Building(if applic") r_I
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SECTION 2.PROPOSED WORK. D cn
l Edition of MA State Co a used_ If New Construction check here❑or check all that apply in the two rte bel
U 1 Existing Building Repair❑ Alteration Addition❑ Demolition ❑ (Please fill out and submit ApilE�Rdix i
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: to
' 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:
Fikoj
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) O
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)lir Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION S.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 ❑ H4❑ H-5❑
1: Institutional I-1❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-113 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 ❑ 111) E3 IIIA ❑ 11111 C3 IV 1 VA 13 VBq SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply✓ Flood Zone Information: ewage Disposal: Trench Permit. Debris Re
Public V Check if outside Flood Zone Indicate municipal A trench will not be Licensed Dispo
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-wa Hazards to Air Navigation: NIA I Ii.storic Commission Revin:w Lnxc•,.
Not Applicable Is Structure within airport aper area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No 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.in Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Properttyy Owner
Jvs*iv e4[was-45 1 4*S$a`C 9/AIV S-F
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owners behalf,in all matters relative to work adthorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
f buildin is less than 35,000 cu. ft.of enclosed s pace and/or/ not under Construction Control then check here 0 and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
103 General Contractor '
Company Name
4 SK.vO%xes kc C 5 —
Name of Person Responsible for Construction License No. and Type if Ap licable
/09- 9YA4fIAST' Ate-- 0•hW&r c�¢ Z"5
Street Address City/Town State Zip
5VO.J6z 3liif
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKEIS'COMPEN ATION INSURANCE AFFIDAvrr iNLG.L 4152 29C(Q)
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEEE`
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
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 Other $ Enclose check payable to
6.Total Cost $ (S' pQd (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I 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 owle ge d understanding. °
r
Please print and sign name Title Telephone No. Date
Street Address City/Town tate Zip J
Municipal Inspector to fill out this section upon application approval• r r `�
Name Date
J
The Contntonwe#lh ojMassachnsetts
Department ojlndusftWAcddents
1 Congress S74M4 Smite 100
Boston,MA 02114-2017
wwwwamgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/ElecWdans/P)nmbera.
TO BE FUM VVITH THE PERM TING AUTHORITY.
Avalewd h formadon Please h t IAdb1v
Name(Businesslownizad.on 'O"duo:
Address:_
City/State/Lp: i244400-5 Phone#:
Are you an ployerr alaerk the Wmpttate�:
type of ed(req"aired):
1.p aemylayerwitll— gees(IIsiaodt6►pmt �•� 7. [ cont on
e.eole yeopufeEor o > apQ Leve uo empbyeo wml�g formes g; d�R
nary aipeelry.(Ko aottait''atiaop.ikii nee nqu6eal
3.0 ism a homeowm doing all wak myMX NO wwkcM'comp.ittsm%aace spied.]t 19000 Dimtolitibn'
4.0I am a homt:owna®d wig be 11MOS eatmectms m cmdud ell vrmtc au my PraPutY. I wal BuHdtrig adtli6ain.
ensu that all conbaama deter Lave wodtae'moa fi mance or am sok 11.0 Electrical repairs or additions
12. Phimbmg itepaiis to tidditibtis
s.Q I am a gateral ea Dt®raw and 1 Lave Wired�e sub +tetme Ifsaed na me aaea6ed abet , '""
7Lcesub-c haveeat*"andhave Wod='=M*mataaomi Roofiepays.
6.0%am a emporado sad its off=have macised tkirrWa of a butioo per MGL e. 14.0 other
_.._ IND wwk='d=IL immanu tegnaed)
ISz,41(41 and we Lave employtxs
_.------- _. .._ .... .._ _... .:.
•Aoy app?ir+ot That atib bin#1 mire situ t3U oia the aewao below tttotvtog their wmker�'oomPmeatlm Poi)
t Homeowaae who t iijh mo a@idn*iodi�Iag`tkey we"s all work sad ibe6 bas outside caubwtus susi etdatia a iiew affdsvit fudimtiog such
ICaaft mm that check this box suet amicIM®ad&dond sheet down ffio name of1Le wb- a®d state wblbv or not Pomo agwo have
employees• If6e6ub-gonbaetmehmemployeq,theyn=Paa**ei-wartcst.00mp Mli�mmber.:..:
I ant ay employer rhosto pmwi ng WorArM ompmraAton inraxcefor nay sera gees 8eloiv ieYhapansya+iatlaa ar(e
Inforatadom
insurance Company Name
Policy#or Self-ins.Lic.M Expiration Dom.
Job Site Address: Cit5r p:
Attach a copy of the w arkei-s'compensation policy declaration_ page(showft the policy number and eaplraflon date).
Failure to own coverage as required under MGL•c.152,¢25A is a triu�al viomen pumisheble by a Soo up to$1.500.00
and/or ontryeer impeisomiaent,as well as civil penalties m the form of a STOP WORK ORDER and'a fine ol'upio$250.00 a
day against the vioLuor.A copy of ft, steternent may 6 forw*"W to se Office ofJnvestigeticme.of the DIA f6r insiraace
coverage verAcation.
I do hereby srrrde!Ike palnsanpest o )wjur'that ache informadon provided above lir true and correct
none M Iz C4? 6 z-3V
F
only. Do not wrhe in shute arra,'to he comleted by laby or Town Offle,
own: PermlMeense#
uthority(circle one):
of Health 2.Balding Department 3.City/Town Clerk 4.Elect ical Inspector 5.Phtmbing Inspector
Contact Person: Phone#'
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for the employees.
Putsaant 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,association,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 in individual;psrtnerahip,.assoaation or other legal entity,employing employees. However the
owner of a dwelling house having not more then three 4mmicuts 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 permft to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the omrmoonwealtb 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 preseated to the contacting authority."
Applicants '
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and.if
necessary,supply sub-Contractor(s)name(s),addresses)and phone numbers)along with their catificete(s)of
insurance. Limited Liability Companies(LLC)or I.®ted Liability Partnerships(LLP)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 polity is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure 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 Department 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-iosumed'companics 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 apphcmt.
Please be sure to fill in the permitticense number which will be used as a reference number. In addition,an applicant
that must submit multiple pernat/license applications in say 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 the
applicant as proof that a valid affidavit is an 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 venture
(i.e.a dQg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax numiber.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017.
Tel.#617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
QTY OF SALEM, MMAaRSEM
BEHDDCDErAMxr
120 WAstMVMS7RWs,3"PimR
7kL(978)745-9595.
%iNIRFR ZYDUSOI j, PAX(978)740-9846
MAYOR
DmcnR CF PueuCrAO"MYdBvoDM aOsxroMM
Construction Debris Disposal Affidavit
(required forall 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 coo,S 54; Building Permit 8 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: L
(name of hauler)
The debris will be disposed of in:
(name of facility)
(!5;f0k7e�eft r A4-
(address
-(address of facility)
i nature of applicant
Date