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10 FRONT ST - BUILDING INSPECTION Z$2S% cr_(OZSz The Commonwealth of Massachusetts W Department of Public Safety Massachusotts State Building Code(780CMR) .M Building Permit Application for any Building other than a One-or Two-Family Dwelling l (niis Section For Official Use Only) 1 Building Permit Number: Date Applied: Building Official: SECTION II: CATION(Pie le indicate Block#and Lot#for locations for which a street address is not available) 10 1 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK �1 Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building® Repair❑ 1 Alleration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix t) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being suppliml as part of this permit application? Yes ❑ No 18 Is an IndependentStructural En meeringg Peer Review ui i? -f-- Yes ❑ No Ot Brie esc of Proposed Work: ��GvA. a_ 3���ii.,t~o 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 CNIR 34) O Existing UseGroup(s): C; Proposed UseGroup(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(it.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I❑ F2❑ - fl: High Hazard H-t❑. H-2❑ H-3 ❑ H4❑ H-5❑ 1: Institutional 1-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage St ❑ - S-2❑ U. Utility❑ Special Use❑and please describe below'. Special Use: SECTION 6..CONSTRUCTION TYPE(Check as applicable) - IA ❑ IBO IIA ❑ IIB ❑ I IIIA ❑ [fill ❑ 1 IV Cl I VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) : Debris Removal:it Water Supply: Flood Zone Information: Serfage Disposal: Trench Perm us d Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P s Private❑ or indentify,Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: 41n Ili_twi:�;..nun.,yiyn tt_�;cp_I'pxt Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Budd enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition art Code: Use Group(s): Type of Construction:_ OLcupant Load per Floor: Does the building,contain an Sprinkler System?:--Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Addre of roperty Owner( - o &at� Name(Print) No.and Street - City/Town Zip Property Owner Contact lnfonnation: I423 630 �Rcra�enJ TIV - 7 i_ ciQcR� -�_- �aoK06PJKl�le,� QU t e5 r Title Telephone No.(business) Telephone No. (cell) e-mail address ow— If applicable,the prope f,Lp-wner hereby authorizes I C•- ` � 1 1� 7 `F (1�6�laln w K� �Pt�.� �1nQ �101 Name Street Address City/Town State - Zip to act 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 than 35,000 cu.ft.of enclosed space end 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 . ColCpvty Ni X rTCo/W� � S - OG6Uq� Name of Person lRespoKsible for Construction icense No. and Type if Applicable \00 0E lS Street Address City/Town State Zip PVTelTNoO e hone No. business Tele hone No. coil maSECTION 11:Vk'ORI:EhS'COAIPENSAl1DN INtiUIt:\.NCE:\PF1bAVt1' M.C.L. 6A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Acce completed andsubmitted with this application. Failure to provide this affidavit will result in the denial of ththe building permit.Is a si ned Affidavit submitted with this a lication? Yes SECTION 12.CONSTRUCTION COSTS AND PERMIT FE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ O c Building Permit Fee-Total Construction Cost x_(insert here 2.Electrical $ - appropriate municipal factor)_$ 3. Plumbing $ d.Mechanical (HVAC) S Note:Minimum fee-$ (contact municipality) f S. hlechanieai Other - $ payable E) �6 � Enclose check a able to © 6.Total Cost $ O U (contact municipality)and write check number here SECTION 13:SIGN TURE OF ll I RMIT APPLICANT By entering my name below, 1 hereby attest un r Ike pains�iRd penalties of perjury that all of the information contained in this application is true and accurate to the best of t w e and understanding. Go 1`�� V�—_ 3-16 l� Ple.ue rint a td sigt e 1 ` -{� ^'Q., /� A Title ,pTelephone No. Date .Jar lll_IS �(]0 V Y.IYD AY/1 " JCL O[ S rt Street Address City/Town State Zip�rXl Municipal Inspector to fill out this section upon application approval 0461W c i y Name Date l h Massachusetts Department of Public Safety g® Board of Building Regulations and Standards License: CS-065097 Construction Supervisor STEVEN J GOLDBERG - - 9 OLD PLANERS ROAD i = BEVERLY MA 0jI915 - n d: P�.jZC;C CA— Expiration': Commissioner 03/7/2018 �N The Commonwealth of Massachusetts f Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia V!rkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibly Name (Business/organization/IndMdual): Address: City/State/Zip: Phone M Are you an employer?Check the appropriate box: FEI 7addton uired): L❑I am a employer with employees(full and/or part-time).* on 2.❑I am a sale proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 3.❑1 am a homeowner doing all work myself[No workers'comp.insurance required.]r 4.❑I am a homeowner and will be hiring contractors to conduct all work on m roe . I will onYP P Yensure that all contractors either have workers'compensation insurance or are sole rs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a genera]contractor and I have hired the subcontractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.= 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. ;Contractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they most provide their workers'comp.policy number. I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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$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 certify under the pains and penalties ofperjury that the information provided above is true and correct. Suture: Dale 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#: 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 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 ed or marked b at has been officially stamped Y the city or town may be provided to the town)."A copy of the affidavit that 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 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. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia : CITY OF SALEg AWsAaiUSETIS BmDm DEPARnffNr 120 WA9MC7WS7REET,3=RCM T L(M)745.9595. FAX(978)740.9846 SIIvJBERLEYDRISGt7l.L MAYOR THWAS ST.PMM 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: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature of applicant Date