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62 LAWRENCE ST - BUILDING INSPECTION The Commonwealth of Massf `� Department of Public Safety PIT " P 1: 39 Massachusetts State Building Code(780 CMR) 0 Building Permit Application for any Building other than a One-or Two-Family Dwelling 0 (This Section For Official Use Only) 1 Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION iPlease indicate Block#and Lot#for locations for which a street address is not available) i No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK. LEdition of NIA State Code used If New Construction check here❑or check all that apply in the two rows below fly' Existing Building❑ Repair Alteration ❑ Addition❑ 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 ❑ Nu Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: y�'pl Q f I: �R�P�A+FROrn `tt S�Ex 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) O 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 ❑ 1 E: Educational ❑ F: Facto F-1 ❑ F2❑ I HH Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ l: Institutional W❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ Ro 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 ❑ ILIA ❑ IIIB ❑ 1 IV ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Su y: Flood Zone Information: Sewage Disposal: pp Trench Permit: Debris Removal: A trench will not be Licensed Disposal Site❑ Public Check if outside Flood Zone Wf Indicate municipal required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: bl\I li.l n it C'on,nusy,n Ko.o: I roa tis: Not Applirablelo Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or NoX Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the buildiinng�containan Sprinkler System?: Special Stipulations: t—x\\ l �- 0 A-0 EzA 'C. —1, 1 : SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of property Owner I-AoMA.S. A LAmIPr 6a (AW lr s4 gak-m m4 0/111-7d Name(Print)`�' ' ; 8` . N6..and Street City/Town Zip Property Owner Contact Information: CJU)LrL � — Title Telephone No. (business) Telephone No. (cell) e-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 fillout Appendix2) - - - (If build ing is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control _Ta, l cC 9)u-sga 2 Tn_ Name(Registrant) Telephone No. e-mail address CpAlto Registration Number Simi keoonk ram_ o I11-A!� 6 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor - 3L G Pv.nf>r\ -C Company Name 7a►1� �C ,W-Nire� LS — ©9SRcis Name of Person Responsible for Construction License No. and Type if Applicable G a, I R wAcnn(£ S9\Qrr-, McA O 1 -.2 Street Address City/Town State Zip ZIL gcn(cv1 Cv"y',;Osom C;)yS�%Oa.ccr Telephone No, business Telephone No. cell e-mail address SECTION 11:WOWCER9'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 12:.CONSTRUCTION COSTS AND PERMIT FEE' Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $Ll OQC, Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=$ 3. Plumbing $ d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check able to ' 6.Total Cost $ P y (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 my knowledge and understanding. �h eaw��e o��e� q78 ao-if- a P�le+ase print and sign name Title Telephone No Date le e1 t♦A:f;ig;fl S}. �a\Qrv� Mq 01 76 Street Address City/Town A State Zip Municipal Inspector to fill out this section upon application approval: � wW' Name Date ! The Commonwealth efMassachusetts Department ofindustrialAceidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FEM WITH THE PERbffrnNG AUTHORITY. Applicant Information _ Please Print Leeib)v Name(Business/Orgaoizetion/Individual): Address: Ga 1 ci hCA S City/State/Zip:__S'�1 P.- % ►'i\4 M� Phone#: Ctt 7�- S Sa—917� Are you an employer?Check the appmprlue box: Type of project(required): 1.�I sin a employer weh�_eatployees(full and/or pact-time).• J 7. ❑New construction 2.❑I am a sole proprietor or partnership and have to employees wonting form my wpar ty.[No wotkers'"comp.hmeumnce required) g• remodeling 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance requited.) 9. ❑Demolition ' 4.❑1 am a homeowner and will be hiring contactors to conduct all work en10❑Building addition my ensure that all contractors either have workers'compensation immence or er11.❑Electrical repairs or additions proprietors with no employees. 5.❑I am a general contactor and I have hired the sub-coahactoms listed on the att12.❑Plumbing repairs er additionsThese sub-contactors have employees end have workers'comp.immumms13.❑- Roofrepairs 6. We are a co enption p14.PfMcr❑ rporatien and its oM have exercised ibeirright of ex157,§1(4),ant wehave rw employees.[Noworkers'comp.+.r�••a•,•.require6'�/PIy1<fOr"� -Any applicam that checks box#1 must also fill our the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such. t Contactors that check this box must attached an additional sheen showing the name of the sub-coonsactors and state whether or not those entities have employees* lithe subKontractors 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 lnformadon, f1 Insurance Company Name: 1 t)fS INS Re-A eN q 7&- '741_0 46e f Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:_G a e Sa City/State/Zip: S fy`1 N1 Q lg7o Attach a copy of the workers'compensation policy declarer g 9 pe p c3' lion page(showing the policy number P S ( g P cY mbar and 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 cerdf�y under the pains and penalties ofperyury that the information provided above is true and correct Suture /�� � Date: Phone C/ 7Cr Official use only. Do not write in this area,to be completed by city or town oftleial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person• Phone#• F Information and Instructions J 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 then 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( )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 thew certificate(s)of insurance. Limited Liability Companies(LLQ 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 pernat/license number which will be used as a reference number. In addition,an applicant that must submit multiple pemrit/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 Ln-YOFSALEA4 A ASSAaRSEM Bmn=DjrFAjmmw 120 WAS MQWNS78BeT,3wROm T�L(478)744984b 7�5-9595. FAX BII�EaLEYDRLSOOIZ AUYCR ZWUAsSTJ'IEW DnacrcacPrtmucrxQmtndsumnmaa amgcw x Construction Debris DisposaiAfdavit (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 c4Q S 54; Building Permit# is issued with the condition that the debris resulting from this work shalf be disposed of in a properly licensed waste deposit facility as defined by MGL c 311, S 156A. The debris will be transported by. (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature of applicant Date F_ Vsee +OoanivrumuleaCC�z o�C�/�.tul�ac�uibeCCo rt Office of Consumer Affairs&Husfoess Regulation OME IMPROVEMENT CONTRACTOR egistration: '182125 Type: V$Ek'plration--- 6/9'2ti Individual JOHN.CAMIRE JOHN CAMIRE j I 62 LAWRENCE ST SALEM, MA'01970 {II Undersecretary assachusetts -Department Of Public Safety M Board of Building Regulations and Standards Construction Sa,en'is.3r mv,,� License Cg pg58S 41 .. .JOHLVJ:CAIVIIRB � . - S 62 L&WREN 019 SpaTA AAA r 'S Expiration OVM2016 Commissioner �F