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ASPECTIONAL SERVICES
The Commonwealth of cl_iue �
Department ofNfil lasaA
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Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
-13 (Chis.Section For Official Use Only)
Building Permit Number: Date Applied: Buildmg,OfficiaL
_fl SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
I -7LK VO4-k-W 4 3eVt/Iu pncSS 017-76
(1 No.and Street City/Town IZip Code Name of Budding(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❑ I Alteration Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1)
K(I Change of Use 13Change of Occupancy ❑ Other Cl Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Reviewed? Ye 13 No C3Br' f Description of Proposed Work: tc.— r3 VI ry 1 I tacty .. 11U hast ���'✓
SECTION 3r COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY.
Check here 6 an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): - Proposed Use Group(s):
J SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
\�
Q No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
( -
SECTIONS:USE GROUP(Check as a licable) - - -
f� A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4 O A-5❑ B.
Business ❑ E: Educational ❑
R Facto F-1❑ F2❑ H- High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional 1-1❑ 1-2❑ F3❑ I-1❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
IJP S: Storage S-1 13S-2❑ U: Utility 13 Special Use❑and please describe below:
Special Use:
SECTION&CONSTRUCTION TYPE(Check as applicable)
[A 13 10 IIA C3 IIB [3 IIIA 13 TIM IV ❑ I VA 13 VB ❑
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:
U Public k Check if outside Flood Zone Ek Indicate municipaIV A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required[03or trench or specify: go AA—
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: 4(A_I listor_c Cummicsiun Ry,w,vv_I?nxc_s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Budd enclosed❑ 1 Yes❑ or No❑ 1 Yes❑ 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:
`.
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property�Owner J,.Vit„T-) -
Gccl�c✓cIC -i U 5-( SGLe"A vct557 �IF2a
Name(Print) 0? p ANotamlStreet.lt, City/Town Zip
r a JJ,. •rl
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Nene 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:CONSTItUCITON CONTROL(Please fill out Appendix 2).- -
If b Uding is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here Omit rid 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
10.2 General Contractor '
///errf4s 07eIV6
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
/S 572� atm r✓yG, t a'T _ ,r5014'IS
Street Address CityTown State Zip
C�L-LSI- 915-1 _-_-
Tele hone No. business Telephone No. cell e-mail address -
SECTION 11:WORKERS'COkIPF.:NSATION INSURANCE.AFFIDAVrf M.G.L:e.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 I2.CONSTRUCTION COSTS.AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 3,4 ,0 CU 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 $ `,j�isd � P6 (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 knowledge and understanding.
/ l•1a�vI4J /TeV0k(� �cr,' q7.1' -FJ _ 3527e lL-2r/S
Please print and signn me Title Telephone No. Date
/.I- S`L`Gv C✓z` Pn wC_ Al/1 ST' 104 Oe Yl S
Street Address City/ mvn State Zip 1
Municipal Inspector to fill out this section upon application approvaL•
Name Date
07Y OF SALE)4 MASSACHLEE M
BLnDING DEPAR7MENf
120 WA2WgGTCNS7nET,3m RODR
7kL(978)745.9595.
PAX(978)740-9846
KIIvJBF.RLEYDRiSQ7J.L
MAYOR THMAS STREW
DntEcrcatorFuRucPRoPERTr/BtII[ mcawmffoi.=
Construction Debris Disposal Affidavit
re uir
( q ed for-all demolition and,renovation work 1'
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:
name of hauler
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Z/ 20t5
Date
The Gommonwea&h ofMasspchuset/_s
Deparftent oflrrdusnialAecidents
1 Congress Streeg Suite 100
Boston,MA 011141017
wnm:massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractor&tElecbiciam/Plmmbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
ApolicautInformation Please Ptiat IAdblr
Name(Business/Orgaiization/hatividuat):
Address:
City/state/zp: el OI 915 Phone M 971- F52." `35'61
Are r m em k v Chetk the a box:
� a ya. pproprtate L14. OthcK_
project(required):
1.❑I am a employer w� .empkryees(full anNorP�t'time).� eyv eonaWetlOn
2.Q l am a cok proprietors paumaship and Leve ro eIDPkruo rl®s forme in modeling .
auy capacity.(No wolketa''ecmy.iuitnrance required) molition
3.Q!=a homeowoer dams all work myself.(No wmkm'�P.inan.n required.)t
4.E]Iain a homeowaa and mill be hiring emaactM to emdtkd all work m ny property. l wall Building addition.
eases that all rnffiac/ms erhahaw worlim'compensation insmaoce s are cale ctrical repairs or additions
poPricromwitLnoe e>?x8 mbingsusoiaddition's
5.O lam a germ]cobbadm and I have Maid the aul.eoiaiaams listed oil the attached sheet. of spa-
Ibiza suboemtaceom have employees nod have"dials'camp.con^=^^^7 -
irs
6.Q we area wuyoratim sad its offiu have exercised theeri&of exemption per MGL c. er
152,§1(4),and we hmao employees:(No worlam'comp:iatamce iegW'eed.7 ': .
. .*Any epplieant That chaaosba c Nil mug Wso ills ons the iecdan hetow Bbox'IDa Pom`woilme'dozappianbrat policy zabormirtica.
t Honeownas who subunit Pois affidavit mducofgthey art doing all wot&and thea hue outside ooatimcam must submit a new alfidavitiodicemig such:
tcmuactosa dw check dura bn muni a ached m additional akeesbowmg are mmeof*embso�and sfnte whedww cot thm eauuu have
employees. Iftbe sidi-rouaCm6ha--Wloyeas,they mast Pmwk atair.warkers..wmP.policy number.. -. ...
I am ng employer tlrotiaproldding workers'Fompenaation insrrraneejor my earylpyeas Below is thepolicyaadj4b site -
Informadon.
Insurance Company Name: r eke ��giLLt.lr1 [�'LtM f7�1 ..!-ff�l.S
Policy N or Self-ins.Lic.A: Expiration Date:
Job Site Address: City/StatdJZip:
Attach a copy of the workers'compensation poley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal viobsion punishable by fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form da STOP WORK ORDER and a fine of up to$250.00 a
day against the violated.A copy of this statement may be forwarded to the Office of Investigations.of the DIA for msiusnce
coverage verification. -
I do hereby certify under tbepains and penaUies ofperjury that the information provided above is tine and correct
signi, efw e1� Date a-CA4 Ael
Phone# /f k?
Official use only. Do not write in this area,to be eompleted by uty or town offldai
City or Town: PeruddLicense g
Issuing Authority(circle one):
1.Board of Health I Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone M
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
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,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 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 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 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 conbacting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to yam situation and,if
necessary,supply sub-contractors)name(s),addresses)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited 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 policy 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 affidaviL 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-insured'companies should eller their
self-insurance license number on the appropriate line.
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 pemnitticense number which will be used as a reference number. In addition,an applicant
that must submit multiple pemrittlicense 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 the
applicant as proof that 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 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 number.
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/din
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THOMAS W. BERUBE 15 Stewart Ave.
CONTRACTING CO., INC. Beverly, MA 01915
Carpenters/Builders
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[976) 927-2099