87 NORTH ST - BUILDING INSPECTION $1 C) cac t 012
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The Commonwealth of Massachusetts
Department of Public Safety Z01b NOV —2 P 2: 49
Massachusetts State Building Code(780 CMR)
Family Dwelling
Building Permit Application for any Building other than a One-or Two-
(This Section For Official Use Ord
Building Permit Number: Date Applied; Building Official: tL Z tSe
SECTION 1:LOCATION(Please indicate Block q and Lot N for locations for which a street address is not available)
_ 7. /rOATI, 5 I a efn Vo l urn r nl�e-
' 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❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 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? i 2�tl Q Yes ❑ No
Brief Description f Proposed Work: 21
sl L aG? ice— tlC lrct'fe12 12/
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: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
l: Institutional 1.1 ❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ Rol❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION'[YPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ Hill ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Si[e❑
Public❑ Check if outside Flood Zone❑ Indicate municipal Cl A trench will not be P
required❑or trench or specify:
Private Cl or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: �lA_i.J� t ! ....... si�n a........ t ro •,,�:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Dues the build ng contain an Sprinkler System?: Special Stipulations:
crr« -f8l . 330 - VG5
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nan e and Address of Property Owner
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Name(Print) No.and Street City/Town Zip }
r
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner herebfyJ authorizes ,
7 II ^
cKY�r� Q evl lam- 7 J1 /7tiit4AS � �7hu M 0/4- a2 LI sj
Nurse Street Address City/Town State Zip
to act on the property owners behalf, in a6 matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If budding is less than 35,000 cu.0:of enclosed space and/or not under Construction Control then check here 13 and skip Section 10J
10.1 Registered Professional Responsible for Construction Control
/�
Ntnrg(Regis
ant) Telephone
e-mail Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - -
Company Name
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Name of Pers n Responsible for Construction License No. and Type if Applicable
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Street Add e s / *— ��Cfty/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'CONIPENSA'I ION 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 E3 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estunated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee-Total Construction Cost x (Insert here
2.Electrinl $ appropriate municipal factor)=$
3. Plumbing $
1. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ o 6, 6� (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 f my know] d understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
U1F www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Business/Organization Name:
Address: /� A::;6 w S
City/State/Zip: Wat-tlzah? IVA Phone#: 32�-
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
��'or part-time).* 6. �RestaurantBar/Eating Establishment
2. I am a sole proprietor or partnership and have no �7. ❑Office and/or Sales(incl.real estate, auto,etc.)
e ,,, employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required]* 11.11Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 1213 Other
*Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providin workers'compensation insurance for my employees. Below is the poll information.
Insurance Company Name: e- ,t &(I.) "e2ee,. Al (-1124 A ,
Insurer's Address: q� u�ln)
City/State/Zip: WO L16 G 0 , � (��
Policy#or Self-ins.Lic.# I? t�W//y/ / J Expiration Date: /1_ * gx - /
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 MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certift,,&mader the pains and pen ! e f perjury that the information provided above is true and correct./
Sienature: Date: /U �ly 2, �Ur
Phone#: `
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: PermitlLicense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City7Town Clerk 4. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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 your insurance company's name,address and phone number along with a certificate 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). 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 bum 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
Boston, MA 02 1 1 4-20 1 7
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Fenn Revised 02-23-15
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Construction Debris Disposa/Affjdavit
(required forall demolition and,.renovation worki
In accordance with the sixth edition of the State Bufi&w code, 780 aft Sectl liis Debri;
and the provisions of MGL 000,S S4; Builft Permit A is Issued with the
condition that the debris resu tiny►from this work shad be disposed of in a property iicensed "
waste deposit facility as defined by MGL c ill,S 1SQA.
The debris will be transported by:
l��sposG� moo. Ral eed sT
(name of hauler)
The debris will be disposed of in:
(name of fadlity)
(address of facility)
Signature of applicant
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Date
Massachusetts Department of Public Safety
#'�ulhiBtg,Re d.5tandarELHw
Construction Supervisor
License: av CS 62569
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James J Devine 4
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94 Adams Street iit f
Waltham MA 02iSi < .a
Expiration
Commissioner 02J08/2017
Unrestricted Buildings of any use group which Y
ca+tain'less;than 35.000 cubic feet(991rti)
enclosed space.
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Failure to possess a Nrrent edition of the Massachusetts
} state Building Cade is cause for revocatb^of this license.
i nvisit: w.v,.Mass-GOvIDP5
. �D�u�ingl�ormatio
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