32 HARBOR ST - BUILDING INSPECTION v
The Commonwealth of Massachusetts
Department Public Safety
'I Massachusetts State Budding Code(780 CMR)
l,•Vl Building Permit Application for any Building other than a One-or Two-Family Dwelling
00 (This Section For Official Use Only)
N Budding Permit Number: Date Applied: IBu lding Official: z )
` SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street addre is not available)
No.and S ect City/'['own Zip Code Name of Budding(if applicable)
/) SECTION 2:PROPOSED WORK.
rIV I Edition of MA State Code used_ If New nstruction check here❑or check all that apply in the two rows below
1( Existing Building Repair❑ Alteration Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
l Change of Use ❑ 1 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 rf�7uire}1? Yes O No Ca/
Brief Description of Proposed Work: if j,
e wu L/L 07 A-f/6
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) ❑
-T- --TPro poseu s -�---
Existing Use Group(sp � ._ Pd Use Gro P( )�
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❑ B: Business ❑ E: Educational ❑
F: Factory F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ 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 ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ IHB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
--^-,---- — — — -- " - Tr erch Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage'utsposal: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ e trench 1 of not c P
required❑or trench "specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \Ir\ li l nc_C,�,tnmi mn I{cyn t r cs:
Not Applicable Cl 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 Flour:
Does the building contain an Sprinkler System?: Special Stipulations:
1
if
SECTION 9: PROPERTY OWNER AUTHORIZATION
[�Name
me and Address of Property Owner
�o��`oo f� Q 3a LI OFF { k4ern�sEe N`( l lS S
(Print) No.and Street City own Zip
operty Owner Contact Information:
6k-_Y1 $00 Ta-750- (536
Title Telephone No. (business) Telephone No. (cell) e-mail'301dress
If applicable, the roperty owner hereby authorizes
q"v-t'� 3 L \\- f ,r Sj-' { Sy�+ w� Vl O(97 0
Name U Street Address City/Town State Zip
to act on the property owner's behalf,in a6 matters relative to work authorized by this building permit application.
SECTION 10f CONSTRUCTION CONTROL(Please fill out Appendix 2) -
If buBdin is less than 35,000 cu.ft.of enclosed-s ceand or not under Construction Control then check here❑and Aip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Ni me(Registrant) e-mail
address
essG egistration Num
v �afb o!
xp DateStreet Address City/Town State ZI iscipline
10._2 General Contractor - -
`l U /�✓l� �Y (�L / O Gam"
CpaV'9ry Name
J.oLla) ✓�� cGw 1 T 7 �6 '��
Name of Person Responsible fqLConstruction License No. and Type if Applicable
.et,ee/et �Addd/ress (�q Z/� DCity/Town State Zip
Telephone No. business Telephone No. cell a-mail address
SECTION 11:VVORKERS'COMPENSA'I[ON INSURANCE AFFIDAWF M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 13 No 0
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact
municif ility)
5. Mechanical Other $ Enclose check payable to / 'z• (/ \-f"`5�
6.Total Cost $ Q U u e (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[rue and accurate to the best of my knowledge and understanding.
PI se m n sign name Title Telephone No ate
cet Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: -
Name Date
E
The Commonwealth of Massachusetts
s Department of Public Safety
llitrsucbusettt5tule building Code r'M CMR)
Building Permit Application for any Building other than a tuna orTwo-Famiiy Dwelling
(TbisTeckiotti;Ffirlal Use On
Suikiing Permit Number Dato Applied: Building official,
SECTION L TION(Please indicate Block►and Lot t for locations for which a sheet address is not available)
7 01j )c coo?
No:.and S64t - City/Tjvn Zip Code ? Name of Budding(if appiicabte)
SECTION z rROPOSED WORK
Edition of MA State Used T- if New nstruttkm check here O or dnxk all that apply in the two rows below
frxlsttng 8u8ding Reps r 0 Attention Add iflon D Demolition O (Please fit]out and submit Appendix t)
�Cfmnge of Use D [Mange of Occupancy D Other t7 Specify
Are building plansAndJorconstructioudocuments"supptG.•daspartof this permit Application? Yes tl No
►s an Independent-Structural Engineering Peer Review�4airt�t? Yes D No f3'
Brief o scripaon of Pmixu d Wattle_ A A*-LOLl
ett 'A' Slsr�7t! rp
(
SECTION 3t COMPLETE THIS SECTION tF EXISTING BUILDING UNDERGOING RENOVATION,ADOTTION,OR
CHANGE IN USE OR OCCUPANCY
,Check:here if to Fxatin Suildi ire • n and Evaluation is enclosed(See 78D CMR.3t) Q _
t xistiny,Use Ccotrp(s) Proposed Use Group(st•
SECTION a BUILDING HFJ(;HT AMP AREA, `
_ Ezistlng Pmpaxd f
No.of FloomIsturkz(Indude basement levels)&Area Per Floor(4(t) I�
Todd Area(sal,ft)and TOW Height(ft.) }
SECTION S:USE CROUP(Check as APR
iiratile
A. AgeatbA-10 A-2C1 tkluti F] A•3C1 ' A-f.D ASR B:. 6usktess.O. .EdocattortatD_-
IF. Facto d D F2D - FL- h hazard H-1 D H-2❑ H:3.I? H-•tQ HSD
l; InaNhttional 13 (-20 1-3 Cl 14(3 M: MetcantlteT3 R Residential R1❑ !tZQ R=1D R-40
Se Stma a S413 S-2 I U: Wit t] ' S al UseDand .te rlbebdoar
i
special Use,
SECTION&CONSTRUCTION TYPE Wbeck as a WAW)
4} a to p tIA 0 1tB D IItA D UIB O- lY L] VA D V8 ❑
SECTION 7:SM INFORMATION(refer to 738 C,NR 111.0 for details on each item)
Trertcta Parmik5 . Debris Remavaty !!.
WaterSupplys Flood Zonefaf oration SewageDisposak Atrcraehwdlnotbn f.itctaawrflispasatSiteCl 4
Public Q Check ll outaido F zoax i] Itnituu!rsunklpd O required 0 orImuch br svedt Y_,,,--,_�,T i
Private Q. or hateaft Zoru�.-. . oronsitusysteatO. . permit isenciaoeaiQ . . f
RaiNtro#�ppf,. kt-d-way:' fiaaardstoAis avlgatiun! '}lA.(.fnl+'gelOtt ."``= +nl+'is"S°'Kfarc�Ct+ 'rt
jy}e Q is Structure wither airport approach area? Ls tharir rawic+is Canfpfrtrdz
rar:{'k+rwrnt to lduitdeadov al D Yes 0 or No O Yea D No O -
SEC[IONS:CONt'ENT OF CERTIF.CATE OF OCCUPANCY t
Low"of C.tHlr, - W.. �Cro+p(s): — Tyro ofC W.14nJ kM.' Gktnptnt Load per Fknu,
f
0letMobmidaognnrt.tfitas5pfinkkKSyetcn+r. ^pTint5a{padat;ors.
c
e
,
tiMROM vt rROFCRTY 5MM A[TtlIt7RI7al7fON
Nate rws ",fort sin vtwr
tm»(ptBr Na,and 5ttuc Cuy/Towo gip
t'mprrty rt otttmtfn ;
3 90611V7,sz L367 fah l� c�
Tehrphcxto W.(baaitt�) Tckplunte Na. (c(ii) �Fl gaidtmts
ff.tpplkablr,thopro) wmrrherebyaultvoijut , .
rbvr .sue S,1 �I
Narita y.tn*Add,"A City/Town Stsho Zap
taxi on thv o` Na 'hnl n all nmttr rek+ttvv to work 3bthoHked tAfs tru i` it:r fcsu
sy ION lot CONS7RUCTION CONTROL(Ple"sAltoutApRMdix2)
tkth ttwt taf ! e or utukr ClNtadihutcherfQatwtale tbnl0:t
t ex i Prerf#aeton�alReeai a Iblsfa�r/C�� InnConISO -
{6 _Ao
N ra(R tot" jtc�utrmktnNum d'.
Strtntt Addnrs► CRY/Town %iH Zip OWiIPUne apiAwon Pa to
]0. GatutralC .
't G
y Notate
NMW of P"So t ReaptAsIble iyc,l,yfttiructkn Lkctw Nm and Type iff AAppllkablc f--
east Addrer �� r Y/Tmwtt _ SWd -zip
tQo 1 "#.T� N-« ,
T - e mailadti�n
A WoARW Compmoon tnsumm AffklavIe from IDS MA Deportment of Intluarlal Acckieala must be canpktetl and .
eiubrWIW with this appkauoa Fauute to provide this a fktsvft will mull In the dental of the tuuattce of the budding perudc
tsaa- tarttAffklavitxubatittttiwtthiltira I n?. Yes Wo 13
SECRON a C'ONSTRAI ON COSTS AN PERMIT FEE
than 6sdmaknt t aedr tf airor Total Cotatruckw Coat(frM Item 6)'S
_ ant!ht»teAals) _
t.8utktln S Buddingparaltpas4TualCattslruAm Cog x_ (fnxrtfare
7.EIMtr" S appropriatemunkiXaffactor)
.I'lumbin S
HVA Note.btlnimum kv (contact municipauty)
Xbn pp
# . Enclose check payable to t
bTaw Cot S a7Ntie *" cWttactcnuttki and wrim check numtierhM i
Et+t'iiUN &iGNnrvRBapBUfGpiNGMRMffAMr NT
fiY a»tecing ttq name ow,l ksatelty !test Under ths plans amt pony . t of p t)ury that au of the information cpnta :4 in this
apptkalton is troe aria accurate to the beat of my knatvkdEe atui utrdcrnanding, ( J
ofsa taurv. . the Tc)epbo�rmrN to
tw Atkir CitY/Tuvm Srate zip
61tmkipal!inspector to fW out thb"etton"out appikatlon appooval:
Name:. to .
\ The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leidbly
Name(Business/Organintion/fndividual): �d/n sJ n� 1,1L A
Address: t2 (A f J I VL ✓ F f''
City/State/Zip: 12 06 Phone#: 7lrf_°F S_
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑I am a employer with employees(full and/or part-time).• . ❑New construction
2.0 I sm a sole proprietor or partnership and have no employees working forme in ][8. ❑Remodeling
any capacity.[No workers'comp.insurance required]
3. I am a homeowner doing all work . ❑Demolition
❑ g myself.[No workers'comp.insurance required.]t
4.❑I am a homeowner and will be hiring contractors to conduct all work on m o0❑Building addition
y pr perry.ensure that all contractors either have workers'compensation insurance m are sole .❑Electrical repairs or additions
proprietors with no employees.
.❑Plumbing repairs or additions
5.❑Iam a general contractor and I have hired the sub-contractors listed on the attached sheThese sub-contractors have employees and have workers'comp.insurance.: .❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c .❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#1 most also fill out the section below showing their workers'compensation polity information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide their workers'comp.policy number.
lam an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: O
Policy#or Self-ins.Lic.M 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 c ' u er t ins and penalties ofperjury that the information provided above is trueand corr
ect
Si aturc: Date:
Phone#: — ,�d
Official use only. Do not write in this area,to be completed by city or town ofciaL
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 pemdt/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 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-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Cgnstruction Supervisor
License: CS-077565 g
JOHN J MULD00A
2 WALNUT ST Y
MARBLEHEAD MA
y
rye`
.�H�a ' Expiration
Commissioner OB/01/2018
Unrestricted Buildings of any use group which
contain less than 35,000 cubic feet(991m')of
enclosed space.
Failure to possess a current edition of the Massachusetts
state Building Code is cause for revocation of this license.
For DPS Li ensinginformationvisit: w -Mass.Gov/'
CITY OF SALE14 A ASSACHL SE M
B[uzmDEPAR7MEw
120 WA9MVMS7REET,31DFLOOR
TIL(978)745.9393,
S
FAX(9978)740.9846
I1v16ER LE Y DR ISOt7I L
MAYOR piss STJ'n=
Dwcrcat crPEzucmt(FEm/BtzmDmcOmm=a=
Construction Debris Disposa/Afdavit
(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 g 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)
dress of facility)
Ignatur of applicant
3 �J- OT a
Date
Massachusetts -Department of Public Safety
> Board of Building Regulations and Standards
,Cgnstruction-Supervisor
License: CS-077565
1¢.
- JOFIN J MULI)OQAi
2 WALNUT ST - S
MARHLEfIEAD
Expiration
08/01/2016
Commissioner
,J