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The Commonwealth of Massachusetts (City of Beverly MA)

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The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
Rev. Sept 2014
This Section For Official Use Only
Building Permit Number: _____________________ Date Applied: ______________________________
___________________________________ ____________________________________________ ___________
Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:
____________________________________________
1.1a Is this an accepted street? yes_____ no_____
1.2 Assessors Map & Parcel Numbers
_____________________ ____________________
Map Number Parcel Number
1.3 Zoning Information:
_______________ ___________________
Zoning District Proposed Use
1.4 Property Dimensions:
_____________________ ____________________
Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40, § 54)
Public Private
1.7 Flood Zone Information:
Zone: ___ Outside Flood Zone?
Check if yes
1.8 Sewage Disposal System:
Municipal On site disposal system
SECTION 2: PROPERTY OWNERSHIP
1
2.1 Owner
1
of Record:
________________________________________ _________________________________________________
Name (Print) City, State, ZIP
_____________________________________________ _________________ ___________________________________
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK
2
(check all that apply)
New Construction Existing Building Owner-Occupied Repairs(s) Alteration(s) Addition
Demolition Accessory Bldg. Number of Units_____ Other Specify:________________________
Brief Description of Proposed Work
2
:_________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
(Labor and Materials)
Official Use Only
1. Building $
2. Electrical $
3. Plumbing $
4. Mechanical (HVAC) $
5. Mechanical (Fire
Suppression)
$
6. Total Project Cost:
$
1. Building Permit Fee: $_______ Indicate how fee is determined:
Standard City/Town Application Fee
Total Project Cost
3
(Item 6) x multiplier _______ x _______
2. Other Fees: $_________
List:_________________________________________________
____________________________________________________
Total All Fees: $_______________
Check No. ______Check Amount: _______Cash Amount:______
Paid in Full Outstanding Balance Due:____
_
_____
SECTION 5: CONSTRUCTION SERVICES
_____________________ ______________
License Number Expiration Date
List CSL Type (see below) _______________
Type Description
U Unrestricted (Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
5.1 Construction Supervisor License (CSL)
________________________________________________________
Name of CSL Holder
_________________________________________________________
No. and Street
_________________________________________________________
City/Town, State, ZIP
_________________________________________________________
_
_________________ ______________________________________
Telephone Email address
D Demolition
5.2 Registered Home Improvement Contractor (HIC)
______________________________________________________________
HIC Company Name or HIC Registrant Name
______________________________________________________________
No. and Street
________________________________________ ____________________
City/Town, State, ZIP Telephone
_____________________ ______________
HIC Registration Number Expiration Date
_______________________________________
Email address
SECTION 6: WORKERS’ COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes ………. No ………..
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER’S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize_____________________________________________________
to act on my behalf, in all matters relative to work authorized by this building permit application.
______________________________________________________ ______________________
Print Owner’s Name (Electronic Signature) Date
SECTION 7b: OWNER
1
OR AUTHORIZED AGENT DECLARATION
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.
_____________________________________________________________ ______________________
Print Owner’s or Authorized Agent’s Name (Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca
Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) _________________________ (including garage, finished basement/attics, decks or porch)
Gross living area (sq. ft.) __________________ Habitable room count ______________________
Number of fireplaces______________________ Number of bedrooms _____________________
Number of bathrooms ____________________ Number of half/baths ______________________
Type of heating system ___________________ Number of decks/ porches __________________
Type of cooling system_____________________ Enclosed ______________Open _____________
3. “Total Project Square Footage” may be substituted for “Total Project Cost”
Homeowner Warning Notice
IF YOU ARE APPLYING FOR A BUILDING PERMIT AS A
HOMEOWNER
As a homeowner acting as your own contractor:
• You will be personally responsible for all work on this project.
• You are responsible to see that all work meets the Massachusetts State Building Code
and the City Ordinances.
• You must supervise all work.
• You must call the Bldg. Dept. to schedule all required building inspections.
• You must be present for all the building inspections.
• You have waived all rights to the Massachusetts Guaranty Fund.
• You are the General Contractor of the project and a court of law will view you as
such if you are sued, or if you should have the need to sue another party.
• Your subcontractors may lien your property.
• Any worker injured on your project may sue you if you or the company they work for
does not carry Workers’ Compensation Insurance.
• Failure to carry Workers’ Compensation insurance may result in criminal penalties,
i.e. fines and/or imprisonment. (Reference MGL c.152 § 25)
This warning has been assembled because we have found that a majority of those
citizens who act as their own contractor are not aware of the responsibilities that go
along with assuming the construction responsibilities. Your signature below verifies
you have read this warning and understand its implications.
Signature_______________________________________ Date _______________
For Office Use Only:
Permit No..____________
Date__________________
BEVERLY, MASSACHUSETTS
Construction Supervisor License Exemption
Supplement to Permit Application
DATE SUBMITTED ________________
JOB LOCATION _________________________________________________________
HOMEOWNER’S NAME __________________________________________________
HOMEOWNER’S MAILING ADDRESS _____________________________________
HOME PHONE NO. ____________________ WORK PHONE___________________
The licensing exemption for “
homeowners” is intended to include owner-occupied one or
two-family dwellings and to allow such homeowners to engage an individual for hire
who does not possess a license,
provided that the owner acts as supervisor.
STATE BUILDING CODE DEFINITION OF HOMEOWNER:
“Person(s) who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two-year period shall not be considered a homeowner. Such
“homeowner” shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she shall be responsible for all such work performed under the building
permit.”
The undersigned “homeowner” assumes responsibility for compliance with the State
Building Code and other applicable codes, ordinances, rules and regulations.
The undersigned “homeowner” certifies that he/she understands the City of Beverly
Municipal Inspections minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
Homeowner’s Signature __________________________ Date: ___________________
For Office Use Only:
Permit No..____________
Date__________________
BEVERLY, MASSACHUSETTS
Home Improvement Contractor Registration
Supplement to Permit Application
MGL 142A requires that the “reconstruction, alteration, renovation, repair, modernization,
conversion, improvement, removal or demolition or the construction of an addition to any pre-
existing owner-occupied building containing at least one, but not more than four dwelling units,
which building or portion thereof is used or designed to be used as a residence or dwelling unit,
or to structures which are adjacent to such residence or building” be done by registered
contractors with certain exceptions.
TYPE OF WORK _______________________________________ EST. COST ____________
ADDRESS OF WORK:_________________________________________________________
OWNER NAME: (PRINT)______________________________________________________
DATE OF PERMIT APPLICATION:______________________________________________
I hereby certify that:
Registration is not required for the following reasons:
____ Work excluded by law
____ Job under $1000.00
____ Building not owner-occupied
____ Owner pulling own permit
____ Other (Specify)____________________________________________________
Notice is hereby given that:
Owners pulling their own permit or dealing with unregistered contractors for applicable
home improvement work do not have access to the arbitration program or guaranty fund
under MGL 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent for the owner:
____________ ______________________________________________ _________________
DATE CONTRACTOR’S SIGNATURE REGISTRATION #
OR:
Notwithstanding the above notice I hereby apply for a permit as the owner of the above property:
____________ ____________________________________________
DATE OWNER’S SIGNATURE
For Office Use Only:
Permit No..____________
Date__________________
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
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 Legibly
Name (Business/Organization/Individual):______________________________________________________
Address:__________________________________________________________________________
City/State/Zip:_____________________________ Phone #:________________________________
*Any applicant that checks box #1 must also fill out the section below showing their workers’ compensation policy information.
†
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 name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors 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
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 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 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: ___________________________________ 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 #:_________________________________
Type of project (required):
7. New construction
8. Remodeling
9. Demolition
10 Building addition
11. Electrical repairs or additions
12. Plumbing repairs or additions
13. Roof repairs
14. Other____________________
1. I am a employer with _________employees (full and/or part-time).*
2. I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers’ comp. insurance required.]
3. I am a homeowner doing all work myself. [No workers’ comp. insurance required.]
†
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
proprietors with no employees.
5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
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.
152, §1(4), and we have no employees. [No workers’ comp. insurance required.]
Are you an employer? Check the appropriate box:
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 (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 burn 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 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Revised 02-23-15
BEVERLY MUNICIPAL INSPECTIONS
CONSTRUCTION DEBRIS DISPOSAL FORM
780 CMR 111.5 & 5111.5 Debris. As a condition of issuing a permit for the demolition,
renovation, rehabilitation or other alteration of a building or structure, M.G.L. c. 40, § 54
requires that the debris resulting there from shall be disposed of in a properly licensed
solid waste disposal facility as defined by M.G.L. c. 111, § 150A. Signature of the permit
applicant, date and number of the building permit to be issued shall be indicated on a
form provided by the building department, and attached to the office copy of the building
permit retained by the building department. If the debris will not be disposed of as
indicated, the holder of the permit shall notify the building official, in writing, as to the
location where the debris will be disposed; also refer to DEP Regulations 310 CMR
7.09(2) and 310 CMR 7.15, when applicable.
In accordance with the provisions of MGL c 40, S 54, a condition of Building Permit
Number _____________________ is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL c 111,
S 150A. The debris will be disposed of in:
LOCATION OF FACILITY ________________________________________________
CONSTRUCTION SITE ADDRESS _________________________________________
Signature of Applicant _______________________________ Date ________________
AFFIDAVIT
As a result of the provisions of MGL c 40, S 54, I acknowledge that as a condition of
Building Permit Number __________________________ all debris resulting from the
construction activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
I certify that I will notify the Building Official by ___________________ (two months
maximum) of the location of the solid waste disposal facility where the debris resulting
from the said construction activity shall be disposed of, and I shall submit the appropriate
form for attachment to the Building Permit.
Signature of Applicant _______________________________ Date ________________
(PRINT OR TYPE THE FOLLOWING INFORMATION)
Name of Permit Applicant _________________________________________________
Firm Name, if any _______________________________________________________
Beverly Erosion - Sediment Control and Materials Management Ordinance application > ¼ ac.
Page 1 of 1
CITY OF BEVERLY
MINOR PROJECT APPLICATION
FOR PROJECTS DISTURBING LESS THAN ONE QUARTER ACRE
Submittal Date of Application: _________________________
TO THE DIRECTOR OF ENGINEERING: The undersigned hereby applies for a permit to disturb less than one
quarter acre of land in accordance with the following specifications:
I. LOCUS INFORMATION
Ward: ___________ Zoning District: ____________ Assessors Map #: ______ Lot #: ______
Street Address of Lot to be worked on: _____________________________ Lot Area: _____________
II. RESPONSIBLE PARTY INFORMATION
Owner’s Name: ___________________________________________Phone No.: __________________________
Cell Phone No.: ______________________ Fax No.: ____________________________
Owner’s Mailing Address: ______________________________________________________________________
Contractor’s Name: _____________________________________ Phone No.: ___________________________
Cell Phone No.: __________________________ Fax No.: ____________________________
License No.: ____________________________
Contractor’s Mailing Address: ___________________________________________________________________
III. PROJECT DESCRIPTION
Describe Work: _______________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Anticipated amount of excavate to be removed from site: __________________ cubic yards
Amount of excavate to be utilized on site: Backfill: _________cubic yards Grading: _________cubic yards
Other: ____________cubic yards
Where and how will excavate be stockpiled on site? __________________________________________________
______________________________________________________________________________________________
The undersigned acknowledge/s that any land clearing, construction, or development involving the movement
of earth must be done in accordance with the City of Beverly’s Erosion and Sediment Control and Materials
Management Ordinance and any Plan approved by the Engineering Department under this Ordinance.
Further, as the applicant representing the owner, I hereby certify that the proposed measures are authorized
by the property owner of record and that I have been authorized by the owner to make this application as
his/her authorized agent and we agree to conform to all applicable laws of this jurisdiction.
Signature of Owner: ____________________________________ Date: _______________________
Signature of Applicant (if not owner): _______________________________ Date: ______________________
Applicant’s Business Address: ____________________________________ Phone No.: ___________________
Cell Phone Number: _______________________ Fax No.: _____________________
Accepted By: ___________________________________________________ Date: ______________________
Director of Engineering: _________________________________________ Date: ______________________
Beverly Erosion-Sediment Control and Materials Management Ordinance application < 1 ac but > ¼ ac
Page 1 of 2
CITY OF BEVERLY
ABBREVIATED EROSION/SEDIMENT CONTROL & MATERIALS MANAGEMENT APPLICATION
FOR PROJECTS DISTURBING LESS THAN ONE ACRE BUT MORE THAN ONE QUARTER ACRE
Submittal Date of Application: _________________________
TO THE DIRECTOR OF ENGINEERING: The undersigned hereby applies for a permit to disturb less than one
acre of land but more than one quarter acre of land in accordance with the following specifications:
I. LOCUS INFORMATION
Ward: ___________ Zoning District: ____________ Assessors Map #: ______ Lot #: ______
Street Address of Lot to be worked on: _____________________________ Lot Area: _____________
II. RESPONSIBLE PARTY INFORMATION
Owner’s Name: ___________________________________________Phone No.: __________________________
Cell Phone No.: ______________________ Fax No.: ____________________________
Owner’s Mailing Address: ______________________________________________________________________
Contractor’s Name: _____________________________________ Phone No.: ___________________________
Cell Phone No.: __________________________ Fax No.: ____________________________
License No.: ____________________________
Contractor’s Mailing Address: ___________________________________________________________________
III. PROJECT DESCRIPTION
Describe Work: ________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Anticipated amount of excavate: __________________ cubic yards
Amount of excavate to be utilized on site: Backfill__________cubic yards Grading__________cubic yards
Other_____________cubic yards
Amount of excavate to be removed from site: _________________cubic yards
Where will excavate be stockpiled on site? __________________________________________________________
______________________________________________________________________________________________
How will stockpiled material be protected from erosion?
Ringed w/ staked hay bales and/or entrenched silt fence_____
Covered w/ staked geotextile or similar fabric_____
Seeded with quick growing grass during growing season_____
Other ________________________________________________
Describe the location of site entrance/exit and how public ways and associated drainage structures will be
protected from soil and debris migrating off site by way of equipment traffic_____________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Describe measures to be taken to protect adjacent properties from sedimentation and migration of trash,
debris and other material ________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Beverly Erosion-Sediment Control and Materials Management Ordinance application < 1 ac but > ¼ ac
Page 2 of 2
Describe measures to be taken to house any hazardous materials, and protocol for mitigating their
release________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
The undersigned acknowledge/s that any land clearing, construction, or development involving the movement
of earth must be done in accordance with the City of Beverly’s Erosion and Sediment Control and Materials
Management Ordinance and any Plan approved by the Engineering Department under this Ordinance.
Further, as the applicant representing the owner, I hereby certify that the proposed measures are authorized
by the property owner of record and that I have been authorized by the owner to make this application as
his/her authorized agent and we agree to conform to all applicable laws of this jurisdiction.
Signature of Owner: _____________________________________________ Date: ________________________
Signature of Applicant (if not owner): ______________________________ Date: ________________________
Applicant’s Business Address: ____________________________________ Phone No.: ___________________
Cell Phone Number: _______________________ Fax No.: _____________________
Accepted By: ___________________________________________________ Date: ________________________
Engineering Dept.: ______________________________________________ Date: ________________________
CITY OF BEVERLY
EROSION/SEDIMENT CONTROL & MATERIALS MANANGEMENT APPLICATION
Submittal Date of Application_________________
TO THE DIRECTOR OF ENGINEERING: The undersigned hereby applies for a permit to disturb one acre or more of land
in accordance with the following specifications:
1. Locus Information
Ward: Zoning District Assessor Map Assessor Lot
Street Address Lot Area
2. Responsible Party Information
Owner Information
Name
Phone No.
Address
Fax No.
Cell Phone No.
Licensed Professional Engineer Information
Name
Phone No.
Address
Fax No.
Cell Phone No.
Mass. License No.
Contractor Information
Name
Phone No.
Address
Fax No.
Cell Phone No.
License No.
3. Site Description
Describe the Nature and Purpose of the Project, the overall site, and adjacent properties:
Describe Types of Soil Disturbing Activities:
Runoff
Coefficient:
Site
Area:
Sequence of Major Activities( in order of occurrence)
Order Description of Activity Estimated Date of
Commencement of Work
Estimated Completion Date
Installation of temporary
erosion/sediment control measures
Stripping and clearing
Rough grading
Construction of utilities
Construction of other infrastructure
Construction of buildings
Final grading and landscaping
Other (specify)
Other (specify)
Description of Receiving Waters
4. Controls—Erosion & Sediment
Details and Specifications on Proposed Stabilization Practices (Erosion Controls)
Structural Practices (Sediment Controls)
Storm Water Management (Waterway/water course protection)
Offsite Vehicle Tracking (Construction site access)
5. Materials Management Practices
Materials Storage, application and disposal (Pesticides/Chemicals)
Hazardous Materials—Storage, use and disposal (Petroleum Products)
Sanitary Waste
Other Materials (Washout concrete/excess pavement etc)
6. Inspection
The Permittee shall notify the City of Beverly Engineering Department at least two working days before the following:
A Start of construction
B Installation of sediment and erosion control
C Completion of site clearing
D Completion of rough grading
E Completion of final grading
F Close of construction season
G Completion of final landscaping
H Removal of sediment and erosion control measures
The undersigned acknowledge/s that any land clearing, construction, or development involving the movement of earth
must be done in accordance with the City of Beverly’s Erosion and Sediment Control and Materials Management
Ordinance and any Plan approved by the Engineering Department under this Ordinance. Further, as the applicant
representing the owner, I hereby certify that the proposed measures are authorized by the property owner of record
and that I have been authorized by the owner to make this application as his/her authorized agent and we agree to
conform to all applicable laws of this jurisdiction.
I further certify that a legal notice in a newspaper of general
circulation will be advertised and abutters notified by regular mail within 3 days of submission of this application.
Signature of Applicant______________________Address___________________Date______
Signature of Owner Date:
Signature of Applicant(if not owner) Date:
Applicant’s Business Address Phone No.:
Fax No.:
Cell Phone No.:
Accepted by Date:
Engineering Dept. Date:
Permit Fee:---$200.00 Check No.: Date:
Bond/LC Amount Date:
Required Attachments:
Natural resources map (Section 20-170.1.a.)
Identification of sensitive or potentially problematic areas or characteristics on and adjacent to the site (Section
20-170.1.c.)
Site development plan depicting the proposed project improvements, existing and proposed grades, and all
erosion control measures (Section 20-170.1.d.)
Vegetation/revegetation/landscaping plan (Section 20-170.1.g.)
An operation and maintenance plan (Section 29-170.1.h.)
Supporting calculations
CITY OF BEVERLY – MUNICIPAL INSPECTIONS DEPARTMENT
STRETCH ENERGY CODE COMPLIANCE
RESIDENTIAL BUILDINGS
1 & 2 FAMILY – MULTI-FAMILY, 3 STORIES OR LESS
Effective January 1, 2012
Project Address: _________________________________________ Date ________________________
Description of Project: ____________________________________
Please check all that are applicable:
NEW CONSTRUCTION:
HERS (Home Energy Rating System) Index Rating (report included)
Rating of 65 or less (for units equal to or greater than 3000 sq. ft.)
Rating of 70 or less (for units less than 3000 sq. ft.)
ADDITIONS:
Prescriptive Option: Addition conforms to current IECC Chapter 4, and complies with:
1. The Energy Star Qualified Homes Thermal Bypass Inspection Checklist
2. Fenestration U-factor meets Energy Star requirements for Doors, Windows and Skylights - Version 5
3. Ducts for new HVAC systems shall be sealed and tested to demonstrate leakage to outdoors of less than or
equal to 4 cfm per 100 sq. ft. of conditioned floor area, except where the airhandler and all ducts are located
within conditioned space
Performance Option: HERS rating for new construction (above)
ALTERATIONS, RENOVATIONS OR REPAIRS
Not Applicable: Proposed work does not affect building energy envelope
Roofing/Siding: Uninsulated roofs or walls to be insulated to Stretch Code requirements when the sheathing is exposed
as part of the re-roofing or re-siding of the building, per IECC 101.4.3 (Mass. amendment)
Exempt: Work is exempt under 780CMR 115AA 101.4.3 Exception #_________
Prescriptive Option: The affected portion of the envelope complies with the Prescriptive Option for additions (above).
Envelope insulation will meet or exceed IECC requirements for climate zone 5, or fully fill existing cavities with
insulating material which meets or exceeds an R value of 3.5/inch.
Performance Option: Meets New Construction Performance Option with the following HERS rating requirements:
1. Rating of 80 or less (for units equal to or greater than 2,000 sq. ft. in conditioned floor space)
2. Rating of 85 or less (for units less than 2,000 sq. ft.)
3. Compliance with the Energy Star Qualified Homes Thermal Bypass Inspection Checklist.
If using the HERS Index Rating, please include the following information:
RESNET Certified HERS Rater:
Name: ___________________________________
Address: ______________________________________________ Phone: _______________________________
Please include copy of Certification of HERS Rater.
I, the undersigned, certify knowledge and understanding of the energy conservation requirements as enforced by the City of
Beverly, and certify that the above information is accurate to the proposed construction.
Owner's Name (1&2 Family) _______________________Signature______________________________ Date ________
Contractor's Name ________________________________Signature _____________________________ Date ________
If work is under design provisions of 780 CMR 107.6, Construction Control, the following is required:
Registered Design Professional (Multi -Family) ______________________________
Reg. Des. Profs. Signature ________________________ Date ______________
_________________
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The Commonwealth of Massachusetts (City of Beverly MA)

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Completed 2 August 2020

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