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The Commonwealth of Massachusetts
250 �O-3� Department of WEIV SERVICES
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IMassachuselts State Build�'Hg' chM(t�`suF&JR)
OBuilding Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use O
Building Permit Number. Date Applied: €27 (t Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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Ci'QoyE 'ST SALE&A 09`(-2 ( MoMY C-�i- e C E�tf12Y
No.and Street City/Town Zip Code Name of Building(if applicable)�p
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 11A
Existing Building❑ Repair% Alteration Cl Addition❑ Demolition ❑ (Please fill out and submit Append
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No�,
Is an Independent Structural Engineering Peer Review required? Yes O No
Brief;�escri lion of Proposed Work:SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
jAsemblyA, -1
g Use Group(s): Proposed Use Group(s):
SECTION 4f BUILDING HEIGHT AND AREA
Existing Proposed
loors/Stories(include basement levels)k Area Per Floor,(.sq. ft.) /
rea(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check ae a Ilcable)
embly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4 O A-5❑ B: Business ❑ E: Educational ❑F-1❑ F2❑ H: Hi h Hazard H-1 O, H-2❑ H-3 ❑ H-4❑ H-5❑
tutional 1-I O 1-2❑ 1-3❑ 14❑ MMercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑ge S-1 ❑ - S-2❑ U. Utility❑ Special Use❑and please describe below:
Use: SECTION 6:CONSTRUCTIONTYPE(Check asa licable)
IB ❑ IIA ❑ 1180 IIIA ❑ IIIB ❑ IV CI 1 VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
: Debris Removal:i Permt
Water Supply: Flood Zone Information: Sewage Disposal: Trench Licensed Disposal Site❑
Public❑ us Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p s+
Private❑ or inJentify Znne: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad rightof-way: Hazards to Air Navigation: %4A I li,top' l}mimisciyw IL'�ie.r.I'r�nI�sp:
Not Applicable❑ Is Structure within airport approach rrea? Is their review completed?
or Consent to Budd enclosed❑ 1 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:
Uses the building curtain an Sprinkler System?: Special Stipulations: _
SECTION 9., PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (ceR) e-mail address
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 budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,0M cu.ft.of enclosed space and or not tinder Construction Control then check hen O and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control.
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Name(Re tislmnt) Tele hone N0. c mail address Registration Number
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Street Address City/Town State Zip Discipline Expinti n Date
10.2 General Contractor -
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Company Name
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Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell mail address
SECTION 11:1V0RFEI:S'COhIPF.NSAI'ION INSURANCE:AFFII IAVFI' M.G.L.c.151§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 M No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
$
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)
1. Building S Building Permit Fee=Total Construction Cost x (i (Insert here
2.Electrical $ - appropriate municipal factor)=5 2
d.Mechanical (HVAC) �-
3. Plumbing _ Note:Minimum fee=$ Zf (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost S C 40o � (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 and accurate to the best of my knowledge and understanding.
WkL_L-11AM Wf�l..�-4 U5bSk'UdZQ nW'ltSA-=-' (2jA 36:D_ 3%1 aCf -7t
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Please print and sign name Title Telephone No. Date
k5 (alC�ttss W � Swt�N MIL olg3fi
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approvaL•
Name Date
CITY OF SALEA MASSACHUSE M
BmDING DEFAR7MEw
120 WAUMgGTON S7REET,310 FLOOR
7kL(978)745-9595.
FAX(978)740-9846
KRAERLEYDRISODLL
MAYOR THOMAS STPIIM
DIRECTOR OFFLsucPROPERTY/BIAIDm oomwssiomR
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 p 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:
\Al'—' WAt4 u
(name of hauler)
The debris will be disposed of in:
C4 tlEuo
(name of facility)
(address of facility)
lam ,
SignatureW applicant
Date
The Commonwealth ofMassaehuseds
Depizi ttent oflndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114--2017
www.massgov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Ledbly
Name(Business/oigam ation/Individual): rr
Address: 15 hN
City/State/Zip:-_'?S\hJiC JA- Phone#: TnD -56(n
Are you an employer?Check the appropriate box: Type of project(required):
I E3I nor a employer with employees(full and/orpart-time).. i 7. Q New,constmCUon
2 1ama sole proprietororpartnership and have noemplayeeaworl®g formem $: Remodeling
any capacity.[No workas'comp.msmariee requved.l .
3.01 am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. ❑Demolition.'
' . . 10❑Building addition
4.EJ Iran a homeowner and will be hiring contractors to conduct all work on my property. l will
ensure that all contractors either have workers'compevmnon insurance or are sole 11.Q Electrical repairs M additions
proprietors with an employees. -
12.]Phmrbing repairs or additions
5.0 ram a general connector and Ihrve hived the sub-cmivarron listed on the attached shear.
These subcontractors have employees and have wodtajs'eomp.msucancet - 13.QRoofrepairs.
6.[-1 We are a corporation and its offices have exercised their right of exemption per MGL c. 14.❑Other
15Z 1](4),and we have no employees.[No workers'comp:.:..,,,.„t required.] -
'Any appumd that checks bar el must also fail our the section below,showing iheii workers wmpmsadm policy information. . ..
t Homeowners who submit this affidavit indicating they are doing as work and than Iwo outside contractors must submit anew affidavit indicating such.
rContuacens that check this box must attached an additional shed showing the name of the sub-contiaaors and slate whether or not those emitter have
employees, tithe sabconuaGms have employees,they must provide their workers.comp.policy m®bw.law an employer that isproviding worlrers'compensation insurmancefor my employees.-Below is thepolicy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.M - Expiration Date: -
Job Site Address: GSty/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 MGI,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$25.0.00 a
Clay 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 of perjury that the information provided above is true and correct
Si®attue: t_� Date: tnC�_
Phone#: ����6C� 71� .
Ojficial use only. Do not wrke in this area,to be completed by city or town OTwiai.
City or Town: Permit/L[cense#
Issuing Authority(circle one): '
1.Board of Health 7,Building Department 3.City/Town Clerk 4.Electrical Inspector S.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 hue,
express or implied,oral or writtep."
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 arid,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 W)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 waist 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 perinit not related to any business or commercial venture
(i.e.a dqg 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. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Office of Consumer Affairs&Business Regulation
VE OME IMPROVEMENT CONTRACTOR
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WILLIAM WALSH CARPENTRY _
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1 WILLIAM WALSH
15 LAKEMANS LN. j,;/
IPSWICH;MA 01938, Undersecretary -
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d` Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
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WILLIAM M WAjtNH
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Commissioner ,