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19 HERBERT ST - BUILDING INSPECTION 4►1 i The Commonwealth of Massachusetts Q4 Department of Public Safety MassachuseltsState Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Budding Permit Number. Date Applied: Building Official: SECTION II:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) Sh6U, th.A O i 4 e No.and Street City/Town Zip Code Name of Budding(if applicable) SECTION 2•PROPOSED WORK -� Edition of MA State Code used-2-0 IJ If New Construction check here❑or check all that apply in the two rows below Existing Building Repair❑ I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other VSpecify, Ebu i Id 2 Ste r FleCAC Are building plans and/or construction documents being supplied as part of this permit application? es No 0 Is an IndependentStructuml Engineering Peer Review required? Yes ❑ No 311, Brief Description of Proposed Work: U P Gra d e w ii-k to\a to Po.t tS U l9a r S Y L.oc(i {C,Ic y' SGlVws� f oil-.S 2erbyjId Qecl� �tov`7S 31, Cac F� c rpo('v y—�—O A Pro fref-� Fi /at k ,me T SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANCE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Croup(s): Proposed Use Croup(s): SECTION4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)k Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION S.USE GROUP(Check as a Lh able) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B. Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: Hi h Huard H-1❑. H-2❑ H-3 ❑ H-1❑ H-5❑ 1: Institutional l-1❑ I-2❑ !-3❑ I-!❑ M: Mercantile❑ R: Residential R-l❑ R-2❑ R-3 R-i❑ S: Storage S-I ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: SpeYiai Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ III ❑ IIA ❑ IIB ❑ 11111L ❑ IIIB ❑ 1 IV 13 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CNIR 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 I�r trench or specify: Private❑ or inilentify Zone: or on site system❑ permit is enclosed❑ Railroad rightof-wry: Hazards to Air Navigation: M,\I li_4gric Qmmiksi.¢1 K-15,11.l'pwr.c: Not Applicable❑ Is Structure within airport approach area? Is their mview completed? or Consent to Build enclosed❑ Yes❑ or No O 1 Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Croup(s): Type of Construction: Occupant Load per Flour: Uses the building Contain-in Sprinkler System?: Special Stipulations: SECTION9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner rto r v C 6 u e ff i I S 184awt s r-d NlR rb/r4e,,W 'Wf A 01 Name(Print) and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If app ' e,the grope 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 buddingis less than 35,1000 cu.ft.of enclosed space and/or not tinder Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control err G kJe- 9-)87V7 &M i16PVe Name(Regis) ant) , Telephone No. e-mail address Registration Number i rmarloV% rive C3eJe't MA 0191S Street Address City/Town State Zip Discipline Expiration Dane 10.2 General Contractor Perm Wh ) ke 0orsTro<-I n Company Name � pe (,ry Whc�e_ CS- Q(c,09,20 Mune of Person Responsible for Construction License No. and Type if Applicable 19 }moirian a0z= 2ej(?r r p94- Mh _ajE� IS Street Address Cdy/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:VVPRGEKS'C0t,1PEN5A'IION INSURANCE AFFIDAvrf M.G.L.c.152§25C b 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 El No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor G O O and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ % OGO, — Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3. Plumbing $ d.Mechanical (HVAC) $ Note:Minimum fee a$ (contact municipality) 5. Mechanical Other $ Yase Enclo check payable to b.Total Cost $ �y QD 0 (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 b f my kn wl ige and understanding. -jjQ2cryl,.6( ;IC_ ©013 928_�67 (Of$ 5 Please print and sign name Title Telephone No. Date is� `eJ A-- Street Address City/Town �State Zip Municipal Inspector to fill out this section upon application approvaL• Name Date I The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite,100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTTNG AUTHORITY. Applicant Information Please Print Leeibly ? L Name(Business/Organization/Individual): C OhJ t_ru c f I o +1 Address: I o1 m aY 10 A V C_ City/State/Zip: 13f_J5( ly :� 0 � S T #: �7 8 (o}' G S 9 s Are you an employer?Check the appropriate box: Type of project(required): I.[S am a employer with J employees(full and/or part-time).' 7. ❑New construction 2.❑Lam a sole proprietor or partnership and have no employees working for $, �'Remodehng any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance ]t 9. �yemohtion 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on mty. I willensure that all contractors either have workers'compensation insurance or 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the sheet.These subcontractors have employees and have workers'comp.insurarim13.❑Roof repairs6.❑We are a corporation and its officers haveexercised their right ofexemptioL c. 14.❑Other152,§1(4),and we have no employees.[No workers'comp.insurance req 'My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy 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. (Contractors that check this box must attached an additional sheet showing the time of the sub-contractors and state whether or not those entities have employees. Ifthe sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site information. . ,„ Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: �+ Job Site Address: i Q /4 N f h e I City/State/Zip: S R L A r A / a 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 crinaa]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. f do hereby certi u der the pains a penalties ofperjury that the information provided above is true and correct. Si ature: Date: a Phone#: 8 (� �O r ,S 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.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 ajoint 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 maybe 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)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 Y" a Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-060820 . PERRY W1IITE - 19 MARION AVIC �@ � BEVERLY J17A 091� , .. I r i 31,1e1s Expiration 021(Iy2077 Commissioner Office of Consumer Affairs and Business Regulation - 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Cntractor Registration Registration: 181542 / ) Type:. DBA -- ,.21P Expiration: 4/8/2017 Tr# 264683 PERRY WHITE CONSTRUCTION WHITE PERRY 19 MARION AVE. BEVERLY, MA 01915v /l n v% Al �� Update Address and return card.Mark reason for change. Y Address ❑ Renewal Employment Lost Card SCA 1 Co 20M-05/11 —_— c-{flee�p'ammw7uaealtl o� aeoacluieetta Office of Consumer Affairs&Business Regulation License or registration valid for indl return use Only UV�Registrafi OME IMPROVEMENT CONTRACTORbefore the expiration date. If found return to: on �181542 Type: Office of Consumer Affairs and Business Regulation10 Park Plaza-Suite 5170 xpiration 4/0/2017-1 DBA Boston,MA 02116 PERRY WHITE CON$TQT WHITE PERRY 19 MARION AVE. -t..=�--- tiurir" � BEVERLY,MA 01915 Undersecretary Not valid without signature C nY OF SALEA A ASSAaRsE TPS BLnDMDBPAR7 AWr 120 WnsfID67MS7REeT,3 DA= UL(978)743-9595. PAX(970)740.9846 R�6rlARR1FYDRISCX0Li• AUYC R NaMST.PM DnwcrcwCFPuuJCntMM/Auwmazw=om Construction Debris Disposa/A l*Vit 1�" (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 d 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: T- � vmist-r,- (name of hauler The debris will be disposed of in: (name of facility) (address of facility) Signature o applicant D to