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The Commonwealth of Massachusetts (City of Beverly MA)

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The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code (780 CMR)
Building Permit Application
to Construct, Repair, Renovate or Demolish a Building
Other than a One- or Two-Family Dwelling
Requirements for Building Permits
Permit requirements are specified in Chapter 1 of the MA State Building Code. Applicants should
review the requirements to avoid common problems. The standard form below incorporates the code
requirements and is provided for use by municipalities to achieve permit consistency across the State.
Municipalities may use a variant of this form but it must contain at least the same information.
Please contact the municipality where the work will be done for the proper form or follow the
instructions below if this standard form is acceptable.
Filing Instructions
Complete the application. The application is available in Word or PDF format so check to see
what is acceptable to the local building official.
Include construction documents, specifications, and other materials required.
Check if the local municipality requires confirmation that property taxes, water fees, etc. are
not outstanding.
Also, check if the local building official requires construction control forms (see section 107 in
the building code) with this application.
Submit the application package with a check made payable to the municipality for the fee as
determined by the municipality.
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code (780 CMR)
Building Permit Application for any Building other than a One- or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: ____________ Date Applied: ______________ Building Official: _______________________
SECTION 1: LOCATION
_________________________________________________________________ _________________________________________
No. and Street City /Town Zip Code Name of Building (if applicable)
________________ __________________
Assessors Map # Block # and/or Lot #
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 Addition Demolition (Please fill out and submit Appendix 2)
Change of Use Change of Occupancy Other Specify:___________________________________________
Are building plans and/or construction documents being supplied as part of this permit application? Yes No
Is an Independent Structural Engineering Peer Review required? Yes
No
Brief Description of Proposed Work:__________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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 A-4 A-5
B: Business E: Educational
F: Factory F-1 F2 H: High Hazard H-1 H-2 H-3 H-4 H-5
I: Institutional I-1 I-2 I-3 I-4
M: Mercantile
R: Residential R-1 R-2 R-3 R-4
S: Storage S-1 S-2
U: Utility
Special Use and please describe below:
Special Use Description:
SECTION 6: CONSTRUCTION TYPE (Check as applicable)
IA IB IIA IIB IIIA IIIB IV VA VB
SECTION 7: SITE INFORMATION (refer to 780 CMR 105.3 for details on each item)
Water Supply:
Public
Private
Flood Zone Information:
Check if outside Flood Zone
or indentify Zone:__________
Sewage Disposal:
Indicate municipal
or on site system
Trench Permit:
A trench will not be
required or trench
permit is enclosed
Debris Removal:
Licensed Disposal Site
or specify:_____________
______________________
Railroad right-of-way:
Not Applicable
or Consent to Build enclosed
Hazards to Air Navigation:
Is Structure within airport approach area?
Yes or No
MA Historic Commission Review Process:
Is their review completed?
Yes No
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: __________ Use Group(s): __________ Type of Construction: ________
Does the building contain an Sprinkler System?: _________ Special Stipulations: ___________________________________________
Design Occupant Load per Floor and Assembly space: _________________________________________________________________
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
__________________________ ______________________________ ____________________________________________ ___________
Name (Print) No. and Street City/Town Zip
Property Owner Contact Information:
_______________________________ _____-_____-___________ ____-_____-___________ _______________________________
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 apply for and 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 1)
If a building is less than 35,000 cu. ft. of enclosed space and/or not under Construction Control then check here .
Otherwise provide construction control forms (see section 107 in the code) as required.
10.1 Registered Professional Responsible for Construction Control (the professional coordinating document submittals)
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address City/Town State Zip
_____________________
Registration Number
_______________ _______________
Discipline Expiration Date
10.2 General Contractor
__________________________________________________________________________________________________________________
Company Name
_________________________________________ ____________________________________________________________
Name of Person Responsible for Construction License No. and Type if Applicable
______________________________________________ __________________________________ ______ _____________
Street Address City/Town State Zip
____-____-_______________ _____-_____-_____________ ____________________________________________________
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11: WORKERS’ 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)
1. Building $
2. Electrical $
3. Plumbing $
4. Mechanical (HVAC) $
5. Mechanical (Other) $
6. Total Cost $
Total Construction Cost (from Item 6) = $_________________
Building Permit Fee = Total Construction Cost x ____ (Insert here
appropriate municipal factor) = $________.
Note: Minimum fee = $________ (contact municipality)
Enclose check payable to __________________________________
(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.
______________________________________________________ ____________________________ ____ -_____- ________ _________
Please print and sign name Title Telephone No. Date
____________________________________ _______________________ ______ _____________ ____________________________
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval: ____________________________________ _____________
Name Date
Appendix 1
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required. The applicant shall fill out
the checklist and provide the contact information of the registered professionals responsible for the
documents. This appendix is to be submitted with the building permit application.
Checklist for Construction Documents*
Mark “x” where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm (may require repeaters)
6 HVAC
7 Electrical
8 Plumbing (include local connections)
9 Gas (Natural, Propane, Medical or other)
10 Surveyed Site Plan (Utilities, Wetland, etc.)
11 Specifications
12 Structural Peer Review
13 Structural Tests & Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review (521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other (Specify)
21 Other (Specify)
22 Other (Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein. Work so identified
must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the
authority having jurisdiction.
Registered Professional Contact Information
Please follow this link for construction control forms to be used by Registered Design Professionals.
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address Cit
/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address Cit
/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
______________________________ ____-_____-___________ _________________________
Name (Registrant) Telephone No. e-mail address
______________________________ ______________________________ ______ _________
Street Address Cit
y
/Town State Zip
_____________________
Registration Number
___________ _______________
Discipline Expiration Date
Appendix 2
(For total demolition only)
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit application.
The building permit applicant attests under the pains and penalties of perjury that the following is
true and accurate.
Property Location
__________________________ ___________________________ ____________ _____________________________
No. and Street City /Town Zip Name of Building (if applicable)
_________________________ ________________________
Assessors Map # Block # and/or Lot #
For the above described property the following action was taken:
Water Shut Off? Yes No Provider notified and Release obtained? Yes No
Gas Shut Off? Yes No Provider notified and Release obtained? Yes No
Electricity Shut Off? Yes No Provider notified and Release obtained? Yes No
__________________ Yes No Provider notified and Release obtained? Yes No
Other (if applicable)
__________________ Yes No Provider notified and Release obtained? Yes No
Other (if applicable)
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
COMMERCIAL BUILDINGS
INCLUDING RESIDENTIAL, 4 STORIES OR MORE
Effective January 1, 2012, Rev. October.24, 2012
Project Address: _________________________________________ Date ________________________
Description of Project: ____________________________________
Check all that are applicable to the proposed project:
NEW CONSTRUCTION
Buildings Under 5000 ft
2
- Exempt from Stretch Code Requirements, but must comply with IECC
Buildings 5000 ft
2
- 100,000 ft
2
(including residential buildings of 4 or more stories)
Performance Option (780 CMR 115AA 501.l.1) - Energy modeling must show a 20% improvement relative to
ASHRAE 90.1-2007 Appendix G
Prescriptive Option (780 CMR 115AA 501.1.4)
Compliant with Ch. 5 IECC, plus Stretch Code requirements plus one of the following:
More efficient heating and cooling equipment
More efficient lighting
Provide at least 3% of the onsite electric load from onsite renewable generation
Buildings Over 100,000 ft
2
(including residential buildings of 4 or more stories)
Performance Option (780 CMR 115AA 501.1.1)
Energy modeling must show a 20% improvement relative to ASHRAE 90.1-2007 Appendix G
Special case buildings greater than 40,000 ft
2
Supermarket ________, Warehouse ___________, Laboratory _____________
Energy modeling must show a 20% improvement relative to ASHRAE 90.1-2007 Appendix G
Work is Exempt from Stretch Code Requirements (but must comply with IECC)
Commercial Building less than 5000 ft
2
__________, Special Case Building less than 40,000 ft
2
__________
ALTERATIONS, RENOVATIONS OR REPAIRS
Project is an alteration, renovation or repair to an existing building and is exempt from the Stretch Code. Project will
comply with all current IECC requirements
The following documentation has been submitted with application:
Energy Modeling Report
Building Envelope Specifications
Lighting Power Density Report (required for any new lighting installation)
Equipment, Testing, and Commissioning Schedule
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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