14 HARRISON AVE - BUILDING INSPECTION (2) C`U The Commonwealth of Mp�a�� ch ss wg t�S
n� Department of I104ie.tStttep .4
Massachusetts State Budding Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
t
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a sheet address is not available)
ri / y Lf/9r/^i50n of S.elem 0-f455• aj970-
\ 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❑or check all that apply in the two rows below
Existing Building❑ 1 Repair❑ . Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
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 Engineerin Peer Review required? Yes NQ ❑ //--
Brief Description of Proposed Work: �Q-✓rl o " iJ/� �Zf.Q AU rGl�. �'/zo ..!/'l..f /La J
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PIY71 yz o 412
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 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 ❑ A3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H. Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ 7 R: Residential R R-2❑ R-3❑ Rif❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check asap licable)
IA ❑ IB ❑ IIA ❑ IIB ❑ I LIA ❑ IIIB ❑ IV ❑ I 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:
A trench will not be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone Cl Indicate municipal❑ required❑or trench or specify:
Private❑ or indentify Zone: or on site system Clpermit is enclosed❑
Railroad right-of-way: 1lazards to Air Navigation: \I.\I I. t nc C"'Iniksi on Wv I rocs: -
Not Applicable❑ (s 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:
Dues the building contain an Sprinkler System?: Special Stipulations:
-S%5-yv p
- .SECTION 9: PROPERTY OWNER AUTHORIZATION '
Name a. d ddress of Property 0wher:
1, oet . i`4 gpgrr1Sa,1 aue • 5,g6m "0 of f,7D .
Name(Print) 1 ',. Nd.and Street' City/Town Zip
Property Owner Contact Information:
OLV �M- S b — 123 6
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable, the propnerty owner hereby autho{izes (III 1/ /
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 permit application. -
SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix 2):
(If buildingis less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then cheek here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control - -
V-a,) l 6Qe1- 31�-7 t ff: 32V,? /a 6 q fo V
NRmi gret 4ta) , sF T•�pC; ,No. e-mail address Registration Number
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G'_S 9=
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor-
CA V-.4S h c. !� Q Q-Z
Company Nam
fR , ..)y �o ea Q L
Name of erson Res,Ponsible f r Construction License No. and Type if Applicable
G o, G �l Z an u Q sS O l qi ?O ,
Street Address G(� City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WOI:KERS'CObIPFN5A I ION INSURANCE AfHDAVI'r M.G.L.c.152.9 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 ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ d O Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
d.Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ /.5- O 00 . ®� (contact municipality)and write check number here
SECI70N 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. /
V- C. ,. bCLeL Jtn— Cr✓�Lft� odo✓ ?�J � i ►= 3z�l�'
Please pr' t and;igy'name g I / Title Telephone No. b Date
SVr t C.�S'`
Street Address - City/Town Late Zip ^�
Municipal Inspector to fill out this section upon application approval: 't1y
Name Date
07'Y OF SAIEM, MASSAaA SE1fi
BuwmDBPAmuw
1M WA9W VG71 W S=Wj r ROOJi
7�L(978)7*5-9595.
$1I�ERIBYDdZiSQ�Ii,
FA% 741498�6
MAYOR 9}soesss7:Pam
Construction Debris Disposa/Affidavit
(required for all demolition and.renovatibn work)
In accordance with the sbA 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 shag be disposed of in a properly lkensed
waste deposit facility as defined by MGL c 111,S 150A.
The debris will be transported by.
(name of hau er)
The debris will be disposed of in:
Lynn .
(name of faculty)
( �-o -tom Xqe 61;� d �/
(address of facility)
Signat6re of applicant
Date
The Commonwealth of Massachusetts
Depardment oflndustriddAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.rrtas.-gov/dia
Workers'Compensation Insurance Affidavit:BulMers/Contractors/Electricians/Plambers.
Appliatot Information
TO BE FH,ED WITH THE PF.RMTIHG AUTHORITY.
Tim
Name(9osmess/OrB``aoizafion/Indiviauan: 1 IQ y� 5 c G n S r y e,
Please Print Legibly
Address: 'S cA.�l'�mC11 �A 1 % �
City/State/Zip: 4q V4g55 , Phone#:_
UV
Are you an emphryer?Check the■ppmprtate boa:
Type�H•ann a employer With empbyee(fuH and/or ). of project(required);
1»°0e' 7. ❑New construction
2.❑I son a sole propaietor or Woovship and have on empbynes working forme m
my eaPaeib.(No workans•"carop.:n .. required] 8. .0 Remodeling .
3.❑I son a homrowffir doing an work myself.fMo workers•croup.insurance requhed.)t 9. ❑Demolition
4.❑I am a homeow�sod wBl be hiring conaac[ms m conduct aH work on my property. I win 10❑Building addition
emme that aH mntraotors tither ban workers•compensation nummoe m are sole 11. Electrical
Proprietors with no employes. ❑ repairs or additions
s. I®s 12.❑Pltmmbing repairs err additions
❑��s>�comrades sod I have hied the subcontractors listed on the attached sheet.
truchms have employee sod have workers•comp,mooaum, 13.❑Roof repairs
6E]We s c a corporation and its offices have exercised their right of exemption perMGL a 14.❑Other
15Z§1(41 and we have no employees.[No wwkm'amp hoomooe requbed.)
'Any applicant that checks boa#1 must dso IM outthe section below showing their workers•compen slim policy information.Hommwnen who summit this affidavit indicating they are doing A work and then hire outside contractors mist submit a new affidavit md1scum g such rContracmrs that check this box must attached an additional sheet showing the Dame ofthe subcmtraeors and State whether or not those entities have
employee. Ifthe sub=mntraUors have crpbyees,tbe)•must provide their wwkm'comp.PalicYnmuber.
lam an employer,that is provideng workers'compensation insurance for my empleyees. Below is the and job site
eajormateoa. `�{"_{/— /n policy I
Insurance Company Name:_ / ! - /0 Y • J J4 S t.i r G PV
Policy#or Self-ins.Lic.#:
U '' // Expiration Date:_ 1e
Job Site Address: / ff/ Y{'/ S UYf Gf y Q City/Stateeip: 5,09 G "n
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required trader 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 fore 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 cert Jy erthe pains amfpenahees ojped"FY that the enjormadoa provided above Is true s/a'd correct
Sio. ature: Cy k - Datr 17y -'
Phone#: 7 1 �,��— Z.�j y
Fr6.Other
ontK Do not wrote en ibis area,to be completed by city or town ofjtctal
Town. PerndVUcense#
hority(circle one):
Health 2.Building in;
3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
on• Phone M
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 aparhnents 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited liability Companies(LLL7 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 MEMate]me.
City or Town Officials `
).
Please be sure that the affidavit is complete and printed legibly. the Department has provided a space at the boom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the app ctten
t.
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 permittlicense 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 bum leaves etc.)said person is NOT required to complete this affidavit.
i
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
WORK PERFORMED AT:
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DATE YOUR WORK ORDER N0. OUR BID NO.
DESCRIPTION OF WORK PERFORMED
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All Material is guaranteed to be as specified,and the above work was performed in accordance with the drawings and specifications provided for the
above work and was completed in a substantial workmanlike manner for the agreed sum of
Dollars
This is a❑Partial El Full invoice due and payable by:
Mont Day Year _
in accordance with our ❑Agreement❑Proposal No. Dated
Month Day Year
8,,adr TC8122 1142
l
wfairsl
6l we of Consumer A6airs&Business`Pr.�
ME IMPROVEMENT CONTRACTOR
eglstraiion: `632ti14- _•:
xpiration r91,1 h616 Individuate' ,
47
RAUL BAEZ
F y
RAhA,BAEZ
' is 1,NHEATL.AND ST
^j SALEM NL\01970 Undersecretary
' i tulassachusetts Department of Public Safety' ,
Board of Bwldin-g.Reg ulations and Standaydt
Construction Supenisor
•` License tS-108464 _.u..� .q
r+ RAUL BAEZ.
8 WHEATL 19707 R
ru-IyI
SaleA 01970�
•.,. �.4:.• �iSrJc:. " '" Expiration
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