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87 BRIDGE ST - BUILDING INSPECTION (4) 6-0 " Glc. The Commonwealth of Ma j t ��TNSQifiSL SERVICES ni Department Public Safety U' AlassachusrttsState Buiui lding Code(78 1 i, qq Building Permit Application for any Building other than aIM'Twb-FAmpp ily bletling l .('Phis Section For Official Use Only) t _ Building Permit Number. Date Applied: Building official: "Buildin :LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) rfl2\ 1LZCity/Town Zip Code Name of Building(if applicable)SECTION 2 PROPOSED WORK te Code used_ If New Construction check here❑or check all that apply in the two rows below ❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition (Please fill out and submit Appendix I) Change of Use ❑ 1 ChangeofOccupancy, ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ Nu x Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work:. 'r n n l� t. D rJ C1 fa-V).l hs kS S� t tJ r 2r�rJ T Q C- s a- 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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I❑ F2❑ if: High Hazud H-1❑. H-2❑ H-3 ❑ H4❑ H-5❑ 1: Institutional W❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R-Residential R-ICI 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 a licable) IA O IBC] IIA ❑ IIB ❑ 11IA ❑ IIIBO I IV ❑ 1 VA VB ❑ 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 Sit ❑ Pubiico Check if outside Flood Zone❑ Indlicate municipalfr requiredoor trench specify: Private❑ or indentify,Zone: or on site system❑ permit is enclosed [] Railroad right-of-way: tl cards to Air Navigation: Not Applicable k Is Structure within airport approach area? -�— (s their review mmpleteJ? or Consent to Budd enclosed❑ 1 Yes❑ or Nolk j Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Croup(s): . Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: _ Special Stipulations: I'APt- —p Cb 31JNd �� fL — 10(Z2 SECTION 9: PROPERTY OWNER AUTHORIZATION Nan •and ddress of Property Owner 4 ✓Q � °o 7tl Name(Print) No.and Street City/Town Zip Property Owner Contact Information: O �h�I� � � 7 3 I -- Title Telephone No.(business) Telephone No. (cell) e-nigil address If applicable,th nrn+erty owner here y authorizes tJ 1/ ZZLI,.VAuy Name Street Address City/Town State Zip to act on the property owner's 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 than 35,000 cu.ft.of enclosed space and or not tinder 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 10.2 General Contractor . i Compw Name e a s e 2 otA II+ �-A/c— 7L/, Name of Person esponsible fur C struction Li ense No. and Type if Ap 1' able Str,4 Add s business( e ho C' /Town State Zip Telephone No. Tclne No. eel e-mail address SECTION 11:FVORKER.9'COt IPF.NSAtION IN9UltANC.'1i APFIUAVII M.G.L.c.L52. 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 0 No 0 SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor p/> 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 $ d.Mechanical (HVAC) S Note:Mininmm fee=S (contact municipality) 5.Mechanical Other $ Enclose check a able to P'Y 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this application is true an�,tccurate to the best of my knowledge and understanding. > d� �L� ✓a, i1 �l ��1% Please print ai si a :r Title T ephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: "l Name Dat The Commonwealth of Massachusetts Department oflndusinalAceidents I Congress Street,Suite 100 Boston,MA 02II42017 wwivmassgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FH,ED WITH THE PERMITTING AUTHORITY: - Applicant Information Please Print Le bl J /7 NaMe(Business/Otganization(Ini ividasl): t:LI'1� ✓ . . .. ✓v��J't p Address: 13dv -elev Phone#:City/State/Zip:�� 3t�- / V Are you on employer?Check [�the,Approprfate box: ,• Type of project(required): rl�l /am a employer with h employees(full and/mpan-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working forme in 8. Q Remodeling my capacity.(No workers'comp.insraance requhed.] _ 3.Q I son a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. iKDemolition _ 4.�I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition. ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or_additions proprietors with no employees. .12.0 Plumbing'repairs or additions: ` 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. . - - ' ✓�—'These subcontractors have employees and have workers'comp.rammurce t 13. Roof repairs. 6.❑We are a corporation and its officers have exercised thekright of exemption per MGL c. 14.❑Other 15Z§1(4),and we have no employees.lNo workers'comp:namance required.) - - *Any applicant that checks box ill must also fill our the section below showing then workers'compensation policy iofurmene, t Homeowners who submit this affidavit indicating they are doing all work'snd than hire outside contractors must submit a new affidavit indicating such 1Conhactors that check this box must attached an additional sheet showing the name of the sub-cohtractors and state whether or not those entities have employees. Ifthe sub-zursxxxx have employees,they must provide then workers'.comp.policy mrmber. - - I am an employer that is providing workers'compensation insurance f my employees. Bel information ow is t erpoUcy andjob-site Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: l! Job Site Address: ESP--- r j _ City/State/Zip: /J jc Attach a copy of the workers'compensation policy declare on page(showing the policy n her and expiration date��,/ Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisontnent,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 Is the nains and penalties ofperjury that the information provide above is true and cogrt Si store: Dat : t7 Phone M s - Official use only. Do mat write in this area,to be completed by city or town ojfwial City or Town: PermiMeense# 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(LLQ 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 perm 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 permit/license number which will be used as a reference number. In addition,an applicant that most 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 perm 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 02 1 14-20 1 7 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia CITY OF SALEA MASSAaimm BEuDINGDEPAR7MEw 120 WA9mgG7icNSmmET,3m'Rom UL(978)745.9595 KIIv>BERLEYDRISODLL FAX(978)740.9846 MAYOR 7)ICUM STMEM DIREcroxofPi aucPRorERTr/BIIIiDmccw s=OmR 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# I 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: avu sU r�c, ..,Iq ce4,yCC (name of hauler) The debris will be disposed of in: (name of facility) jell"I'ley—Z - IN (address of facility) Si re of applicant Dt Details Page 1 of 1 e Ginn 1t-' eau If he Execu8va O':ce of Put! .afety and 3e ur,ty tEOPSS Hass.0",dome S'ts!e Aye.ltdea ense e Details Full Nae: " ' J N J GAUVAIN Gender: er Name: dress: ddress 2: City: Peabody 'State: MA ipcode: 01960 olintry. U 'led tales icense No: CS- 6 766 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 8/13/2015 Issue Date: Expiration Date: 8/15/2016 License Status: Active Today's Date: 10/20/2015 Secondary License: Doing Business As: atus Chan e: Lic se Renewal o rere uisite Information No Discipline Information ocumen um Close Window i ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.usNerification/Details.aspx?agency_id=1&license_id=25871... 10/20/2015 SearchResults Page 1 of 1 F^c O vebsre off zc-tjnva Jf c.'of lub;_' afety end SC wily!EOPM Fdas<_.Gc-t-lomc Ste'e FCendes Search Results Select the licensee name below for more information. (If your search produced more than one page, you may select page numbers at the bottom of this screen.) Select the Search for a Person or Search for a Facility button to perform a new search. Select the Preview File button to view a sample of the fields included in a file you can download. Select the Download File button to download a text file of your search results at no charge. Select Public Information Request Form for a form to order a data file. _ Search for a Person L Search for a_Facility �.Preview File, Download File rxae 6iai�::�sase &.lumber t.fr.�aas� y'yyse 4a6eens�.�it�tus ttelstress GAUVAIN. JOHN J CS-069766 lConstruction Supervisor cove Peabod MA 01960 k ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.usNerification/SearchResults.aspx 10/20/2015