76 LAFAYETTE ST - BUILDING INSPECTION (11) ✓ The Commonwealth of Massachiiset "
Department Public Safety
Massachusetts State Building
lding Code(780 CMR)
Building Permit Application for any Building other than a One-o m' welling
(This Section For Official Use Only)
Build big Permit Number: Date Applied: uilding Official: -
SECTION V LOCATION(Please indicate Block#and Lot#for locations for which a street addFdKs is not'available)
0 9 7o
No.aild treat 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 S Repair❑ Alteration JS I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes a No ❑
Is an Independent Structural Engincerin r er Review requir�ed? Yes ❑ No ❑
Brief Pescription of Proposed Work: jXom ,_� ✓E,L�GOrCa _
WtKIL .!/ /7 34�tfS. D.O. LL/riis 4 -CAe&; L. -
�l.�ed:g T �t�pLa�uEiAfe Cuan�o7itL.. -
4 ..
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.) 'eW$4 er Z
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 IJ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business Re E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ 1-2 El El14❑ M: Mercantile❑ It: Residential' R=10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ TV 1 VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water SuppI Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Zone❑ Indicate municipal lie A trench will not be Licensed Disposal Site
required ❑or trench or specifyVJNV M*$A—
Private❑ or indentify Zone: - or on site system[Ir,
•":r permit is enclosed ❑ QilAA.l
Railroad right-of-way: Hazards to Air Navigation: MA i islom i oy,,w Prose:
Not Applicable❑ Is Structure within airport;rpproich area? Is their review completed?,,♦ •,
or Consent to Build en closed❑ Yes❑ or Nu O 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:
i
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and ALI ess of Property Owner
✓r r6A&z 2ps
P P34r.or yXijJyrnlGG hq yif�i0
amc(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, e property owner hereby authorizes
ITAA /U,u I/Ak LETf- sr Soso
Name Street Address _ City/Town State Zip
'
to act on the property owner's behalf,in all matters relative to woWauthorized b tliis3�bufldin ermit a �lication.J,,._r-' •. '*
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) "
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here Brand skip 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 ,-` .
Comp. y Nar e
x 'FOY/ Mesa 7
Name of Person Responsible for Construction License No. and Type if Applicable
y AILuL.ErTfr- ,�i'� ids /%P- t�/906
Street Address City/Town State Zip
L Z�s"7
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKEPS'CONII1FNSA['ION INSURANCE AFF'IDAVI'l M.G.L.c.152.§ Z5C 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 B No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
1. Building $ 40,fogger Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ / Enclose check payable to
6.Total Cost $ �/o6Q (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 r and accurate to the best of my knowledge and understanding.
X Y � _ r --z&-Z3 S33s
Please print and sign name Title Telephone—No. Date
h HAWL&r -t �
s- 0�f A ZAP
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
CI-l'Y of si1LE.NI, AkSS.ICHL'SEM
BuiLoiNG DEPART>IE1iT
�Z s¢'`{ " 'i •1 l?O CU.�SHL�IGTON STREET, 31O FLOOR
Z`�"" "• . T EL (978) 745-9595
FAx(978) 7•10-9844
klNIBERLEY DRISCOLL
NLAY01 THONLNS ST PIERRs
DIRECTOR OF PUBLIC PROPERTY/BCRDI'NG CO%CQlSSlONER
Workers' Compensation Insurance Affidavit: Builders/Contractorv/Electrfeians/Plumbers
A t lleant Information Please Print Leaihl
Mimi:t0usitw,rUrglniration.indivitlual): D111 ♦`%iB�
Address:__ �E4JL ET7` S-r—
City/State/Zip:S.F✓6'US /1"S G/ 901n Phone N: /Z33S�33
Are you an employer?Check the appropriate boa: 'type of project(required):
I.❑ I am a employer with Al d. ❑ I am a general contractor and 1 g, Now construction
employees(full and/or part-time)."' have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached shecL t 7• (L7[Zemadeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working tier me in any capacity, workers'comp.insurance. q, Building addition
INo workers',comp, insurance 5. ❑ We are a corporation and is
required.) officers have dxerciscd their MCI Electrical repairs or additions
3.❑ I an a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs ar additions
myself. (No workers sump. C. 152,$1('f),and we have no 12.❑ Roof repair
insurance required.) t employees. (No workers' I I C1 Other
comp, insurance required.)
'Any epplicarn du1 checks bus rt mtat alw rill out the wulien below showing their waken'compenudon pulivy far%, Lion.
'I huneownns who.uhmit this smdavit indicsring they an doing all work and then hire oagide caninicton mown mhmk now allldevil inditoling ruck
=<'nmrrtun that chmk this box mull machod un additiutwl.hoot showing the nwne of the rubaonlnctora and their workers'romp.policy information.
f um an employer that Is pruvidlnK)vorkers'camprrarailun Insaruneejar my employers. Below Is the polley anti site
hiforaludam
Insurance Company Name: sh/yG a�_ e1 1jelJjg,��
Policy Our Sclf-its. Lic.-N://��✓I;�OS'�iG/f1�/�Z// Expiration Data:0$`1- Zz—/Z
tub Site Citylstute/2ip-fAmef t'R O/f70
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration data).
Pailuru to secure covdrage as required under Section 25a\ ot'%IGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the r'ortn ofo STOP WORK ORDER and a fine
of till to 5230.t10 a day against flit violator. Ile advised that a copy of this.statement may be furvvurdad to ilia Oflica or
Invesligatiuns ofthe DIA for insurance covemgc vcritiealiun.
I du hereby eert`i Q1(,14 rde aRuins artd prytalrles afRerjury that the injurniatlun pravided above Iv true uad correct
ii ureJ� 4Y1�/I Data:
Prone;l
011icial use oily. Oo oar Nrire in thiv area, to be coarpleled by city ar town njfit ia!
I
City nr fawn:
Pcrmiul.lccme 4
Issuing Aulhurily(circle one): ---- - _---
I. hoard of Ifealth '. ❑uildinq Department 1.Cityi ruun Clerk J. F.reetrical Inspectur 5. Plumbing Inspector
6. Other
f.unlaet V,:rtup:,_
i'hntle is:
I
Information and Instructions
\la;sachuscus 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 sub-contractors)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
he renamed 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. Scif-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 till out in the event the Office of Investigations has-to contact you regarding the applicant.
Please be sure to till in the permitilicense number which will be used as a reference number.,ln addition,an applicant
that must submit multiple perrn t/license applications in any given year,need only'aubrtiit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant,should write"alViucations in (city or
town)." A`copy of'the affidavit thabhas been officially stamped or marked by the ciy or town.mayhe•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 ctc.)said person is NOT required to complete this affidavit.
The Off ice 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
Of11ce of investigations
600 Washington Street
Boston, MA 02111
Tcl. 9 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Rcvi;cd 5-26-05 www.mass.gov/dia
CITY OF S,U-&N(, A1SS,ICH(.'SETTS
9CLIOLNG 0EP.1M E\T
120 WASULNGTON SrXggr, )'O FtOOR
I-EL (979) 74&9595
KIMBEA? Y DRMOLL FAX(978) 740.9sU
MAYO)t Tko.�W ST.Pmjtxs
DIRECTOR OP PL BLIC PROPERTY/gt:MDLVG COWWSSIOrEX
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 111.3
Debris, and the provisions of MGL a 40, S 34;
Building Permit 4 is issued with the condition that the debris resulting from
Ihis work shall be disposed of in a properly licensed waste disposal facility as defined by AoIGL c
111, S I30A.
The debris will be transported by;
(name ut'hOuter)
The debris wi 11 be disposed or in
��r�711
(name or racdijy) �—
(jddrefs of racil,iy L-bdy�lr�ig �zOYy
x � _
- uynanrre o(permrt�pplwint
Jate
Office nf�BnYdfi7t'S+PPF1fVS �Sap Ss°Rtg6Tl�NdH��a License or registration valid for individul use only
� HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
'_��Registration: 130307 Type: Office of Consumer Affairs and Business Regulation
,Expiration: 2/16/2014 DBA lO Park Plaza-Suite 5170
'. Boston,MA 02116
EASTERN CONST.CO
STEVEN KALMAN
ST.
4 HEWLETT ST.
SAUGUS,MA 01906 Undersecretary Not valid without signature
Ma"achawtt.- Ucpnrtment ur Public sarcli
0 Baard ui'Buildin_ Rceulali in.and 1,1:mdard.
*W C"Sitroclxm suprrrvasasc Lsurose
License: CS 75948
STEVEN R KALMAN
PO BOX 1266
SAUGUS, MA 01906
1'/ Expiration: 3/6/2013
(..mmi..i... Tm: 13553
I
u �
NOTICE W NOTICE
TO
v
m >
- o TO
EMPLOYEES Q EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — htti)://www.mass.gov/(Iia
As required h)' M:IS,S;IChu8CIIS GcnurtiI Law. Chapter 152, Sections 2I, 22 & 30, Ibis will give you no tic C Ih;u
I (wc) h;i%c plovicicd GIr payment to cur injured Cmployccs under the ahovC mcntioncd Chaptcr by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P .O . BOX 1450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE_ COMPANY
(7PJUB-053GN39-2-11 ) 05-22-11 PO 05-22-12
POLICY NUMBER EFFECTIVE DATES
JOSEPH 0 DANCA JR INS 182A HIGHLAND AVE
MALDEN MA 02148
NAME OF INSURANCE ;\GENT' ADDRESS PHONE #
A A & K CONSTRUCTION, INC DBA 4 HEWLETT STREET
EASTERN CONSTRUC7ION CO
_ SAUGUS
MA 01906
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER (IFANY) DATE �
MEDICAL TREATMENT
The rihovc named insurer is rcyuircd in cases of personal injuries arising out of and in the course Of
employment to furnish ;icicyualC and reasonahlC hnspil;II and medical services in accordance %with the
previsions of the Workcr.s' Compensation Act. A copy of the First Report of Injury 171uSI he given to the
injured employee. The employee miry select his or her own physician. The reasonable cost of the services
provided by the treating physician will he paid by the insum, if the treatment is necessary and reasonahly
cUnnCCICd to the work slated injury. In Cases requiring hospital attention, employees are hereby notified
that IhC insurer has in—mngoel Inr.such intention at the
NAME OF HOSPITAL ADDRESS
W20PG02 TO BE POSTED BY EMPLOYER