0083 NORTH STREET - BPA-15-350 TRIUMPH DLRSHIP �
G� l�'� 3 Z �916rao
� The Commonwealth of Massachusetts
�4� Deparhnent of Public Safety
� O A4assachusettsSt.ite BuiWing Code(7SOCMR)
Building Perniit Application for any Building other than a One-or Two-Family Dwelling
� _(Chis SecHun For Official Use Onl )�
M BuilJing Pcrmi[Number: Date Applied: Building O[ficinl:
� SECTION 1:LOCATION(Please indicate Dlock k and Lot#for locaHons for which a slreet addresa is not available)
� � t�- � �'�2tL•�.Pf'H( G��i��cV,i �
— No.and Sfreet City/Town Zip Code Name of 8uilding(if applicable) _
I�� �SECfiON 2 PROPOSED WORK � �
Edition of MA State C�le useJ_ If New Construclion chiek here 0 or chak all Iha[apply in the�wo rows below
I' Existing Building 0 Repair❑ Allrration ❑ Additiun O Demolifion O (Plc.ue(ill out and submit Appendix t)
�
Ch:inge uf Use ❑ Change uf Occupancy ❑ Other ❑ Spt�cify: -
Are building plans:md/or constmctiun ducuments being supplieJ ns part of Mis permit applicetion? Y��s No ❑
Is an IndependentStructural Engin��ering Pecr Review reyui Yes ❑ Nu ❑
Brief Descri tion o Propose�l urk:. 7 " IJ �
�.i�
SECTION 3:COh1PLETE TFIIS SECTION IF EXISTING BUILDING UNDERCOING RENOVATION,ADDPCION,OR
CHANGE IN USE OR OCCUPANCY
Ch�ek here if an Existing Building[nvestigaHon and EvaluaHon is endosed(See 780 CbIR 3!) O
Esisfing Use Cmup(s): Proposiwl Use Group(s):
, � SECfION 4:DUILDING HEIGHT AND AREA �
� � � �� Existing Propused
Nu.af Floots/Sturies(include basement levels)&Area Per Fluor(sq,ft.)
Tutal Ama(sy.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a plicable)
A: Aseembly A-1❑ A-2❑ Nightclub ❑ A-3 O A-4❑ A-5❑ B: �Oueiness ❑ E: Educallonal ❑
F: Facto F-I ❑ F2❑ � H: Hi h Huud H=l❑. H-2 O H-3 ❑ H-1❑ H-5❑
1: InstituHonal 4l❑ 1-2❑ I-3❑ I-!❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-0❑
S: Storage �SI❑ � S2❑ U: Utility❑ Special Use O and please describe beluw:
. Special Use:
SECfION 6:CONSTRUCiION 7'TPE(Check as a licable) - -
(A ❑ 16 ❑ IIA ❑ IB � IIIA ❑ IIIB ❑ IV ❑ VA ❑ VOO
SECiION 7:SITE INFORAIATION(refer to 780 CMIt 1llA for detaiis an each item)
4Vater Supply: Flood Zone Infarmatian: Sewage DispasaL• Trench Permih Debrie Removal:
Public❑ Ch�Yk if uutside Fload Zune❑ InJicate municipal❑ ���rench will nut be Licensed Dispos.I Site❑
myuired�or trench uFspecify�
Privale❑ or indentify Zune: uron site system❑ vi�mit is enclused❑ '
Railroad ri�hf-obtvay: I�la[ards fo Air N�vigation: \I\I li:h n� �_,unmisci n I �i•,�I'n,c�•..:
_.....__ _. ._ :__.._.. . _
Nut Applicable❑ Is Stmcturc within airpurt appronch area? Is N�eir review cnmplehd?
or Cunsunt to Build enclosed❑ Ycs O or No❑ Yes❑ Nu O
SECTION H:CONTENI'OF CERTIEfCA'IE OF OCCUPANCY
Gditiun uf Ci�de: U.ee Group(s):_ Type of Conslrucliun:_ Occup�mt Load per Plnur: _
Dues�hebuildingcantain.mSpriuklerSystem?: _ ti�,aialSlipuleliuns� --
Sovv � SfL(
, ���j�`�1'k-.�
�
SECT[ON 9: PROPERTY 04VNER AU'CHORIZA"fION •
Name and AdJress of Property Owner �/� b
,�'�Z/,f3JS.4'l�lr� 9� c'Uc�'7Z1SY ���( �G� (�l� �i
Name(Print) No.and Street � City/Town Zip
Pruperty Osvner Contact Infon ation: � )
�i G lzu t.c� (ow�-S �-t= �`�S"rl.d 5��� ���2��-��
Ti�le Telephone No.(business) Tclephone No. (mll) -e-mail address
If applicable,the property owner hereby authorizes ,f a r,� �/J L�, �,// ��
�/c: ��--vGtitf� '7�1V°,�n/Ci7 �`t`7"z"> .�rTC.:rEc,jcLcr•C 7�
Name StreetAddress City/Town State � Zip �
to act on the ro er owner s bchalf,in atl matters mlative to work authorized b this buildin ermit a licntion.
SECTION 10:CON5TRUCT[ON CONTROL�Please fill out Appendix 2J
If buildin is Iess thin 35,000 cu.ff,of encloseA s ace and or not�mder CorehvctionControl then check here�and ski SecNon lU.l
lU.l Re istered Profeasional Res onsible for ConstrucHon Conhol
Name(Registmnt) Tclephone No. e-mail:�ddrcss Registration Numbcr
Strcet Addrcss City/Town S4�te Zip Discipline Expiration Date �
102 General Contrutor � � �
�j � .� C: 7 . �
Cump.�ny Name
��rGl�i.1l�Pt?% d'7-�''J�'� ' C7(�
Name of Person Responsible for onstructiun Lic nse Nu. �md Type J Applicable
7�/U� �", �)� Q�� ��n �� 0� •.
Strcet Ail resL✓,�,�/ l [l. _ r- �ity/TowF`G" Ci �`�/'�Zi
�__ ���� �S�Z. �iiC-�(?.Ca
Tcic hone No. business Tcle hone No. cell e-mail addmss
SECfION Il:VVQR1�Eh5'COAIPENSAI'IQN WtiUlt:\.NClS:�PF'IUr\Vl'I' M.G.L.c.152 25C 6
A Workers'Compensefion Insurance Affidavit from the MA Deparhnent of[ndustri:il Accidents must be cumpleted anJ
submitted withlhis appiicntion. Failure to provide this affidavit will result in the denial of the issuante of the buIlding permit.
Is a si ned Affidavit submitted�vith this a IicaHon? � Yes O No ❑
' SECfION 32 CONSTRUCI'ION COSTS AND PERMIT FEH
Item Estimated Costs:(Labur � �
and Matcrials) Total Constmction Cost(from Item 6)_$
�' �P�`�Nx � �'�pV Building Permit Fee=Tutal Construction Cust x_(Insert here
. - 2.Electrinl $ y�-GC7 ' appropriate municipal factor)�$
3.Pluuibing � �p .-�
d. �fechcmical (HVAC) $ Nute:Mininwm fce=$ (contatt ntunicipalitY)
5.MiKhanical Other �6 Enclose chcck puyable W '
5.Total Cust � S�C7'-� (contact municipality)and write check number here
SECTIO�N 13:SICNATURE OF 6UILDING PERMlT APPL[CAN'1'
6y cnlering my name below, 1 hcreby attest wider t and penalties uf perjury that all of the informatiun cuntained in this
application is true and accurate m the b 't uf in edge �)ler�s� Jin �S ��
��c.�� _ ��7�Sqo�SS
�. .2�fG ��f_ " _
Ple�ue�rint and sign nome ' Tide Tclephune Nu. it•
`7S �ll��:� S�-. �X�4-�'8.� S<�-t-�� �� �`��iSK_
Stmet Address City/'fuwn , State Zip �
i�lunicipal Inspector to fill out this section upon applicativn approvaL• '�*!/'+*" '�7.0
Name Dalc
. ' � , �
The Commonwenith ofMassachusens
� - � DepartmentoflndustrialAccidents
:� _ , I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
�\'orkers'Compensation Insurance Affidavih Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Intormation Please Print Le ibl
N2TI18 (Business/Organiza[ion/Individua]): �� � j
Address:� ���( �Tr (J� �C7�}'�
City/State/Zip: �':i�Q�/l /t'� Q� Phone#: . '7� C7 �
nre yo�a�empioyer?Cneck me approprtare box: Type of project(required):
1.�I am a employer wi[h employees(full and/or part-[ime).' 7. ❑New conshuction
2.�I am a sole propne�or or partnership and have no employees working for me in $, �Remodeling
any capaciry.[No workers'comp.insurance required.]
3.Q I am a homeowner doing all work nryselE[No workers'comp.insurance required.]i 9. ❑Demolition
10�Building addition
4.�I am a homeowner and will be hiring contracrors m conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.�Elecfical tepatts or additions
proprietors with no employees �
12.Q Pl�mbing repairs or additions
5.�I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑RoOf repairs
These sub-conhacrors have employees and have workers'comp.insurance.=
6�We are a corpora[ion and its of�cers have exercised[heir right of exemption per MGL c. 14.❑OthB7
152,§1(4),and we have no employees.[No workers'comp.inswance required.]
*Any appliwnt that checks box#1 must also fill out the sec[ion below showing Iheir workers'compensation policy infortnation.
r Homeowners who submit[his affidavit indica[ing[hey are doing all work and then hire outside contrac[ors must submit a new affdavit indicating such.
IConnactors that check this box must attached an addi[io�al shee[showing the name of[he sub-contractors and state whether or not those enti[ies have
' employees. If the sub-conhactors have employees,they must provide Iheir workers'comp.policy�umber.
I am un emp[oyer tha[is providing workers'campensation insurance for iny einployees. Be[ow rs the policy and job si[e
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(showi�g 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
ancUor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up[o$250.00 a
day against the violator.A copy of this statement may be forwarded[o the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby c nd _ . in erjury that the information provided above i,true an correct.
� � �
Si ature: Date:
Phone#:
Officia!use only. Do not wri[e in this area,to be completed by city or tawn officiaL
City or Town: Permit/License#
Issuing Authority(circle oue):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
I �
Information and Instructions ` �
Massachusetts General Laws chapter 152 requires al]employers to provide workers' compensation for their employees.
Pursuant to this sta[ute,an employee is defined as"...every person in[he service of another under any contract of hire,
express or implied,ora]or wntten:'
An emp[oyer is defined as"an individual,parmership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and induding the lega]representatives of a deceased employer,or the
� receiver or trustee of an individual,par[nership,association or other lega]enti[y,employing employees. However the
owner of a dwelling house having not more than three apartrnents and who resides therein,or the ocwpant 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."
'. , � � . 4 � .. . ..
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 insurauce coverage required."
. Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its politica]subdivisions shall
enter into any contract for the performance of public work unti]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 checidng 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 Parinerships(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 Indasfia]
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retumed to the city or town that the application for the peimit or license is being requested,nat the Depar[ment of
Indusfial 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 lis[ed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure[hat the affidavit is complete and pnnted legibly. T'he Department has provided a space at the bottom
of[he affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure[o fill in the pemuUlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pernvUlicense applications in any given yeaz,need only submit one affidavit indicating current
policy information(if necessary)and under`7ob Site Address"the applicant should wtite"all]ocations 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 pemvts or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or perntit not related to any business or commercial venture
(i.e. a dog]icense or pernut to bum leaves etc.)said person is NOT required to complete this affidavit.
T'he DeparhnenYs 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
Revised 02-23-IS www.mass.gov/dia
G�TY OF SALE MASSAC�IUSE775
� �
c� � 1 BUILDIIVG DEPARTMENf
\ ' 120WnsHIIdGTOIVS19iEET,3'�F7.00R
� HI
�L.(978)745-9595
FAx(978)7449846
KIlv�ERLEYDRISaOLL
MAYOR TxoMns ST.P�xtt�
DIREGTpR OF PUBLiCPROPERTY/BLIILDING COIvIlvIISSIONER
. Construction Debris Disposa/Affidavit
(required for ali demolition and renovation work)�
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit#! is issued with the
condition that the debris resulting from this work shail be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
��i��-S�� �
(name of hauler)
The debris will be disposed of in:
���-�r�C�,�-ii,�
(name of facility)
���L�-�".:�7r" � ��
(address of facility) �
Signature of applicant
� � �-� � �5
Date
+ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - � � � �
r �
� • � J �
� � � �
� ' � J � J
; R R�pP S Aoa�me,Ina
� Hodo.edos s At�u.
' � tta6�60iaat
, � B�Lm,lf�molb N976
� New �ull-Height Partition , ��„
' 2" x4" � 16" OC , �'"��""�
1/2" CsWB TBP, Screw �`"
Attached Both Sides
; ; �.�
� ' rra 15-031
�
, �� �i � , f�4/29/15
, � � y� , .. e. ..�.. .�
, � , � ,
� i � �
� ,
� � / �
� i �, ,
; � i 0. ' —
� �---------------�---- �
� �i �------ � � , ��
; ,' � ��y ' auwma,ve �ealer
� Shawoom Mocif�cauons
i I I \ '
� I I �
� ��_���
� i� I I � � B�, s�
' � I I � � �,M�w�.�
� Fvat Floar Plan
� �
� � as noted
� m.w.�
- - - - - - - - - - - - - - - - - - - - - - - - - ;, - - - -, - - - ,; - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - � A1 . 1
1 First Floor Plan, 1/a = I -� �
rre 6-031 (04/Fi)