51 HIGHLAND ST - BUILDING INSPECTION (2) RECD ED ICES
1 rt
The Commonwealth of Massachusetts
W
Department ofPublHi fe(�{jtl A 9, 00
h1assachusetts State BuilJing���c(77$$��t1J11�� �_
Building Permit Application for any Building other than a One-or Two-Family Dwelling
U ) .(This Section For Official Use Only)
BuilJing Permit Number. l'.-• Daie Applied: ,Building Official: ^ -
S ION II:LO ATION(Please indicate BIdck ff and Lot 4Pfor locations for♦vhich a streef address is not available)"
Ln S 6 0
No.and Street City/Town Zip Cade Name of Building(if applicable)
SECTION 2.PROPOSED WORK
f`f I Edition of MA State Code used_ If New Construction check here[:Ior check all that apply in the two rows below
l:= Existing Building Vj Repair❑ 1 Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ 1 Change Of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 01�
Is an Independent Structural Engineering Peer Rgview rec)utre l? Yes ❑ No Ip�
Brief Descrip`ign of Proposed Work: re"'w'y e_Xij 7,LeA fwt..cTi A.4 Cali of
11 ar IAr T.If14 Acw Flwr
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 Gioup(s): N - Proposed Use Group(s): 1` ° c -i
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-t❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1 ❑. H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional I-1❑ 1-2 Cl 1-3❑ 1--1❑ NL• Mercantile❑ R: Residential R-l❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ I 0 1❑ 11B ❑ IIIA ❑ IIIB ❑ •IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Perm Licensed Dts usal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑
A trench hull not be P
\ required❑'or trench or specify �
Private❑ or indenlify Zone: or on site system❑ omit is enclosed❑ t
Railfoad right-of-way: j
Hazards to Air Navigation: �I,-\Ilk t r� �_,innn�;ti n i
Not ApplicWe Cl ` ;t,'ds 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 Constriction: Ocoipant Load per Floor:
Does the building,contain an Sprinkler System?: _ Special Stipulations:
IVlla�t�lp � I ( p
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner ] `p
Jahn SToecrrjraJ f5 f1�� In.� S.T . 5Gf ein O11 �6
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:'
Ouacr
Title Telephone No.(business) 'Telephone No. (cell) e-mail address
If applicable, the property jj��caner her y authorizes
Name Street AL dress City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this-building ermita lication.,
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,600 cu.ft.of enclosed space and or not Linder Construction Control then check here 0 and ski 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
terT �,o rU TrorTrm r,
Coinf�rmy Name /�t q
/(Ter J�e .,W CS - V C H 7 V Le
Name of Person Responsible for Construction License No. and Type if Al�App icable
•2 SII
S 0S26�.A ff <I ✓•1 Off '70
Street Address City/Towne State Zi
zvK 617-Sff- y1.C 'i kLWQ >L&Sr � .cm
Tele hone No. business Telephone No. cell e-mailraddress
SECTION II:WORNF:R.S'CONIPENSAIION INSUNA.,' tQ! FFII IAVII' 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 budding permit.
Is a signed Affidavit submitted with this application? Yes Cl No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ ,5-0 0 Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ /SO 0 - appropriate municipal factor)_$
3. Plumbing S a a.00
d. Mechanical (HVAC) S Note:Minimum fee=$ (contact mmnicipality.)
5. Mechanical Other $ Enclose check a ibie to (M
6.Total Cost $ P y Q ab O (contact an
and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 hereby attest uglier the pains and penalties of perjury that all of the information contained in this
applic�n is true and accurate Itbest o ny knowledge anal understandin
Please tint all n nm Title Telephone No. a
Street Address City/Town State Zip !�
Municipal Inspector to fill out this section upon application approval:
Name ate
CITY OF SALEM, MASSAaiuSE m
BuQLDING DEPARTMENT
120 WASHNGTON STREET,YDFLOOR
TkL(978)745-9595
FAX AX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBMPROPERTY/BUILMG OOMM SSIONER
Construction Debris Disposa/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 facil' y)
Signat re f applicant
Date
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
kj
Boston,MA 02114-2017
www mass.gov/dia
workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
y
Name (Business/Organization/Individual): T Ir+r7
Address: Grp
City/State/Zip: , !^t Yn A • r;a?d Phone M VU 410--24
FArean employer?Check the appropriate box: Type of project(required):
a employer with 6 employees(full and/orpart-time).• 7. ❑New construction
. m a,sole proprietor or partnership and have no employees working for me in S• remodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself rNo workers'comp.insurance required.]t 9. ❑Demolition
10❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 1 LD Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5. I am a general contractor and I have hired the subcontractors listed on the attached sheet.
❑ 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.[
6.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.1No workers'comp.insurance required.]
*Any 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. If the sub-contractors have employees,they most 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.Lie.#: Expiration Date:
Job Site Address: or- Ci rl City/State/Zip:s B!N PwAs Ot0-7d
Attach a copy oftheworkers,cilimp6sati5n policy declaration page(showing the policy number alid expiration date).
Failure to secure coverage as required under 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 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.
I do hereby certify and r airs a ies ofperjury that the information provided abov is true and correct.
Signature Date: 7/ '/f—
Phone#•
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#:
II
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 lice using agency sha11 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 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 besure to fill in the.pemutilicense number which will be used as a reference number- In;addition;an applicant
that must submit multiple pemut/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 bum 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 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
1 Massachusetts-Department of PublicrSafety-
Board of Ruilding._Regulations and Standards
Cunstrurtion_Supcn kor.
License: CS-064766
PETER A SHEPP6RD -
25 OSGOOD ST f
SALEMMA 01970
Expiration
Commissioner - 1 0/0 112 01 4
U�e��eneawmm�(1e �llatiorn
Oti7ce of Consumer Affairs O B"ilTRACTOR
ME IMPROVEMENT CONTRA Type.
p,egistronon. 177430 DBA -
xpuanon 12I912015
AFF1NITy CONSTRUCTION
PETER SHEPPARD -
25 OSGOOD ST Undersecretary -
-SALEM,MA 01970 -
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given are subject to verification on T owoiee not be released or copied unless Printed: 6/29/2015
job site and adjustment to fit job applicable fee has been paid or job
conditions. order placed.
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job site and adjustment to fit job applicable fee has been paid or job
conditions. order placed.
John 51 Highland St Salem KMl 62812 El 3 Drawing#: 1
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job site and adjustment to St job applicable fee has been paid or job
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given are subject to verification on Tech OIOOIE6�� not be released or copied unless Printed: 6/29/2015
job site and adjustment to fit job applicable fee has been paid or job
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The Commonwealth of Massachusetts Property Address:
Department of IndustrialAccidents
Office of Investigations
I Congress Street, Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g• ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
Any 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. If the sub-contractors have employees,they most provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name: —
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address:• City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: NEWTON Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Ci /Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other INSPECTIONAL SERVICES DEPARTMENT
Contact Person:John D. Lojek, Commissioner Phone#: (617) 796-1060
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
i 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 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) 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.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE
Revised 7-2013 Fax# 617-727-7749
www.mass.gov/dia