85 LEAVITT - BUILDING INSPECTION :e.Qii ...h x Rp y I
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The Commonwealth o�np `� $ai 8hussetts
(� n� Department of Pulfl'1X Q* 31
O Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
/VYVI (This Section For Official Use Only)
t
9 Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
,I 86�2ehuI Brn l-Isar er Sa�e�
t�l 1 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 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ NoA
Is an Independent Structural Engineering Peer Review required? Yes ❑ No}✓�
Brief Description of Proposed Work:
rirrn - e r- ✓e ✓, rve tv�1 5 e rrl eG�J
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.)
SECTION 5:USE GROUP(Check as applicable) -
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational Cl
F: Facto F-1,ffi1 F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage S-1)9 S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION'[YPE(Check as applicable)
IA ❑ Ill ❑ 1[A ❑ IIB ❑ 1 ILIA ❑ IIIB ❑ 1 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❑ indicate municipal❑ A trench w01 not be Licensed Disposal Site❑
Private❑ required❑or trench or specify:or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: :MA I I.aor_c_Cninnystion_ILggi�._�r„I'.uu,_s
Not Applicable❑ Is 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 Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
� 3 C o w , o"w
-7F t _ 3 2 9 0--7 20 rvi pxz Ic_ C j P] u
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Prop e tyQt�ner
Ed..,4p, Re,v1Ty/�)P&,3 ' /fly Noffbde Swrr,�As Off /yl Olgo7
Name(Print) :r j;No.and Street City/ own Zip
Property Owner Contact Information:
Xy6-_%264 AKodqe
Title Telephone No.(business) Telephone No. (cell) a-midaddress
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 budding permit application.
SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix 2) - -
f bu ddin is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control-then check here Kind 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
M F13 M 0v1ev 1 ie o/f J e Bd 5
Company Name
j'1'I"k �orJ.�.u�e C5 -6,5 IuiV auresArr.kd
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
_ 9792 W1 _M o a 2) Ctr 0,ldprl 9 M1944, cov?
Telephone No. business Telephone No. cell a-mail address
SECTION 11:WORKERS'COMPEN5A'I ION INSURANCE AFFIDAVCr 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? Yesp, No ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ 0 • 610 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ ` G appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Mininmm fee=$ (contact municipality)
5. Mechanical Other $
6.Total Cost $ Enclose check payable to
(9r Q�' (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.
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7 p t
Plygs�prin�i�sign n / Title Telephone N4. Date
Street Address City/Town State Zip --7
Municipal Inspector to fill out this section upon application approval: /
Name Date
Office of Consumer Affairs and Business Regulation
10 Park Plaza --Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 158287
Type: Private Corporation
Expiration: 1/5/2018 Tr# 285387
NORTH SHORE BUILDERS INC
MARK FOURNIER
P.O. BOX 8084
LYNN, MA 01904
Update Address and return card.Mark reason for change.
Address D. Renewal ❑ Employment ❑ Lost Card
-_ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
€HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 158287 Type: Office of Consumer Affairs and Business Regulation
'.'Expiration: 115/2018 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
NORTH SHORE BUILDERS INC
MARK FOURNIER
63 COMMONWEALTH RD.
LYNN,MA 01904
Undersecretary Not valid without signature
Massachusetts Department of Public Safety
- � Board of Building Regulations and Standards
License: CS-056614
Construction 3uoervisor
ti�4 r� i
a-
MARK M FOURNIER
P O BOX 8084
LYNN MA 01904 �''
^M CA-- Expiration-
Commissioner 06113/2018
1
The Commonwealth of Massachusetts
Department oflndustndAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WFM THE PERWITING ADTHORMY
Applicant lnformation L Please Print b
Name(Business/Otganization/Individual):
/� P Y<'S
Address_o hoic �O,�y�y l�
City/State/Zip: � A l }'"[ 4 Q y' Phone#:
Em&yer?0�Ae"p"P no employer?Check the appmprtate box:
m a employer with / Type Nof ew
(required):
(O of
employees(full and/or part-time).• 7. New construction
m a sole proprietor ur partnership and have no employees working fur me to S. Remodeling capacity.[No workers'comp mmmance requbed]a homeowner doing all work myself[No workers'comp.insurance required.)t 9. ❑Demolition a homeowner and m716e hiring centractmstoconductallworkonmy property. 1 will 10❑Bltilding addition
ore that aU contramors tither have workers'compematim insurance or are sole 11.0 ElectriCal repairs or additions
rietoms with m enmployees. 12.0 Plumbing repairs or additions
a general conaac r and I lave hired the subcoabactora listed an the attached sheeLse sub-contractors have employees mid have workers'comp mma tm: 13.❑Roofrepairsm a corporatim and its officers have exercised their right of exemption per MGL c. 14.❑Other§I(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box ill must also BE out the section below showing their workers'compeusatim policy mfmmatim.
t Homeowners who submit this affidavit indicating they sue doing all work and the hive outside contractors must submit a new affidavit indicating such
lContnumus that check this box must attached an additional sheet showing the anmo of the sub-commcoms and state whether or not those entities have
emplOYeea Ifthe subK mractcrs have employees,they mutt provide their workers'c°mP.poky number.
I am an employer that is providing workers'compensatlon insurancefor my employees. Below is the policy andjob site
informadon. 1 f
Insurance Company Name:0_,56 of:-�//ate/-edi �N�/ C-4
Policy#or Self-ins.Lic.#:f(2CC-6: ,[ O ,[fA 6_7 Fxpnation Date: e,J `6 t�
Job Site Address:�T Z e/fur y /, sr Glty/State/Zip.s,4/Ppw OA
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 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 carder the pane and penalties ofper/ary that the information provided above * Mare and correct
Suture: �i Dale /�/
Phone#: t2.. �/ 0"2 n2 141 J
Official use only. Do not write in this areq to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one).
I.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 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(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 be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pemrittlicense 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
I Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-NlASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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Dnwcrm CFFLWJ1bPAQMOY/BUMDMaMAMONn
Construction Debris Disposa/Afdd7vit
(required for all demolition and.renovatibn work
In accordance with the sixth edition of the State Building Code, 780 CAM, Section 111.5 Debris,
and the provisions of MGL coo, S 54; Building Permit#i is issued with the
condition that the debris resulting from this work shall be disposed of in a properly Ikensed
waste deposit fadlity as defined by MGL c 111,S 15oA
The debris
//will be transported by.-
(name of hauler)
The debris will be disposed of in:
(name of facili
tY)
Aeue-re Kl� -6 S
(address of facility)
Signature of applicant
�� Date