3 1-2 BECKET AVE - BUILDING INSPECTION cr, zq�
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The Commonwealth of Massachusetts
Department of Public Safety .
r 4YY - Massachusetts State Building Code(780 CNIR) Z
Building Permit Application for any Building other than a One-or Two-Fa ng Dw4ng
(This Section For Official Use Only) o
` Building Permit Nurnbee Date Applied: Building Official
V ' SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street eddres is nqT vail rllf-
r L GGl1G rn
No.and Street City/Town Zip Code Name o (if app rc f Building able)9
^I SECTIONT PROPOSED WORK. n
Edition of NIA State Code used_ If New Construction check here O or check all that apply in the tw�ows beh)w
Existing Building R,paia I Alteration ❑ 1 Addition❑ Demolition O (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 Peer eview regu(red? e - Yes O No ❑
Brief Description of Proposed Work: G nGv tka C ters.S.7fri`.-
O{trY O1 CfClSl�iar GtIC �t�5'f t%L.�
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): Proposal Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor.(eq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE CROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 O A-1❑ A-5❑ B: Business CIE: Educational ❑
F. Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 O, H-2 Cl H-3 Cl H4❑ H-5❑
1: Institutional [-IQ I-2 O [-3❑ 1a❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑
S: Storage S4 ❑ S-2❑ U. Utility❑ Special Use❑and Please describe below:
Special Use:
SECTION 6.CONSTRUCTION TYPE(Check as applicable) -
IA O ID O IIA ❑ 1160 IIIA ❑ HID O 1 IV 13 1 VA ❑ VD Cl
SECTION 7:SITE INFORMATION(refer to 780 CNIR 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❑
raluired O or trench Or specify:
Private❑ or Indentify,Zone: or on site system❑ permit is enclosed Cl
Railroad right-of-way: Hazards to Air Navigation:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes O Or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
E.litian of Coda: Use Group(s): Type Of Construction: Occupant Load per Floor:
Dues the building,contain,u,Sprinkler System?: Special Stipulations:
0 • $I1 �
SECTION 9: PROPERTY OWNER AUTHORIZATION f
Tot d Nil Df P er O reAeSty
Name Print) No.and Stre t City/Town Zip
Property.Owner�C tact ha(on a 'on: ( / ` ' CDC
`m
Title • -, Tele hone No.(business) Telephone No. (cell) a-mail address
If op licable,the roperty owner hereby authorizes
'j/a9,rti
Name. Street Address City/Town State Zip
to act on the property owners behalf, in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here D and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(RegistrarS lephone No. e-mail address Registration Number
-2v-1 7
Street Address - City/Tow n State Zip Discipline Expiration Date
10.2 General Contractor
Name( N
of Person Responsible for Construction License No. and Type if Applicable
�/ /L /�/�01 , ( /"—
Street Address City/Too - State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:1VORKERS'COAIPENSA I'ION INSURANC 'AFFIDAV T M.G.L.c.152. 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents most be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issL&ce of the building permit.
Is a signed Affidavit submitted with this application? Yes Er No G
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
I. Building $ V00 Building Permit Fee=Total Construction Cost x(Insert here
2. Electrical $ appropriate municipal factor)_$
3.Plumbing 5
4. Mechanical (HVAC) S Note:Minimum fee=$ (contact municipality)
5. Mechanical Other - $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering any name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true aniLaccurite to the best of my knowledge and understanding. ,.
�
Pleat?rfntandsign fne Dille , TelephoneDate
J/ w P
Street Address City/Town/ State Zip
municipal Inspector to fill out this section upon application approval:
Name Date
�,�1 Massachusetts Departme�t�otPdjbp °$" �'S;
h ,866(daf'Buildmg0egulatwlEsa '.
Coh3trucf�on'Supert nur��.nii
PETER J DANIEI$ `2l ; f.*
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DANGERS MA 0923' g,� ,, �.` a 9
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Office o�s mer Af airs&Bus,ioes late ions
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OMEIMPROVEMENT CONTRACTOR
egistONIE I PR EMENT Type:
xpiration 6120/2017, Individual
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'PETER DANIELS
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Page 1 of 1
Harry Wagg
From: Jackie Giordano [Jackie@northshorecdc.org]
Sent: Thursday, August 13, 2015 1:53 PM
To: Harry Wagg
Cc: premierbuilders@yahoo.com
Subject: 3 1/3 Becket Permit
Hello Harry-
As the owner of 3 1/2 Becket Avenue and representative for the 3 1/2 Becket Avenue condo
association, I am allowing Premier Builders to pull a permit and complete work on my
property. Their work entails structural and aesthetic repairs to my front deck within all
property guidelines. If you have any questions, please do not hesitate to reach out to me
directly at my work line below or my mobile 774-454-0170.
Thanks-
Jackie Giordano
Jackie Rose Giordano
Director of External Affairs
North Shore Community Development Coalition
102 Lafayette Street
Salem, MA 01970
p: (978) 825-4016
f: (978) 594-8826
jackie@northshorecdc.org
www.northshorecdc.org
Annual Report
Facebook
Twitter
8/13/2015
CITY OF SALEA MASSAalUSEM
( Bm DjNG DEPAR7wNT
120 WASHINGTDN STREET,3'D FLOOR
7kL.(978)745-9595.
RIIv18ERLEYDRISOOLL FAX(978)740-9846
MAYOR TEAS ST.PIEBRE
DIRECTOR OF PUBLICPROPERTYIBLIIIDm ax&msioiait
Construction Debris Disposa/Affidavit
(required for all 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 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:
Mgjl C uIIjwS
(name of hauler)
The debris will be disposed of in:
c5�t.�. f ra►.s'� �J�+u�
(name of facility)
nA1 Gvuxkae A .
(address of facility)
Signature of applicant
Date
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,Mil 02114-2017
www massgov/dia
WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le 'bl
Nam (Business/OrganiutiordIndividual):: �l ""
Address: l t t C L R/t:tpsr. t r e 4 rW c
City/State/Zip: C&o ev Z Phone#: 92d' 33J y(e
Are you an employer?Cbeck the appropriate boa:
Type of project(required):
1.0 I am a employer with—employees(full and/or part-time).' 7- New construction
2.1 &am a,sole proprietor or partnership and have no employees working forme in g• E]Remodeling
`Y-'our capacity.[No workers'comp.insurance requiredl
3.0 I am a homeowner doingall work 9. 0 Demolition
myself[No workers'comp.insurance required.]t
10 Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I wt71 -
eoswe that all contractors either have workers'compensation insuance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. - 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the subcontractors listed on the attached sheet. Roof repairs.
These sub-contractors have employees and have workers'comp.imsum mt 13.E] I
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14�Otbef Pdral� e-S& t S
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box Nl must also fill out the section below showing their workers'compensation policy mtormation.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside man=on must submit a new affidavit indicating such.
rContramrs that check this box must attached an additional sheet showing the mare of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide theirworkers'comp.policy number.., -
I am an employer that is providing workers'compensation insurance for my employees.-Below is the policy and jobsite
information.
Insurance Company Name:C t,�AY. :F�ne.
Policy#or Self-ins.Lic.#: Expiration Date:: /
Job Site Address: Z 111 � � ✓liiL r City/State/Zip: }Ve,,+r
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$I,500.00
and/or one-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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cerd 51 under the Dains and penaUies ofperjury that the information provided above ' true and correct
d i
Si ature: Date, �/f S i S
Phone#• �7J' 3�Il y(Iirjt
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 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 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 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 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 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(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 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-insured companies should enter 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 permittlicense 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 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 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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