400 HIGHLAND AVE - BUILDING INSPECTION (7) The Commonwealth of Massachusetts
y�1 a Department of Public Safety .
14 Massachusetts State Building Code(780 CMR)
IBuilding Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section Foi•;Official Use Only)
Building Permit Number: - Date Applied: - Buil'dingOfficral'.:
SECTION I:LOCATION.(Please indicate.Block-tt and Lot N for locations for which a`street address is not available)"
4CY7\i nh\nrc\ Avg #llp S \ew. w-A0
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❑ 1 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 IR
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
GV�1 i.:' CSU s7 bJ
"C70
c- L X
G C�
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.) wDs, F PA-
SECTION 5:USE GROUP(Check as a p p licable) '
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto' F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ 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:CONSTRUCTIONS TYPE(Check as applicable).
IA ❑ IB ❑ IIA ❑ IIB ❑ [IIA ❑ IIIB [I 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 k Indicate municipal)Q A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑
required❑or trench or specify: -
permit is enclosed❑
Railroad right-of-way: Hoards to Air Navigation: NIA Historic Commission Review Pnre�x
Not Applicable it Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No Yes❑ No ❑
SECTION 8:CONTENT.OF CER ICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9:.PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
cn\off mce I 1 C KkO S4\'cnisor\�L'N 1ACAtla2heoc9 Mai y_ aq LA,s-
Nmne(Print) No.and Street City/Town Zip
Property Owner Contact Information:
1LLz2
'Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,tha om�y�1•!v owner hereby authorizes
LiC R4- `,�
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.10t CONSTRUCTION CONTROL:(Please fil;I ql'out Appendix 2), r
If buildin' is less thin 35,000 cu.ft:of enclosed"s o ace and br.notunder Cohstmction.Control then check here❑and.skio Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. _ e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
L o
Com�pany ame 11`
�A. c�naQ\
Name of Person Responsible for Construction License No. and Type if Applicable
_Sc) S� g1\ar4ke\-e� �AA- MqLff—
Street Address City/Town State Zip
1I-1a3.1- 20D—I o ---
Telephone No. business Telephone No. cell e-mail address
SECTION 11:.4YORKERS'.COMPENSATION INSURANCE AFFIDAVIT 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'12i CONSTRUCTION COSTS.AND PERMIT FEE'.
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ —
1.Building $ Q'C%2C'3 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
d. Mechanical (HV AC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ — (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 best of ny knowledge and understanding.
AState
�L-JU _45Please pri tandsignname Title ho N8 o. Date
�Street Address City/Town Zip
Municipal Inspector to fill out this section upon application approval: U t,.
Name' ate
CITY OF S:u2m:l, \/L1SSACHUSETTS
v BUILD IN DEPA RTNIENT
120 WASHNGTON STREET, 3w FLOOR
TEL (978)745-9595
FA-X(978)740-9846
KIMBFRLEY DRISCOLL THoMAs ST.PmuE
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%C IISSIONER
Workers' Cumpensatlon Insurance Affidavit: Builders/Contracture/Electricians/Plumbers
Applicant Information Please Print Legibly
Nalilt:(0usinxy*0(&3nir2tiowlndividual): 11 voytm
Address: \cn V\QA—�cxsrA
City/State/Zip: Mix)Ils�QcA\SN OM\5 _ Phone N: IS 1— (0)l
Are you an employer?Check the appropriate boat Type of project(required):
I.MI am a employer with 4. 111 am a general contractor and 1 6. ❑Now construction
employees(full and/or part-time).• have hired the subcontractors
2.❑ I am a solo proprietor or partner- listed on the attached sheet 1 Z ❑Remodeling
ship and have no employees These subcontractors have S. Demolition
working fur me in any capacity. workers'comp.Insurance. 9. ❑ Building addition
(No workers'comp.insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.) officers have exercised their
3.❑ I am a homeuwnur doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,$1(4),and we have no 12.❑ Roof repairs
insurancarequired.)r employees.LNoworkers' 13.D Other
comp,insurance required.)
'Any uppllc:mr th,1 chucks box.e I most else rill our the xcliao below showing their workers'compmnduo policy inrurmadom
'1Lwwownen who suhmit+his Affidavit indicaing they am doing all worst and than hire outside eonnect re must submit a new,affidavit indicating such.
:Gmrrscom that cheep this box most anachad an adrkllumishrove showing the none of the aubatimrxbn and their workers'comp.policy inion adon.
I arm an eoployer that is provldlnR workers'compearadan fmlarunae jar my emp/oyeest Below is the poliq and fob site
in/armatloa _
insurance Company Name:1'IS 5CY'\C��2j F rv��p �r S �_v,t,r�r c-e (h n
t
Policy 4 ur Sclf-ins,Lic.N:(i lCG 201,1/4 Expiration Date' -s) itTS
Job Slit:Address: LNle UY\II-+- O City/SlatdZip:..�v�wh o\4-1 O
,\itach a copy of the workers'compensatlon pulley declaration pegs(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment.as well as civil penalties in the form oft,STOP WORK ORDER and a line
of up to$330.00 a day against the violator. Ile advised that a copy of this statement may be rurwarded to the Office of
Invesligutiuns of ilia DIA fur insurance covcraga verilicaliun.
I du hereby certify dr dr palms rut911191 u/perlury thus the h+ifuratadon provided a6uve is true uud correc6
si,nillurc )are:
I011fcial use umly. Do not wrire in ddir array to be completed by city or lawn allletud i
City nr Town:
IssuiagAulhorily(circle one): -_------
1. hoard of liealih 2.nuitding Deparement .1.Cilyffown Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Cunlact Person: _ __ Phone M:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
f (800) 876-2765 NCCI NO40959
POLICY NO. WCC-500-5001342-2013A
PRIOR NO. WCC5001342012012
ITEM
1. The Insured: Village Construction Inc
DBA:
Mailing address: Mr Michael Rockett FEIN:"'-"`1709
190 Pleasant Street
Marblehead, MA 01945
Legal Entity Type: Corporation
Other workplaces not shown above: See Location
2. The policy period is from 03/11/2013 to 03/11/2014 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,006 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 A
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 137531
INTER SEE CLASS CODE SCHEDU E
Minimum Premium $550 Total Estimated Annual Premium $550
MM
OV GOV Deposit Premium $138
ATE CLASS
A 42 MA Assessment Chg.
$.00 x 4.2000% $
This policy, including all endorsements, is hereby countersigned by 01/18/2013
Authorized Signature Date
Service Office: Boston Insurance Brokerage Inc
54 Third Avenue 24 Federal Street,4th Floor
Burlington MA 01803 Boston, MA 02110
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
1
CITY OF SiULEtit, NL-�SSAC
HUSETTS
BL:mnNG DEP-Al ML&NT
1 '0 WASHLNGTON STREET 3" FLOOR
TEL (978) 745-9595
FAX(978) 740-9346
KIJ[BHRL.EY DRISCOLL
AWLWOR -ftLOb(AS ST.PIERRg
DIRECTOR OF PLBLIC PROPERTY/BCILD0zG CO%BlISStONER
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 1 l 1.5
Debris, and the provisions of MGL c 40, 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 disposal facility as defined by fV1GL c
111, S 150A.
The debris will be trinsportcd by:
Goer- SeLo�
(name of hauler)
The debris will be disposed of in
—Y)nzo)t-_ cv C25
(name of facility) _
(address of facility) G Z.15�
signature of permit applicant
date —
t,
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