12 HARRISON RD - BUILDING INSPECTION CK `6 �{ a
The Commonwealth of Massachusetts
Department Public Safety
Massachusetts State Budding Code(730 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
1 v (This Section For Official Use Only)
Building Permit Number: Date Applied: -Building Official:
SECTION 1:LOCATION(Please indicate Block p and Lot k for locations for which a street address is not ava' le) "w
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No.and Street City/Town Zip Code Name of Building(if applicabtO
SECTION 2 PROPOSED WORK. r
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Edition of MA State Code used If New Construction check here❑or check all that apply in the two ro belor :=..
Existing Building Repair Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out mid submit Appe ix 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 ❑ Nu
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work: -
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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 ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ I If: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION'IYPE(Check as applicable)
IA 16 ❑ THA 0 11IIB ❑ 1 ILIA ❑ 1116 ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Zone Indicate municipal A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: I Hazards to Air Navigation: \Ir\fait ri unm, Isi,,—i .icw ro ,vs:
Not Applicable❑ 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 Floor:
Does the building contain an Sprinkler System?. Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner 1�V1 I
Name(Print) No.and Street City/Town/ Zip
Property Owner Contact Informatio
Title Telephone No.44Maimrs) Telephone No.-4cefl) 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 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 D and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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Name(Reg I tram) I -- Telephone No. e-mail address Registr ti n Nw be[�
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Street Address City/Town State Zip DiscipR4 Expiration Date
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10.2 deneral Contractor - - -
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tn of Person Responsible for Construction License No. and Type if Applicable
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Stree Address City/Town State Zip
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Telephone No, business Telephone No. cell e-mail address
SECTION 11:W0RKERS'C-0MP6NSA I ION INSURANCE-At FIDAWY M.C.L.c.152.§25C6
A Workers'Compensation Insumnce 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 O No ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE
Rem Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Elcrtrical $ appropriate municipal factor)=$
3. Plumbing $
d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost is 1,50 (contact municipality)and write check number here
SECTIO 13:SIGNATURE OF BUILDING PERIYIIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
applicat�io7 is tme, d accurate to the best of my knowledge and understanding.
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Plc ue print and sign- t ne _ Title Telephone No. Date
Street Address /1...` \ City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
i Massachusetts Department of Public.Safety
IF Board of Building Regulations and Standards
License: CS-063059 f
Construction Supervisor
JOHN C BABCOCK"
77 SOHIER RD#6-De,
BEVERLY MA OJ916,�
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mmis Expiration:
Commissioner 06/08/2018
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR 1
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ReglatraB 1467 TYP®-
Eapiratic DBA
V.J.CAP,OZZII
VICTOR CAPOZZI 6E
138 BRIDGE ST a'%Z ,,,c ,�_:z�.•;,,_
BEVERLY,MA 01915 - Undersecretary
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VDAC
ace group WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (6S62UB-2E42739-2-16)
RENEWAL OF (6S62UB-2E42739-2-15)
INSURER: ACE AMERICAN INSURANCE COMPANY
1. NCCI CO CODE: 12165
INSURED: PRODUCER:
CAPOZZI , VICTOR APPLEBY & WYMAN INS AGCY
138 BRIDGE STREET 152 CONANT ST.
BEVERLY MA 01915 BEVERLY MA 01915
Insured is AN INDIVIDUAL
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 08-29-16 to 08-29-17 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
m= item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 100000 Each Accident
Bodily Injury by Disease: S 500000 Policy Limit
Bodily Injury by Disease: $ 100000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
�= COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
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D. This policy includes these endorsements and schedules:
o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
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4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
-� DATE OF ISSUE: 08-15-16 WC ST ASSIGN: MA
OFFICE: ORLANDO DA ACE 24M
PRODUCER: APPLEBY & WYMAN INS AGCY 268SN
012309
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ace group WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
EXTENSION OF INFO PAGE-SCHEDULE WC 00 00 01 ( A)
POLICYNUMBER: (GS62UB-2E42739-2-16)
INSURER : ACE AMERICAN INSURANCE COMPANY
121 65-MA
INSURED'S NAME : CAPOZZI , VICTOR
RATE BUREAU ID: 000788241
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
TOTAL ANNUAL PER $100 OF ANNUAL
CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM
LOCATION 001 01
FEIN 123123123 ENTITY CD OOi
CAPOZZI , VICTOR
138 BRIDGE STREET
BEVERLY, MA 01915
SIC CODE : 1751 NAICS: 238350
CARPENTRY NOC 5403 IF ANY 11 .00
CARPENTRY - INSTALLATION OF
CABINET WORK OR INTERIOR TRIM 5437 IF ANY 5 .52
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CARPENTRY - DETACHED ONE OR
TWO FAMILY DWELLINGS 5645 IF ANY 8.11
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DATE OF ISSUE: 08-15-16 WC ST ASSIGN: MA SCHEDULE NO: 1 OF MORE
012310
The Commonwealth of Massachusetts
Department of Industrial Accidents
a 1 Congress Street,Suite 100
Boston,MA 02114-2017
't www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: j /2
Address:
City/State/Zip: Phone#:
Are u an employer?Check threw rropriate box: Business Type(required):
1. I am a employer with !/ employees(full and/ 5. ❑Retail
or part-time).* 6. ❑RestaurantBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4),and we have 10.0 Manufacturing
no employees. [No workers'comp.insurance required]* 11.❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers'comp. insurance req.] 1 12.0 Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#l.
t am an employer that is providing orkers'com tsatioon'innssurancefor my employe Below is the policy information.
Insurance Company Name: / j .y
Insurer's Address: 1 J t- C Oh.,e w
City/State/Zip: deh
Policy#or Self-ins.Lic.# 7]'z Expi� -7on Date: /
Attach a copy of the workers' compensation policy declaration page(showing the policy number nd expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
f do hereby certify, under th. sins and penalfies of perjury that the information provided above is true and correct.
Si nature: Date:
Phone#: 9 1
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. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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 your insurance company's name,address and phone number along with a certificate 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). 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
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Fenn Revised 02-23-15
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Construction Debris Disposes/Affidavit
(required forall demolition andrenovation work)
In aocordanw with the sbA editbn of the Stale BuMng code, 780 Oft Sealbn 111.S Debris,
and the provisions of MGL oeo,S 54, Building Permit B is issued with the
condition that the debris resu ft from this work shag be disposed of in a properly Ik:ensed
waste deposit faculty as defined by A46L c 111,S 1S6A
The debris will be transported by.-
(name of hauler)
The debris will be disposed of in:
(name of fadilty)
(address of facility)
Signature of applicant
Date