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18 MALL ST - BUILDING INSPECTION C f , / 7Dwelling C—>kt rt The Commonwealth of MassachusettsrtL � VIC Department of Public Safety MassachumitsStateBuildingCode(780CMR) ;201b JUNA 11: 1 Building Permit Application for any Building other than a One-or Two-Family .(This Section For Official Use Only) 6� it Number. Date Applied: Building Official: [., N 1:LOCATION(Please indicate Block 8 and Lot►for locations for which a street address is not available) ST SA LPG d l 7D City/Town Zip Code Name of Building(if applicable) . 1 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 I Existing Building Repair Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) r Change of Use ❑ I Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans:md/or construction documents being supplied as part of this permit ma�pplication? Yes ❑ Nu Is an Independent Structural Engineering Peer Review required? ` Lfa`1_t 1 'J'Z yes ❑ No Brief Description of P,{�posed Work._Rr1949 U l: H6PJL=H'/ jA 4AINgn S (.htlt/wL /ite,"q gf atkj( 4 2: wA1.LS o{ bA�.+2 !S(- .teovr (3Lir�6o�is1 �Ls9JTL�J2 � �JvJ.rIA-+�� L 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): Proposal Use Group(s): SECTION4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)k Area Per Fluor(sq. ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a licable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I❑ F2❑ If: High Hazard H-1❑. H-2❑ H-3 ❑ H4❑ H-5❑ 1: Institutional 1-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ - S•2❑ U. Utility❑ I Special Use❑and please describe below: SixYial Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) - JA 0 IB O IIA ❑ fin 0 ILIA ❑ 1118 0 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CfvlR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal: Public�i( Chck if outside Flood Zone Indicate municipal A trench will not be Licensed Disposal Si[e rcquiredXortrench or specify: Private O or indentify Zone: or on site system O permit is enclosed❑ Railroad rightof-way: Hazards to Air Navigation: �I4 I Ii_togic G"mggsunn¢,�'w"1'nnp.p: Not Applica ble�F Is Structure within airport approach area? Is their review completed? or Consent to Budd enclosed❑ 1 Yes❑ or No Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition u(Coda: Use Group(s): Type of Construction: Occupant Load per Fkxwr. Dues the building amRain an Sprinkler System?: _ Special Stipulations: ro A to ( 119 SECTION 9: PROPERTY OWNER AUTHORIZATION ' Name and Address of Property Owner Oa,Act- S L. 6 rv,>w,4r a Att i L c r- CSA+t tn, ©lF�o Name(Print) No.and Street City/Town Zip m Property Owner Contact Inforation: Title Telephone No.(business) Telephone No. (cell) a-mad 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 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 O and 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 Company Name 1 l L //c? i 6 7 AlVI, F, ol GS D1- 7Sb2 3/3o/aaje Name of Person Responsible for Construction License No. and Type if Applicable If y 0jtN0kX-e lx4- n1Zz 3 Street Address City/Town State Zip 7Sa! Telephone No. business Telephone No. cell mail address SECTION 11:W'ORKEW COMPENSATION INSURANCE AFFIUAVrI' 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 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ SRO 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 payable to 6.Total Cost 1 $ Q So (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT r By entering any name below, 1 hereby attest under the pains anti penalties of perjury that all of the information contained in this apoplication is true and accurate to the t my k9ewleand undo Ple ue print and sign name Title Telephone!*. Date o f1t,fcA-Z- ' l�tn�vcz s W-&-- z:)I - z3 Strut Address City/Town /�/,,Sttatte Zip Municipal Inspector to fill out this section upon application approval• ' ` Name Date The Commonwealth of Maysachusetts Department oflndustrialAccidents I Congress Street,Suite l00 Boston,AL4 02114-2017 UV www massgov/dia 'Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH:THE PERNTITING AUTHORITY. Applicant Information PlessePrint Leeibly Name(Business/Organization/fndividua): PF7 L Address: If CL-_X�T10- 5T City/State/ZiP: JQA"txJ WA. 6 ( (2,3 Phone#: 7e yi 7-i-A- Areyou an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with employees(fiill and/or paK-time).• ,. 27 am a solo proprietor or �- New construction 7 partnership and have no employees working for Jmg, Remodeling y capacity.[No workers'comp.insurance required.] 3.❑lain a homeowner doing all wotk myself.[No workers'comp.insurance r9. Demolition4.❑I am a homeowner and will be hiring".tractors to conduct all work on m10❑Building addition ensure that all tontragors either have workers' willproprietors with no employees. compensation tnsuran"mI I.❑Elechical repairs or additions 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hived the subcontractors listed on the tThese sub-conbactms have employees and have workers'comp to min13.0 Roof repairs6.O We are a corporation and its officers have exercised their right of exemption14.❑Other]52,§1(4),and we have no employees.[No workers'comp.insurance requi 'Any applicant that checks box#1 must also fill out the section below showingtheir workers'" con r contractors Policy information. 1 Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such. employe s. that check this box most attached an additional sheet showing the name of themp sub-conhactors and state whether or not those entities have employees. Ifthe sub=cmitractors have mptoyees,dray most provide their workers'comp.policy number. I am an employer,that is providing workers'compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name:_ '%/'i(' f f fhi.T Rn Policy#or Self-ins.Lic.#: O 9 5 464 L ^Z 70 O 6 j) f Expiration Date: a 0 -a&j 6 Job Site Address: /,2 629 L r-S-- 0 -i I 1 City/State/Zip:�2 L r-A-r W 9 CYf�O 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 ce .der the pains penalties ofperjury that the information provided above is true and correct: Si nature: Date: Phone M f �t,I FFOther only. Do not write in this area,to be completed by city or town official n: Permit(License# hority(circle one): ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone M 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 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(L LQ 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 confirmationof 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 permittlicense 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 021 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/clia OTY OF SALSA MASSAa-"E M Buz=wcDBrAFmwrrr 120 WAgmwTSTxBFT,3=FLOOR IkL.(978)745.9593. FAX(978)7449846 SI1v�ERIBYDRiSQ7LL MAYOR DiCUMSTMEM Dnmcrca cFruvjcFxaFwY/Buff.DmamoA=c@uc Construction Debris D1spos17/Aff1dav1t (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 coo, S 54; Building Permit 8 is issued with the condition that the debris resulting from this work shall be disposed of in a property licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by. J�/112 l�sf}Slt� �Is /0 dY3- 33-?d (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature of applicant Date Massachusetts Department of Public Safety f Board of Building Regulations and Standards License: CS-W562 Construction Supervisor PAUL F MILLER 194 CENTRE ST DANVERS MA 01923' - P-j-^n l— Expiration: Commissioner 031=018 - e`ner Affairs Bu ihess Regulation le Lieense or registration valid for individual use only Office of Coosomer Affairs&Bnsi ess Regalstion HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _ Registration•,;"q�g167 Type-_ Office of Consumer Affairs and Business Regulation Expiration; 51- 1LQ'1 10 Park Plaza-Suite 5170 -_-__--=8 Individual Boston,MA 02116 PAUL F_MILLER _ .. - PAUL 184 C MILLER 184 CENTRE ST DANVERS,MA 01923 "`-- Undersecretary - - Nat id w" oat signature I , 06 This Spectrum Policy consists of the Declarations, Coverage Fonns, Common Policy Conditions and any 70 other Forms and Endorsements issued to be a part of the Policy. This insurance is provided by the stock • IV insurance company of The Hartford Insurance Group shown below. SBA INSURER: HARTFORD FIRE INSURANCE COMPANY ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 COMPANY CODE: 1 Policy Number: 08 SBA LV7006 DW THE HARTFORD SPECTRUM POLICY DECLARATIONS ORIGINAL <r Named Insured and Mailing Address: PAUL MILLER D/B/A � (No., Street,Town, State, Zip Code) PAUL'S WALLS 0 184 CENTRE STREET DANVERS MA 01923 . Policy Period: From 11/20/15 To 11/20/16 1 YEAR 12:01 a.m., Standard time at your mailing address shown above. Exception: 12 noon in New Hampshire. 0 Name of Agent/Broker: TGA CROSS INSURANCE INC/PHS a Code: 087173 m N Previous Policy Number: 08 SBA LV7006 0 0 Named Insured is: INDIVIDUAL Audit Period: ANNUAL Type of Property Coverage: SPECIAL Insurance Provided: In return for the payment of the premium and subject to all of the terms of this policy, we agree with you to provide insurance as stated in this policy. TOTAL ANNUAL PREMIUM IS: $839 Countersigned by 09/09/15 Authorized Representative Date Form SS 00 02 12 06 Page 001 (CONTINUED ON NEXT PAGE) Process Date: 09/09/15 Policy Expiration Date: 11/20/16 S/ 2&':�—i cJ& T .J3 A)6 So ,yl>12- > s Ly 37- 1— S Lrot