28C FEDERAL ST - BUILDING INSPECTION The Commonwealth of MI a ��1�}tluy� tts
Cr Department of Public Sao SVi 1 ; A 8: 3b
(— Massachusetts State Building Code(780 CMR)
�— Building Permit Application for any Building other than a One-or Two-Family Dwelling
/n1 (This Section For Official Use Only)
y Building Permit Number: Date Applied: Building Offici.•d:
l SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
I Re if 6a',?Q1' sr Uvd3 y"lem o197o
{-- No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK.
Edition of MA State Code used_ If New Construction check here O or check all that apply in the two rows below
Existing 8uildin Repair Alteration
Addition❑ 1 Demolition O (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 4R
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Descri lion of Proposed Work:
�nAv1 t)De) (� rrhPtJ � n0 '"iWJ dN't f1)CW i'/dJRih! r � /Wu yv�
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 Fluor(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❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2 d 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 applicable)
IA ❑ 1B ❑ IIA ❑ 1180 I11A0 IIIB ❑ IV ❑ 1 VA ❑ VB ❑
l SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
i h Trenc Permit:Water Supply: Flood Zone Information Sewage Disposal: Licensed Disposal Site
Public� Check if outside Flood Zone Indicate municipa- A trench will not be p
Private❑ or indentify Zone: or on site system❑ required�r trench or specify:
permit is enclosed❑
Railroad right-of-wa 11azards to Air Navigation: _\_M I li to,is t,-n_.nun ksi m Ito.u v 1 r�,i_<,.:
Not Applicable Is Structure within airport app ach area? Is their review cnmpl• d?
or Consent to Build enclosed❑ Yes❑ ur No Yes❑ No r
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:
n7�' 7 Yo - 9jc;L/(o '
ra
SECTION 9: PROPERTY OWNER AUTHORIZATION r
Name and Address of PbJperty Orvner
)w(o S,IerJ 4661)eroi J J _�2 _ �/41 , /Lim C�157U
Name(Print) y' ,7 r^1 rtJ { No.and Street City/Town Zip
Property Owner Contact Information:
Title v _ Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereb authorizes
Name Street Address City• own 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 Appendix2) -
if building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
—. w t k
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
��ICC' 1-dnJ�'�✓��Jhi
Company Name
NKme of Person Responsible for Construction License No. and Type if Applicable
7 yern CP /I✓e �cuJj�s �� 151�6
St� Address City/Town State Zip
Ynfckuel(d ueAice- Cd—
Tele hone No. business Telephone No. cell e-mail address
SECTION 11:4V0I:KERS'CObIPFNSAI'iON INSURANCE;AFFIUAVLf M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the NIA 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? Y No O
SECTION 12:.CONSTRUCTION COSTS AND PERMIT TEr
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Budding Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $ ()a
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality) _
5. Mechanical Other $ 4( 6 I,
Enclose eck payable to
6.Total Cost $ I (contact ch municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,[hereby attest undffthpand penalties of perjury that aB of[he information comained in this
application is true and accurate to the be of mye and understanding.
dS6
Please pruit anSign na:7�e C` Ti le D Telephone No. Date
��7/-2 S o
Street Address City/Town State Zip
i
Municipal Inspector to fill out this section upon application approval: vGfj
Name Date
7YOFSALEA4 MAS'SAa"ETP
B[uZEWDJFPAFMMrr
120 WA9MV7poSnWs YORO a
110. 74s-nos.
FAX 74498�/6
B1A�ERIBYDRISQ�.L
AUYCaR TJAMMSSM"M
D=C7McwPusuc r/Bmnmcremaw
Construction Debris Disposa/AfJrdavit
(required forall demolition and.renovation work)•
In accordance with the sixth edition of the State Builds. ng Cie, 780 pNR, Section 111.5 Debris,
and the provisions of MGL c4o S 54• Builds Penult R
n8 is Issued with the
condition that the debris rewlting from this work shall be disposed of in a Properly licensed "
waste deposit facilityas defined by L c 111,S 15l1A.
The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
6/j- &ram ,
(name of facility)
P A4A
(address of facility)
Signatur of pplicant
7 /y 6
Date
_ ,^p'p� � ter».- ..
Massacnu :76 -[3ep6rtmeoft.off'r4(2.IicSafety (
Board of'Building Regulations and iitandards rt
L:unuruumn�uPcr,�acor
License CS-107733
MICHAEL DIGIROLAMQ '
22 VEMCE AVENLJEs 'e-4i ,
Saugus MA 019041
b
F+�,Commissianer ,.'3 µ 1;b7/10/2017,
$tl P
The Commonwealth ofMassachuseikr
Depardnent oflndushWAccidents
1 Congress Street'Suite 100
Boston,AM 02114-2017
wwncmassgov/dia
Workers'Compensation Insurance Affidavit:Bunders/ContractorsMectricians/Plumbem
TO BE FMW WI THE PERMHTING AUTHORITY.
AnnBcant Information TH ^ Please Print Leelbly
Name(Business/organindion/Individual): �jM_ C�c,e 1 I, (1 Y ui c',
Address: � ✓P�rl CC -14,c / )
City/State/Zip.---SG f V5, '41 & Phone#:_
Are you s m empbyerr Check the appropriate bus:
1/,1/r.1 am a employer �_earpbyes(full auNm part-time).
with Type of project(required):
� � •
2.01 em a sole WWrietor m pam ship and have on 7• 0 New construction
my c apacity employes woddmg forme in
[No wodrrr•comp.�.s..e•.�-. rtyuired,] 8-6ff4temodeling
3.01 am a homeowner doing all work myself(No workers,romp.hamance requ re&]1 9. ❑Demolition
4.01 sm a homeowner and will be hiring conlrectur to conduct as work on my property. I will 10 0 Building addition
easur that all eOubadm either have workers'cenpeaatien mnnom,,or are sole proprietors with an enggoyes. 1].0 Electrical repairs or additions
5.01 me a 12.0 Phnnbing repairs or additions
7hese sub•eontia have 1 oyebbea listed attached sheet
employes and have workers,comp.irsmance.f 13.0 Roofrepairs
6.0 We s c a corportien and its officers have exercised disk nght of eaemption WMGL a 14.0 Other
15Z§1(41 and we have no employees,fNo worker•gyp.i.,..,.ence,mqubed)
*Any applicant that checks boa#1 must also fill out the section below showing their ,workers'compeoypm policy hime utien.
Homeowners who submit this affidavit indicating they are doing as work and then him outside contractors must submit a sew affidavit indicating such ICamhacom that check this boa must muched in additionel shell showing the name of the subeomtragor and state whether or not those a a Gave employees. Ifthe aubcontraGers have employees,they must provide then vmdnxs'
comp-Po1loY mm�ber.
I am an eerployer,that is providing workers'eonrpensatlon insurancefor my employees. Below it thepoliry andjob site
brformadon / '
Insurance Company Name:_ XQl� — � 44 tc�el�
Policy#or Self-ins.Lic.M Expiration Date.
Job Site Address: City/Statcaip.
Attach a copy of the workers'compensation policy declaration page(showing the policy number and eapfration date}
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a Sue up to$1,500.00
and/or one-year imprisonment,as Well W 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 111 11 under the1p penaMes ojperjury that the information provided above true d correct
ate, 7 /`�' /G
Pha
Q�cial use only. Do not write in this area,to be completed by oily or town official
City or Town: Permit/Ucense#
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 cnterprise,and including the legal representatives of a deceased employe,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 then 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 wbo 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(Li-P)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or UP 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 a ate 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 perrmtAicense number which will be used as a reference number. In addition,an applicant
that must subunit multiple pernittlicrose 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 dog license or perrrit 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 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
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