48 WEBB ST UNIT 2 - BUILDING INSPECTION The Commonwealth of Massachusetts
r X11 Department of Public Safety
Massachusetts State Building Code(780 Cb1R)
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:
J SECTION 1:LOCATION (Please indicate Block#and Lot# for locations for which a street address is not available)
b5sd-.,Lw c(,CIVX
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No.and Street City/Town Zip Code Name of Building(if applicable)
L!1 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❑ Alteration 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 ❑
Is an Independent Structural Engineering jeer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: f/�L d—t 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): 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(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ I H: High Hazard H-I ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-111 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 11 IIA 13 IIB ❑ IIIA IIIB ❑ 1 IV ❑ VA ❑ VB Q_
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:
A trench will not be Licensed Disposal Site ❑
Public❑ Check if outride Flood Zone❑ Indicate municipal1111required 11 or trench or specify:
Private❑ or indentify Zone: or onsite system permit is enclosed❑
Railroad:ghof-way: Hazards to Air Navigation: SIA Histur_c<_innnistiiiJl i�2��ie_Prc�n^ss:
Not Able❑ Is Structure withinairportapproacarea? Is their review completed?
or Consent to 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 an Sprinkler System?: Special Stipulations:
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(ICIAIC 1aJmA�
SECTION 9: PROPERTY OWNER AUTHORIZATION l
Name and Addess of Property Owner
Name(Print) No. and Street City/Town Zip
Property Owner Contact Information:
�J7JD?- 336
Title Telephone No. (business) Telephone No. (cell) e-mail address
If I cable, the operty owner hereby authorizes
Name 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 that 35,000 cu. ft.of enclosed s ace and/or not wider Construction Control then check here❑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 o to
)& Pam
Company Name S _ ✓ice r I7 _Z� ) -7
N� e o Pe7on Responsible onsible f cr Construction License No. and Type if Applicable
Street Address City Town State Zip
f!
'fele phone No. business Telephone No. cell e-mail address
SECTION 11: VVORKERSCOMPGNSArION INSURANCE R1TIDAVIT 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)_$
I. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
-1. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
S. Mechanical (Other) $ q Enclose check payable to
6.Total Cost $ 7 (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
al2plicition isttute and-accurate to th w t of my kn midge and understanding. �/7
Gn C�Vn n IGe (�r ^ �C-9�7a 6 DY6
Plea riot and sign name Title A/1 Tele Ghon i Date
Suet t\ cress City/Town State Lip
Municipal Inspector to fill out this section upon application approval:
Name Date
CARPENTRY - REMODELING - ROOFIN( 4, ,w,
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JOHN J. HORGAN ,(,� Q�
78 LOCKWOOD ROAD �
LYNN, MA 01904
(781) 599-5949 ��
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( em,e . /NiQ,��x/pM�ti � R¢�yrs <,rA 'o,�F'� 8.11 2ai7
LIC,-eA) 543 (o / Z3 017.
The Commonest pJdi ofMgssachus:*
Departinertt ofLdtts7riri�AccdenLs
I Congress&W4 Suite 100
Boston,M4 02114-2017
wwwavasxgov/dio
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electdciaas/Plumbm.
TO BE FU"WITH TRE PKlUWMfNG AUTHORITY.
Aipplicant Information
Phase Print lAdbJv
Name ^
(Easiness/(O+'mrizatia�n/_Ind/i-vimun: . �b� .. Gn ..
Address: -79 L oC� L s oJ I c.l
City/State/Zip: Pr D ROLt Phone#:
Are you as employer?Check the approprlak hoz:
Typa ofproJrci'(iequired)i
l.p t s employer w�i empbyces(full end/mn®'t-rune)•' 7. QL'1� ..-MucCon
2. . Iwai e.sok psoprreemorpaMetahip aodhavem employges woflp'mg formpm g, Rt�OdthDB
any Waalry•[No avimrx'�•f requhed j 9. 01)emohtion'
3plamehomeowmdoiogaltworj nowY..[Noww6rra'cowl) iasmmaerapmee.lt ]OQBIn7dmg'edd oA-
4.p Ism a homeowoa ad win be hiring eonbactma m cmdm all wod;m my poperty. I will -
eaoaethe all convaOmstithuhaveworlms'wmpmgM1minsurance ormsole 11.0 Electrical repairs or additions
jaoFxmawiihmempiuyera. - 12.s•��i Phmbin oradditions
5.0 lama general tam said lheve hhed due snb•eoaefe(ae Meted aur dm mea shoot: L.� �•
7hesesub-amtractasbm employees and!rave wo ns,comp mnnaoo$ - i10RoofiepaQs_
6.p We mea corporation sod its offiwa hsve cmeised Aikdgk of ea®ptiomper MGL c. 14.p Otber
15$11(4),end wehavero employees.[No worl®s'F.amp.manrmce rearmed.)
-.-
. •A�appliamt met dmolmEaatlmwtatro50mad�e sec>iom below ahowLrg�s&irmlcge aamv➢moum pohryaaa. .
t Hoaoeow�who aubmitmie aeKdawt iedieelmg mey see do,bgan WO*sad dit bW aftide eonk m mist submit a,. , iTeave s each
lCoomcbw*9 ohe&dui bur must atleclod suadkbooO smetsbowmg�mme;ofdrtsub-wzeo ss and so"whedwol not diose anift have
employes_ifi esuNcwuadmheve.mwmmoCY.mnnPeovide&ea:we*=':emp poheynnoo; :<.. : ..
. ..-. .
Inman ployerthattsprmWdus8ilw>'kers'pom a4oninawq�saejoreryeelpJ�y'ser. Atiox,sthepoltysto$jobake -
►njo>r+alloa
Insurance Company Name: /. ✓7 I t /
Policy#or Self-ins.Mo.#: [_ L7 d0-<�l0 (� Expiration Datc: f�
Job Site Address: T��Gb.S J- Gyty/State/Zip:� �a
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coveragess required under MGL c.152,§25A is a criminal violation punishable by a Sae up to$000.00
and/or ono year mVns�t,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 stateirxnt may be forwarded to the Office of Investigatitnts of the DIA for insurance
coverage verification.
I do hereby ce pains aloes olper%ury that the iajormation provided above is state and rosreax
Phone M. 7 F1(
Ofjidd use only. Do sot write fa this area,to be eva paled by co or town offaciaL
City or Town: Perndt fAcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CHy/I'own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r
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 ofbire,
express or implied,oral or written."
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 ruwre 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 cornmonweaM nor any of its political subdivisions shall
cuter 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 checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)narne(s),address(es)and phone number(s)along with thea oertificate(s)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 confimration 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-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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license application in any liven you,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"ail location 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 proofthat a valid affidavit is on file for future permits or licenses. A new affidavit mut be filled out each
year.Where a home owner or citizen is obtaining a license or peanut not related to any business or commercial venture
(i.e.a dog license or peanut 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. #617-7274900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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1� Massachusetts -Department of Public Safety
�f Board of Building Regulations and Standards
Li c License:
Sup 61123
License: aCS-036123 Fp
JOHN J HORGAft
78 LOCKWOODRD� f
LYNN MA 01%f IVWWI
Expiration
-- Commissioner 07/31/2017
-
`..
Office of Consumer A-
MEIMPROVEME
� egistration 1085:
xpiration: 8/39/20''�
JOHN J. HORGAN 60T1_T06T6'i
John Horgan
78 Lockwood Road A.viy
Lynn, MA 01904 2.0(6
A? l08S7,
Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet(99lm3)of
en,closeu space..
r
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DPS licensing information visit: www.Mass.Gov/DPS
Q'TYOFSALEM, MMSAa-R SETlP
BEWMD8rAIMENr
1201WA9RV7wSnw,3ORom
7bL 00)745-9595.
BII�ERiZYDI,
FAr 701W
MAYCR DUMSr.PUs
DmacnxtcFPuurc r/stuw4ca
Construction Debris Disposa/Af}idovit
(required forall demolition and.renovatibn work)
In awrdanm with the sixth edition of the State Building Code, 780 CMR, Sects 111.5 Debris,
and the provisions of MGL o40,S 54; Building Permit If is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed "
waste deposit fadiity as defined by MGL c 111, S 156A
/The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
(name of f cllity)
(address of facility)
gnr 2 i app cant
ate