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19 NICHOLS ST - BUILDING INSPECTION (2)
The Commonwealth of Massachusetts Department of Public Safety �JU 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: 6ExistingBuildh 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) -fir d l S S'd- Sill?r *IA— e I`�7d City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK tate Code used If New Construction check here❑or check all that apply in the two rows below Repair Alteration Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied its part of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: JQ2 2r Ice�+-ram- 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): I Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) ^� Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A=1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1.1❑ 1-2❑ 1-3❑ 1-4❑ NL• Mercantile❑ R. Residential R-113 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION"TYPE(Check as a plicable) IA ❑ IB ❑ ILA ❑ IIB ❑ HIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system El required is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: %I-A I,Livt n Gnnnu 4i m It �_��sp,i r r.:t.•,.5: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed ❑ Yes❑ or No❑ 1 Yes❑ No ❑ SECTIONS:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SE—t�;C T-t� 0 •(fox LIs�IZ SECTION 9: PROPERTY OWNER AUTHORIZATION ! Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: / ss�,, _ Ri/k7}'1 - S cr 97�Z6s-s1-I-? '�.wzz@goC. 0 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 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 /ham_ Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor - Company Name Name of Person Responsible for Co truction License No. and Type if Applicable Street Address City/Town State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:W0RKI'I6'CObIPFNSA'I[ON INSURAN('E-.41°F11:to\Vrf M.G.C.c.152.9 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) Total Construction Cost(from Item 6)_ L Building $ Z4010 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3. Plumbing S f/� - 3.Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality) S. Mechanical Other $ Enclose check payable a able to 6.Total Cost $ 1 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby 11 t"AWK9 the pains and penalties of perjury that all of the information contained in this application i e to es my knowledge and understanding. e-c 7 PI pu t ag4vign mune Title Telephone No. Date CC 'A�.X �lZ. � .� �'L d1'97o 0/92o Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date Y it) CITY OF S ILEm7 NL-1SSACHUSETTS F BUILDING DEPARTMENT 120 WASHEVGTON STREET, 31D FLOOR TEL (978) 745-9595 FA.r(978) 740-9846 KI\fBERLEY DRISCOLL THoNw ST.PiERRE AAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CO>L\If55(ONER Workers' Cornpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly VaII1ClBusiness0/r�ganiratioro'Imlividual): Address: ✓ 0 City/StateiZip: :E� _. 414 0/476 Phone 737,Kf_ — y�5_/ � Are you an employer?Check the appropriate box: Type of project(required): 4. 1 am a g contractor and 1 \ I.El I am a employer with ❑ general 6. ❑New conswetion employees(full and/or part-time).* have hired the subcontractors 7, ❑ Remodeling _.❑ lama sole proprietor or partner- listed on the attached sheet.t ship and have no employees These sub-contractors have 9. Uv r+emolition working for me in any capacity. workers' comp. insurance. 9_ ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.Cg-I�Ilumbing repairs or additions myself.(No workers'comp. c. 152, 91(4),and we have no 12.❑ Roof repairs insurance required.)t employees.LNo workers' comp. insurance required.] I].❑ Other •Any applicant due chocks box at must also fill out the uctiun below showing their woAcri cumpenaatiun policy inllamatium 'I tumcowncu who.submit this affidavit indicating Ihcy arc doing all work and Ihcn hire outside cuntncton mot submit a new aaidavit indicting such. $'imtmerora Out check this box rout acach d an additional shral showing IN none of the subKontnetors and(heir workers'comp.policy information. l ant an employer drat is providing Ivorkers'cotnpeasailon insurmtcefor my eatployers. Ldelaw is the pulley and fob site iujonnminn. Insurance Company.Name: �� Policy H or Self-ins. Lic. H: ko/ �f dC 1 s O(�/ / C.) Expiration Date: lob 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 Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a ine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to$230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Oflice of Investigutiunx ol'the DIA for insurance coverage verification. /do hereby certify fur a t nal a /ury that the inform an ation pravido�d7�b�ve is to a d correct si ',rllltl rC' Dal J I Phtlne 1: Official use only. Do nut write itt this area, to be completed by city ur fown officiuL l City or To%vn: _ .__ Permitti'lcensc Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.Cityfrowu Clerk a. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: __ _. _ Phone 8:�._--___--_._ CITY UE S�1LEm, tiL1SS:ICHUSETTS ?' ©UILONG DEPARTJLErT 130 WASHLNGTON STREET J w FLOOR Tt!L. (978) 7.45--9595 FAX(978) 740-9844 KIJBERLEY DttISCOLL NL-%YO1 Tl;OAASSTPIERRa DIRECTOR OF PUBLIC PROPERTY/BCILOLNG CO.%ajISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CM section l 11.5 Debris, mid the provisions of NIGL c 40, S 54; Building Permit f#this work shall be is issued with the condition that the debris resulting from l It, S I SOA. disposed of in a properly licensed waste disposal facility as defined by tMGL c T lic debris will be transported by: rn / J C le (name ut'hauler) The debris will be disposed or in (name of Facility) — -----(aJJress of IScilb i signature of permit applicant date