22 HAWTHORNE BLVD - BPA B-14-1871 RECEIVED
The Commonwealth of Massac lusetts
�A�' Department of Public Safety Sq
'"i Massachusetts State Building Code(780 Clvl p DEC —3 A
e Building Permit Application for any Building other than a One-or Two-Family Dwelling
(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 street address is not available)
)--'a 14&UK kQ C!W 41" M4 0147o
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$ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ft' No ❑
Is au Independent Structural Engineerfng,Peer Review required? Yes ❑ No ❑„J
Brief Description of Proposed Work: /—Grl f !✓ x y r T�( Pm-
ion
rA
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-I ❑ F2❑ F1: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-d❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ 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 TYPE(Check as applicable)
IA ❑ Ill ❑ IfA ❑ IIB ❑ IIIA ❑ IIfB ❑ IV ❑ 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:
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: Hazards to Air Navigation: %1 A t I. trait l'm n em H., r I n•y.v:
Not Applicable❑ Is Struchre 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): 1 ype of Construction: _ Occupant Load per Floor:_
Does the build iny,cunlain.m Sprinkler System?: .__ Special Slipulalions:
SI1JT O-OT 12� rj
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name,and Addfess,of Pi ipe'rty Owner
c''
Name(Print) No.and Street City/Town Zip
Property OwnerContact Information: _
'rifle Telephone No. (business) Telephone No. (cell) a-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 Appendix 2)
if builm is less than 35,000 cu.it.of enclosed space and or not under Construction Control then check here O and ski Section 10.1
[10.1 Re istered Professional Res onsible for Construction Control
e(Registrant) Telephone No. a-mail address Registration Number
et Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Nrg2f es L1 c
Company Name
-SoLi✓r �G9/tve % _S-D�Z706
Name of Person Responsible for Construction License No. and Type If Applicable
76
Street Address City/Town State Zip
`}7k- %20 6 'IY6 �G.S/l92LW- gp_S/,q//oo . Con ,
Telephone No. business Telephone No. cell a-mail address
SECTION 11:WORKERS'COAVIENSA IION INSURANCE AFF11MVI'I 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❑ No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) 'Total Construction Cost(from Item 6)_$
1. Building $ Q'i 10 Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
_ N
4._`lechanical (EIVAC) Note: Minimum fee=$ (contact municipality)
5. Mechanical Other Mi Enclose check ay able to
payable
6.Total Cost S Ito -coo (contact numicipality)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.rnd accurat o the be f my knowledge anal understanding. q
�An Nw2�/ ')A 'C20 6yyG A? V y
Please print and sign name - Title Telephone No. Date
?� 4 2 0 +tee Si -c e T �S/'i &AA /LI/�
Street Address City/Town State� Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen-isor
License: CS-0g3706
HNC HAR VEY7
e+
LA GROVE STlem -
MA 01970= _
Commissioner Expirition -
05/o1f2016
NOTICE OF ASSIGNMENT
EMPLOYER
COMBO I.D. STATUS OF EMPLOYER
JOHN HARVEY LLC 001017802 Limited Liability Com
30A GROVE STREET
SALEM, MA 01970 COVERAGE GROUP
1072539
The Waiver of Our Right to Coverage under this assignment
Recover from Others Endorsement applies to Massachusetts
operations only. For coverage
is available on P001 policies. outside of Massachusetts.ssachusetts, contact
your agent. for details. the appropriate Pool or Plan for
that state_
AGENT ROSE INSURANCE AGENCY INSURANCE COMPANY:
OR RICHARD E DION AMGUARD INSURANCE CO
PRODUCER: 66 LORING AVE ( INSURANCE AND SUPPORT SERVICES
SALEM, MA 01970 I16 S. RIVER STREET
1 P O BOX AH
WILKES-BARRE, PA 18703
AGENCY FEIN:043157449 1 (800) 673-2465 `
CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED
CODE TOTAL ANNUAL PREMIUM
-_ REMUNERATION
___________________________________________
ELECTRICAL WIRING - WITHIN BUILDINGS & DRIVERS 5190 $3,000 2.74 $82
EMPLOYERS LIABILITY 100/100/500 9845
STANDARD PREMIUM
LOSS CONSTANT 0032 $82
EXPENSE CONSTANT 0900 $50
TERRORISM CHARGE $1$159
RISK MINIMUM PREMIUM 9740
. 0990 $305
TOTAL POLICY MINIMUM PREMIUM $305
TOTAL ESTIMATED PREMIUM $305
DIA ASSESS. 5_8% $5
TOTAL. EST. PREMIUM PLUS ASSESSMENT ----------
INSTALLMENT BASIS: Annual DEPOSIT PREMIUM: $310
THIS IS NOT A BILL
COMMENTS
Coverage effective 12.01 AM on 11/20/14_
DATE OF NOTICE: 11/19/14 PREPARED BY: Sherry Jones
EXT 516
• • SERVICIRG CARRIER ASSIGNMENT w
LETTER ID: 4279261
The Workers'Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street• Boston, MA 02110
(617)439-9030 • FAX(617)439-6055 • WWW.Wcribma.org
CITY OF SALEMIa l-LuSACHUSETTS
BUILDING DEPARTME?iT
120 WASHOVGTON STREET, 3'a FLOOR
6 TEL (978) 745-9595
F.ux(978) 740-91M
KI\IBERLEY DRISCOLL THMUS ST.FIE"s
;1fAYOR
DIRECTOR OF PUBLIC PROPERTY/BCII.DIVG CO\NfSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Jllicant Information T Please Print Leelbly
NainC (BusinessOrganiratinm'Individual): .. �/ohh li;kef/`Qy
Address: 2 0 X (Jl?Dt -e- ,f-7-e E%
City/Bract/Zip: e/f'7. tneO/Y�4kne H: %7� �/�D-6c/L/G
F2.
e you an employer'.'Check the appropriate box: L�ON
project(required):
am a cmpioyer with 4. 0 I am a general contractor and 1ew construction
�nployees(full and/or pan-time).• have hired the sub-contractorsI ran a sole proprietor or parinor. listed on the attached sheet. Imodeling,hip and have no employees These sub-contractors have molitionworking'f,r me in any capacity. workers'comp.insurance. ilding addition
(No workers•'comp. insurance - 5. 0 We are a corporation and itsrequired.) officers have exercised their ectrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL mbing repairs or additions
myself. [No workers'comp. c. 152, g 1(4),and we have no of repairsinsurance required.) t employees.[No workers'cutup. insurance required.) er
-Any appric:un dw cheeks bus II molt also fill Out the sediun below showing their workeq'tumpensatfun policy inlbm,atlon.
t I Ism wwm"who submit this alAdnvil indicating they arc doing all work and then hire outsldo canine x,mini submit a miss affidavit indicating such.
$.....tacos that chwit Ibis bus man mtarhal an addidunal,heel showing the mmno of the aubavnlrsrton and their worker'comp.pulley inform ition.
l rnn ua nnpluyer drat Is pruvidlnK workers'contpenradun insuranes jot my e�np/uyrrs. Boloty/s the poBoy turd jab silo
iujururatfnn.
Insurance Company Vmne: _-.__--
Policy it or Sclf-itm. Lic. d: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation pulley declaration pale(showing the policy number and expiration data).
Failure to ucure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
orup to S2M.00 a day against the violator. Be advised that a copy of ihis statement may be furwarded to the Office of
bovcstigali ns ul'Ihe MA for insurance coverage verification.
/do hereby re 'y under th is turd penohles ujperjury that the b furmut/ou provided above is•true and correct.Date: gala l Iy
P d: y --
{
O//iciu!use un/y. u our,vrife in this area,to be cunsplefar/by city ar town official.
City nr Tuwn:
Issuing Aulhurity (circle one):
I. Board ul'lleallh Z. Building Departmem .i.Ciiyfrn,vn Cierk J. Electrical Inspector i. Plombiug Inspector
6. Other
I I
r, QTY OF SALEK MASSAMUSEM
;ice e fir; BUILDING DEPARTMENT
120 WASHINGTONSTREET,31DFLoOR
TEL. (978)745-9595
KIMBERLEYDRISOOLL FAX(978)740-9846
MAYOR THOMAS ST kERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 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)
*V �c
of applicant
-/g
Date