45 MASON ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts'
ri ItI� Department of Public Safety
G 7 1 r bfassachusettsState Building Code(780 CMR)
Building Permit Application for any,Building other,than a O Two-Family Dllingno-
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1: LOCATION(Please indicate Block k and Lot N for locations for which a street address is not available)
D
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 0
3 Repaiiel Alteration ❑ '. :\dditiini❑` ' Demolition ❑ (Please fill out and submit Appendix l)
Change of Use -0 Change of Occupancy . •f7 . . Other ❑ Specify: - t
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer R M w required?,/ ' '� Y s ❑ o
Bri f Description of Proposed 4iork: /{lS`t`/1 L ��� .�o fN' OH (x-'Jt& 4 1, "s
9l�X �f��iCGO QROIJ T
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 CNIR 34) ❑
Existing Use Group(s): Proposed Use Grou p(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(scl. ft.)and Total Height(ft.) - MOR4
SECTION 5:USE GROUP(Check as ap Iicable)A: Assembly A-I ❑ A-2.❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business l�F: Facto F-I ❑ F2❑ 11: Hi h flazud tf-1 ❑ H-2❑ H-3 ❑1: Institutional [-1 ❑ 1-2❑ [-3❑ I-k❑ M: �(ercantile❑ R: Residential R-1❑ R-S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please des
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a Iicable)
IA IB ❑ IIA ❑ HB ❑ IIIA0 111B0 . • IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
vPr
Water Supply: w
Flood Zone Information: Selvage Disposal: Trench Permit: Debris Removal:
Public Er Check if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Dispusal Site❑
Private,[] or indentify Zgne: Cron site system❑, required CI or trench or specify:
permit is enclosed❑
Railroad right-of-way: ILizards to Air Navigation: VIA 11i 1 rn „< nvni si n ci,nv I nxrvs: -
:Not Applicable❑ Is Structure within airpor[pNprpach area? Is their review completed?, e
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION&CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code- Use Grntp(s): _ Type of Construction: Occupant Load per Floor:.
Does the boddinl;contain,m Sprinklor System?: Special Stipulations:_
SECTION 9: PItOPER'rY OWNER AUTIIORIZA'rION
Nana and'a RAI& OwnepuA r •9( _1
.— City/Town Town UI Zip
Name(Print) NO.and Street Y/
Property Owner Contact Information:
nl')r� ��49��_ '181 -'784� , <fz Q
Title Telephone No. (business) 'relephone No. (cell) a-mail address
B 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 omit a2pliLation.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildut is less than 35,000 cu.ft.of enclosed s ace and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
W.-W 2_5�5. ra40117
Nnuy�Re isl ant rcle h to No. (, a-uwil Jd'LQCS5 Re 1's 11tioll Numb'.
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
4
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 a-mail ndalress
SECTION il:k1Wi:KVlcs N. l[ON NtiuJ;: NCn Al fil!AVII' M.G.L.c.152.§ 25C6
A Workers'Compensation Insurance Affidavtt from the MA Department of Industrial Accidents must be completed cull
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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item anti Materials) Total Construction Cost(from Item 6)_S
I. Building 5 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=5
3. Plumbing $ Contact Municipality)
Note: �lininuun fee=$ ( V• Y)
1. Mechanical (FIVAC) $
5. Mechanical Other S Endow check payable to
6.Total cost S 00 (contact uumicipality)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 Containcd,in this
application is true and accurate to the best of try knowledge ana understandi'nlg. �Q� �A
Plc is m[ nld/ssihIt t t r Title Tdepha ne Na1. Date
P iL7lJlY � (,
Street Address y/To vi State Zip
41
Municipal Inspector to fill out this section upon application approval: 3
Nante D. c
CITY OF SM.ElM, NLXSSACHUSETTS
BUIMLNG DEP AIMIENT
120 WASHIINGTON STREET,3'a FLOOR
' TEL (978) 745-9595.
RuX(978) 740-9846 _
KINtBFRt EY DRISCOLL
MAYOR THOdtaS ST.PIERRH
DIRECTOR OP PUBLIC PROPERTY/BUMDING COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Ptumbers
Applicant Information Please Print Leaft
Name(Business,Orginizatiorvindividual): �_STE AU 1 liCl.G f
Address: 4 AAASSON S-C
City/State/Zip: SAt� � AA Phone hi:
Are on an employer?Check the appropriate box: 'type of project(required):
1. I am a employer with In 4. ❑ I am a general contractor and 1
employees(fLll and/or part-time).* have hired the sub-contractor b. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 1 7. 9 Remodeling
ship and have no employees These sub-contractors have a. ❑Demolition
working.for me in any capacity. workers'comp.insurance. 9. ❑Building addition
(No workers'comp.insurance 5.'❑ We. a corporation grid its
required) officers have exercised their 10.0 Electrical repairs or additions
J.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.(No workers'camp. C. 152,§1(41,and we have no 12.0 Roof repairs
insurance required.]t employees:[No workers'; MCI Other,
comp,insurance required.),.
•Any applicam that chucks bran$1 moat al:w fill out the wain blow showing their workers'compensation policy infurmotfon.
I fnmauwn m who submit this affidavit indicating they am doing all work and then hies outside"ntmemrt must aahmtt a new amdevit indicating such.
!Contractor that chuck this box matt attached an additional sheet showing rho name of the subcoatruten and their workers'camp,policy infannanan.
l um an-employer that Is providing ivorkes'compensation firsurancefor my employeez Below/s I/repolfcy and fob sty
lllforinal/am
insurance Company`lame. NYVC L• rz> �)`Id�iCInG(.�2�5 ��5 LS✓. r��
policy 4 or Seibins.,L'icc.. N: ` h�S0125-- 45a2.,11 L' I' 'I a Expiration Dater�A(7
Job Site Address: "I.:J /NYL7t.JM / .> t. City/State/2:ilr...'SAL-t�A"-
Attacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to wcure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to SI.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to$230.00 a day against the violator. Be advised that a copy of this statement may bo forwarded to the Office of
Investigations ofthe DIA for insurance coverage verificaliun.
/du hereby cerrlfy a der t/ pubts and penulde of perjury that the hifurrnatlare provided above;Y true and correct.
1, { Dat 3
OJjlcfal use duly. Do rat write in urea,to be completed by city or town ajjirlut
City nr'ruwn: Pcrmit/f.lecnse* __
Issuing,\uthority(circle one):
1. Board of Health 2. Building Department J.Cilyfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
b.Other
Contact Person: .._ _ __—_.. phone ti:
(
CITY OF S.IL E,tiI, Ws.: CH usETTS
'' t.•tLnt:rc
\� { l?O Cr/13F16VGTON STREET, 1"E LOOZ
'rFL (973) 745-9595
KI1fOHRLSY DRISCOLL F X(973) 7.10.934.5
��.L�YO.Z T}lOSG1.9 ST.PtF.dtig
❑t.1ECTaR OF pl:OLfC PROPE47y/BCiLOL�IC CO1L�1155tO,VEQ
Construction Debris Dlspasa! Aft7davit
(required fbr all demolition :uid m'nuvatian%York)
In accordanca with the sixth edition of the State Building Coda, 730 Cj,,iR section ! l 1.5
Debris, :utd the praviaions of MOL a 40, S J4;
Building Permit hiis this wur!c shall issued with the condition that the debris resultin Ge dispused of in a properly licensed waste disposal g from
I11. S 150A. fauility as defined by,titCL o
1'hc debris will be trnnsportcd by:
7TRL NAVGIN6 -,,tT25NMIH6
(mina ut'hautur)
The debris will be dispo•+ed of in
_IRS A #ALX 6 +' 12�? YCLlM6
(namu or t�udit�)
I
.Sr ��AVow
(iJJrasa ur r.t,y6ty)
'i ranve'��parmit.ippli�urt