27 NORTH ST - BPA-13-108 Q
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
,^ Building Permit Application for any Building other than aOne-or T ily Dwelling
1�\v\ (this Section For Official Use Only)
\11 Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which e 0
2-ilL A✓Pa-?�Y V• SAIeM JV4 .
No.and Street City/Town Zip Code Name of Building(d 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 Repair Alteration ❑ 1 Addition❑ 1 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 as part of this permit application?"Yes ❑ No
Is an Independent Structural Engineering Peer Review required n/9 `t/ Yes ❑ No
Brief Description of Proposed Work: R2 14 �n �y([r � e. ?`
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 ❑ Awl❑ A-5❑ 1 B: Business E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R. Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill ❑ IIA O IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
i Permit., Debris Removal:Licensed Dis oral
Water Suppl Flood Zone Information: Sewage Disposal: TrenchSite❑
Public Check if outside Flood Zone❑ Indicate municipal A trench will not be � `
Private❑ or indentify Zone: or on site system❑ requved�or trench or spccify: 05Te
permit' enclosed❑ AfA�
Railroad right-of-wa Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicably Is Structure within airport ap oath area? Is their review com 1 ted?
or' to Build enclosed❑ Yes❑ or No Yes❑ No
SECTION 8:CONTENT OF CERnFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
4-wddllQe ay a-5' A !0A&f - m ,
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information,'
h7AI'/ANA! ?ANiP,IAr-1S lio--N57 9 i - -
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 propertyownei 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❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
game(Registrant) TeN e-mail a dr s o
Registration Number
Uo�` � v� Qlc�)
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
0A\\� ��3�ArlC
Company Name
\S 1,cW-A�1L C5 - �`130 %-,,a
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) Total Construction Cost(from Item 6)_$ qi 1W
1.Building Building Permit Fee=Total Construction Cost x JI (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $ 1qq
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (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 owl/dge and understanding.
Please print and . Tide Telephone No. *atsign name
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
it
CITY OF S.U.EM, INLsSACHUSETTS
BUIIAING DEPARTMENT
• + 130 WASHINGTON STREET,3so FLOOR
T L (978)745-9595
FAX(978)740-98"
KJ,,jBF3RIEY DRISCOLL
MAYOR 'It•loatAs Sr.PIERas
DIRECCOR OF PUBLIC PROPERTY/lIUMDLNG COMMISSIONFIt
Workers' Compensation Insurance Affidavit: BuildersiContractots/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Busitxss/Organization/Individmi): L
Address: �.i
City/State/Zip: `dAk y_v`. v-%A-- DftdPhone #:
Are you an employer?Cheek the appropriate boa: Type of project(required):
1.0 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
/1 am asole pmpriemr or partner-
(full and/or part-tine).' have hired the sub-contractors
2_
® listed on the attached sheet.t 7� ❑Remodeling
ship mid lave no employees These sub-contractors have 8. 0 Demolition
workingfor me in an capacity, workers'comp.insurance.
Y P tY� 9. ❑ Building addition
(No workers'comp.imurance 5. ❑ We are a corporation and its
w 10.❑ Electrical repairs or additions
required.) officers have exercised the
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself(No workers'comp. c. 152,§I(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks boa#I most also till out the sectioa below showing their wotkets'compensation policy information.
I lnmeowoen who submit this affidavit indicating They are doing all work and then hits outside contmctm mien submit a new affidavit indicting such
:C,nn s,.n than cheek this boa most attachsd an Wditiomal sheer showing the name of the sub•contructon and their workms'comp.polity infumation.
i am un employer that it providing workers'compensation Insurance jar my employe!" Below is the policy and jab site
information
insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Sire 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 requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.0o and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invcsfigatians of the DIA for insurance coverage verification.
i do hereby cert y//YYnder the pains and penahies of perjury that the informadan pruvided shave is true and eorred.
Sign�nnre' ZE Date � V2_
t
Phone#;
Official use only. Do not write in this urea,to be curnpiered by city or town ojftciaL
City or Town: Permit/Llcense#
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
tr'
i CITY OF S. .ENI, TN'LA sSACHUSETrs
BtiILDING DEPsRTJMNT
• 130 W 1SHINGTON STREET, 3�FLOOR
TEL (978) 745-9595
FA.Y(978) 740-9846
Kl.\IBERLEY DRISCOLL
MAYOR TI ohw ST.PmR&E
DIRECTOR OF PUBLIC PROPERTY/BUUMING COMWSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the six edition
sixth ed hon of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
5 �'V�>
CW
(address of facility)
Aa
r^� signature of permit applicant
v 7i
date
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