194 FEDERAL ST - BUILDING INSPECTION RE tti0 CV- q3I
CEIVED
UR
PurlIAL ERVICES The Commonwealth of Massachusetts
B 29 Department of Public Safety
A 32 Massachusetts State Building Code(780 CMR)
1 _ Building Permit Application for any Building other than a One-or Two-Family Dwelling
l (This Section For Official Use Only)
Building Permit Number: Date Applied: Building OfffciaL
1 SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
`Q 1(1y Federrj S4 6cle.r.,, 01Ci -1O
No.and Street City/Town Zip Code Name of Building(if applicable)
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 Mr Repair 91' 1 Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
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
Is an Independent Structural Engineerin.�yPeer Review required f /� Yes ❑ No ❑
BriefRescription of Proposed Work: Ke L 2-' + �Qo✓ "-t7-, ro vr.�„ f�e�
F�t r l S�t eS G�. lnJ 4(( ✓ 2 )-L✓ 4 W 47(d vr(�1 v�0 K v ✓ es
r
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 CUR 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. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 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 ❑ IIA ❑ IIB ❑ HLA ❑ HIB ❑ 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:
Public Ef� Check if outside Flood Zone❑ Indicate municipal Er A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process.
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build 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:
o4-,)GtJo�S�I�
� �� ld ��tL � Z
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner /�
'wtllla�-, h'l,cl,la-4 a-7 wo-odside YZr� To S , ol9
Name(Print) No.and Street ty/Town Zip
Property Owner Contact Information:
q* _kk1_ ✓o�g W r�t�tr o���P a7 L
Title Telephone No. (business) Telephone No. (cell) e-mail address 4
If applicable,the property owner hereby authorizes
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 rmtt application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 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
GY k ec's CCA,S Co . TKc�
Company Name Wtlltti � " hvyLlcL, C S ' 0S (0 )L
Name of Person Responsible for Construction License No. and Type if Applicable
1'1 w L7 t `�Sej er 1 �w. 0 l( ij �
Street Address State Zip
Telephone No. (business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 O
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ U o Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ 300 appropriate municipal factor)=$_
3.Plumbing $ 2000
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact unicipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 0, Lj_V 0 (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(nan__d accurate to the best of my knowledge and understanding. G�fi
\Gw� TZ I yw( ---� �Y� 1 Is -q_Lz2�L�
Please print and sign name Title (� Telephone No. Date
�� LJ<1\YrG� 5� 2JL11 1 m O\q(l�
Street Address City/To State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF SMY.M, iNvLxSSACHUSET 'S
• BUILDING DEP tRT.%mN-T
j 120 WASHINGTON STREET, 3'0 FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIJt9ERLEY DRISCOLL
J tAYOR THoaus ST.PtERRs
DIRECTOR OF PUBLIC PROPFRTY/BUILDING CMDUSSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
4-YN4/ k �IStac, C,
(name of hauler)
The debris will be disposed of in :
(na of facility)
&0 Lo ( eS � W- Pee-
(address of facility)
14 fir
signature cff permit applicant
date
dcbrivlTdx
a
CITY OF S ��,t, 2%1AS&-kCHL'SETTS BLILDLNG DEPART%IENT
I20 W.ksHiNGTON STREET,Y'FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
[O.NIBFRi RY DRISCOIL
MAYOR THOt fAs ST.PIERR6
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG COWWSSIONFR
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Nalne(Businss.eOrpnizationrinLlividu d): 'r } ^S C ^^S . a ,
Address: \'l 1n12 (� "ten-_ Z-v
City/State/Zip: 1 )R-i'4 'f �A 015 ( 5 Phone#: 9 -1
Are you an employer?Check the appropriate box: Type of project(required):
1.811 am a employer with 4. 0 1 am a general contractor and 1
employees(full and/or part-time)." have hired the sub-contractors 6. ❑New construction
2.0 1 am a sole proprietor or partner- listed on the attached sheet.: 7. [ Remodeling
ship and have no employees These sub-contractors have & ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. 0 Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its
required.)
Officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 13.0 Other
comp. insurance required.]
Any applicant that checks box a1 most also fill out the section below showing their werkess'compensation policy infum odor.
'1 kzncowness who submit this affidavit indicating they too doing all work and then hire outside contractors must submit a new atrtdavit indicating such
lComractors that check this box must attached an additional sheet showing the name of the sub-contractors and their worker'comp.policy inatmunioa.
I am an employer that Is providing workers compensation insurance for my employeex Below is the policy and Job site
information. _
Insarrnce Company Name: V A✓•f I .�
Policy k or Self-ins. Lie.#: (014 u k3 a L 7/7 S 2,20 /S Expiration Date: �/(
Job Site Address: 1 Fe y rt / 9 J City/State/Zip: &l P)'r� �r c, 019
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the firm of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerdj under the ins and penalties ofperjary that the information provided above Is true and correct
Sianattire: r¢y Da : "aA.
Phone : 7e Z `L
Offlefal use only. Do not write in this area,to he completed by city or town ojrcheL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Ifealth 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
IZv Wus�, w.g� S�-
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GTE
n Office of Consumer Affairs and Ilusiness Regulation
10 Park Plaza - Suite'5170
Boston, Massachusetts 02116
Home Improvement CQntraFtor Registration
Registration: 173846
Type: Corporation
Expiration: 11/20/2016 Tr# 259488
MARCHAND & SONS CONSTRU 10UMCCQ ' _-- aly�
WILLIAM MARCHAND ;mT == 1>�
17 WELLMAN ST
BEVERLEY, MA 01915 "t -----
Update.Address and return card.Mark reason for change.
Address- Renewal Empint Lost Card
- CAI 0 50M-04/04-G101216 oyme - - -- _-
Office o me°""r ai�n rs&"Bfiness ffegu o� License or registration valid for individul use only
U
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
IegisR
tration 173846 Type:, Office of Consumer Affairs and Business Regulation
Expiration 11/202016 Corporation 10 Park Plaza-Suite 5170
-=- Boston,MA 02116
Mho HAND&SONS_.CONSTRUCTION CO INC.
WILLIAM MARCHAND
17 WELLMAN ST -
BEVERLEY, MA 01915 Undenecretary Not valid without signature
M�sachusett�`
hoard ofB Department or P�tr— -�Sad
uilolm9 Re90lations and Standards
�9nstt'[Ictton&P.ervisor" -
License:
--XLIAMR �w r rr
MA�OI -
Commissioner Expiration
0111012017
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where a licable
No. Item Submitted Incomplete Not Required
_ 1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may r uire repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas atura1,Propane,Medical or other
10 Surveyed Site Plan(Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&.Ins ections Program
14 Fire Protection Narrative Report
15 Existing Building Surve /Investi ation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State zip