20 FEDERAL ST - BUILDING INSPECTION (7) -7
RECEIVED
The Commonwealth of Massachusetts
U N i r Department ofoTtlip�afetp A a 2 8
x, hfassachuselts State flui mg o e(78 CMR)
gBuilding Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Budding Permit Number. Date Applied: Building Official:
SECTION 1: C TION(Please indicate Block#and Lot#for locations for whichskeet a dress is not avail le)
l� D
No.and Street City/Town Zip Code Name of Budding(if applicable)
S^ 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
I Existing Building❑ Repair 01 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix l)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No W,
Is an Independent Structural Engineering Peer Review required? Yes ❑ No lr7
Brief D- vescription of Proposed o kIz
i?
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 UseGroup(s): Proposed Use Group(s):
SECTIONS:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(eq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A•L❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: business ❑ E. Educational ❑
F: Facto F-I ClF2 O H:. Hi h Hazard H-t❑. H-2❑ H-3 ❑ H4❑ H-5❑
L• Institutional W❑ 1-2❑ 1-3❑ 14❑ M: Mercantile O R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U. Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IBO IIA ❑ IIBO IIIA ❑ IIIB ❑ I IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: H Trench Permit: Debris Removal:ood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not bes
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: fit,\I l jtor'u_'Gnpndsl m Re,;.•....I'n wI C
Not Applicable❑ Is Structure within airport.ipproach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code Use Group(s): Type of Construction: Occupant Load per Flour:
Does the building contain an Sprinkler System?: Special Stipulations:
rnpl ,U Gl.l �z ; m�tL -ED l (�
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name mad Address of Property Oyv R 1 / j& ,/,-�� . t
Name(Print) ✓y Noo./anndd Street (I; - /j�,'� City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) mail addres +'
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to net 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 thin 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Re istered Professional Responsible for Construction Control
Nan Re islr t F Te I� ho • o. e-mail addr••}s a ion Numbe
Street Address - City/To - State Zip Discipline Expiration Date
10.2 General gontractor -
"t. od d f
ComEpny Name
Name of Person Fe ponst le fu Constructi n License No. and Type if Applicable
d1,4 ��I, u�l�� a 0ajYA
Street Address City own State
.��
Telephone No. business Telephone No. cell e-mail address
Ir
SECTION 11:4VORFFhS'CObIPEN5A I"ION INSU&LNCE.:VFIDMIrr M.C.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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Budding $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ / �f/ (contact municipality)and write check number here
SECTIO 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 anal ucurat t the best of my knowled and understanding.
Pleas7lD - P� j / /� �„ Title Icl.Zhu Date
Street Address G j`- U, City/T wn 'Jf�/ttaaitteee Zip
Municipal Inspector to fill out this section upon application approval: Pim,
WDte
Name
L
CITY OF SALEA MASSAaA SEM
1 Bu !i DngG DEPARTMENT
120 WAstm GwNSTREEr,3xDFLOOR
7kL(978)745-9595
KDOERLEYDRISCOLL FAX(978)740-9846
MAYOR 711MW ST.PIEPM
DIRECTOR OF PLMUCPROPEMAIAI.DING 0CMUSSIONER
Construction Debris Disposal 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 00, S 54; Building Permit#t 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)
Signat re of applicant
Date
y
The Commonwealth of Massachusetts '
Department oflndustrialAccfdents
I Congress Street,Suite 100
Boston,MA 02114-1017
www.mass gov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/.Plumbers.
TO BE FILED WITH TBE PERMWING AUTHORITY.
Applicant Information n Please Print Le 'bl
Name(BusmesstOrganization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
l.❑I am a employer wilh employees(full andtorpart-tune).* 7. ❑ cw Construction
2�am a.sole proprietor or partnership and have no employees worl®g forme m g. IffRemodeling
any capacity.[No workers'comp.insurance required]
3.❑I am a homeowner doing all work myself.[No workers'camp.insurance required.]t 9: ❑Demolition
10❑Building addition.
4.❑ rs I am a homeowner and will be hiring contracto to conduct all work on my property. 1 will .
ensue that all contractors either have workers'compensation insurance or are sole I LE)Electrical repairs or additions
proprietors with no employees. _ 12.❑Plumbing repairs or additions
5.❑I am a general connector and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub�conlractors have employees and have workers'comp.msmence3 - -
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have no employees.(No workers'comp.insurance required.)
•Any applicant that checks box#1 must also fill out the section below showing their workers'dompenmation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such
IConhactors that check this box must attached an additional sheet showing the name of are sub-contractors and state whether or not those®tines have -
employees. If the sub-conuactms have employees,they must provide their workers'-gomp.policy number,
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jobsite
information. qqq{
Insurance Company Name: j� ✓"
Policy#or Self-ins.Lic.#: 17 - Expiration Date:
Job Site Address: r i cC.i��slfet V/ &- City/State/Zip: &9!
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 line up to$1,500.00
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 c der the pains an penak' ofperjury that the information provided above iissprue and correct
Signature t /�Z; Date•
Phone#:
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#:
J
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-contractors)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 employces 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 pemrit 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 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 pertrrits 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/dia