208 NORTH ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Department of Public Safety
\Iessai husetts Slate Building Code(780 C'AIR)
Building Permit Application for any Building other than a One-or'I'w F, roily w, ' ' %g
(I his Section For Official Use Only)
Building Permit Number: -__ Date:Applied: — I Building Official:
SECTION 1:LOCATION(Please indicate Block B and Lot N for locations for which a street adqws not available)
'NO.,utd Street City/Mown Zip Code Name Of Building(if applicable)
t SEC'nON 2:PROPOSED WORK
"17dition Ol MA State Cale used If New Construction check here❑Or dteck all that apply in the two rows below
Fxisting Building❑ Repair-❑ :kitcratiun ❑ AJdition❑ Demolition ❑ (Please fill out and submit Al+pendis I)
Change Of Use ❑ Change Of Occupancy ❑ I Other ❑ Specify:—_—' _
Are building plans and/or construction d(Wl1II1C11tS being supplied as part Of this permit application? 1'es ❑ No -----_
Is an Independent Structural Engineering Peer R•view rec wired? � I' Yes ❑ No(QI
Brief Description Of Proposed Work:- Re� )a L" W KI�(�wn
fI Uv 4'r1rr, )-
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 78O CNIR.N) O
Existing Use Group(s): Proposed Use Gruup(s):
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
NO.Of Flours/Stories(include basement levels)&Area Per Floor(Sy. ft.) 4
Tula):Area(sq.ft.)and Total Height(ft.) N
SECTION 5:USE GROUP(Check s applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ rA-1 ❑ A-i❑ B: Business ❑ E: [educational ❑
F: Facto F-1 ❑ F2❑ If: High Hazard H-t ❑ H-2❑ 11-1 ❑ 1-I-4❑ 11-5❑
I: Institutional 1-1 ❑ 1-2 C3 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 It=_'❑ R-3❑ It-I❑
S: Storage S-1 ❑ S-2❑ 1 U: Utility❑ I Special Use O and please describe below:
Special Use
SECTION 6:CONSTRUCTION 7MPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIAO IIIB ❑ IV ❑ I VA ❑ VB ❑
SECTION 7:SITE INFORh1A'LION(refer to 780 CNIR 111.0 fur details on each item)
Water Supply: Hood Zone Information: Sewage Disposal: Trench Permit Debris Reutnvil:
A trench %sill not be Licensed Disposal Site❑
Public 6Check if outside FInoJ /_on%� Indicate numiiipal� I ,
myuinal ❑or Ircndt or spec if1':.". _
Private❑ or indentily Lone: -___—_— ar On site syshmt ❑ permit is enclosed ❑ g /
wk1M E . 14
.WaS.
Railroad right-of-way: Hazards to .\ir Navigation:
..\ol :\pplicdhle�, Is Structure within airport opproarh,Oea? Is Ihrir review rongdcleJ'
.v Gntscnt lO Hit lid enclosed ❑ \es❑ nr.No❑ I Yes❑ No ❑
SI[Cl'ION 8:('UNl'li N'T OF C•F.It'1'IIICAII[OF UCCUI':\NCY
Iidown nI Code: - _. ('se Gnmp(s(. _ - fvpc Ol C�melnn ton: OuuP•utt l..ad per l irn+r. _
11nes the buildingcanlammi Sprinkler}%stem? Spotot Stipulations _ _
SLC'11ON9: PROPFR'IY OWNERAUTIIORIZAIION
N,unv and Wdress of I'ngn•rh'Owner --
_kJal _ akc2� _ m4jf�- ---- ------ -
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
I itle telephone No. (business) Telephone No. (cell) c-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/rows State Zip
Io act on the property owner's behalf, in all matters relative to work authorized by (his bmiding Permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
1f bu ildin p,is less than 35,00t)cu.ft.of enclowd s ace and or not under Construction Control then check here O and skip Section W.l
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. c-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
COQZ411he uJ 10
Company Name
En I . ?Tjoclgla y�S7
Name of Person Responsible for Construction License No, and Type if Applicable
1 q Q�z�YA 0 �uxLv Mil alb 1S
Street Address City/Town State Zip
�P7>St,gggb7 _�ng�lboc,tips@gma) � • Co:�,
Trle phone No. business Telephone No. cell a-mail address —
SECTION II:\n ga.nt: p I7rpN I \111 H. M.G.L.c.152.1 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 Ihm 6)=S_
I. Building S 15,00 b Building Permit Fee=Total Construction Cost x_(Insert here
'_. Electrical S y 1000 appropriate municipal factor)=S
3. Plumbing S
4. Mechanical (HvAC) 5 Nate: :\lininnun fee=!S__(Contact nmaicipality)
3, MCChoniCal Other S
-s Enclose check payable to _--_
n.Total Cast S (V (contact municipahiv)and write check number here
SECTION 13: 'IGNATURE OF BUILDING PERMIT APPLICANT
BY enuring My nanpe below. I hereby attest under the pains and penalties of perjury That,dl of the information Contained in this
application is Irue and accurate to the best of my knowl • ;e, nd understanding.
1'I0 pse print anJ sign name Title rch phone No. Date
Unit Address Cil\'i fnpci� Stale /i p
I
Municipal Inspector to fill Out this section upon application approval: ___.__—___________._.__-._
Name
1
CIn OF SIUE.N[a NvWSACHUSETTS
1, r BUILDING DEPART\LENT
120 WASHLNGTON STREET, 3oa FLOOR
FAX(973) 7d0.9846
K _NIBERi.EY DRISCOLL
%LAYOaq T wmAS ST.PIERRB
DIRECTOR OF PUBLIC PRO PERTY/BU MDING COSLUISSION ER
1Vurkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumber$
A a illcant information Plcase Print Leaibl
.Nitinc illu.tiiws.to(Lwniratiom[ndividual);
Address: �ak aq--L-Z-A City/State/Zip: CJt -\� Phone K: 9 / D-7�i c/SIJ S -Z
Are
eetyou an employer?Check the appropriate boa: Type of project(required):
I.el I am a employer with,_ 4. C1 I am a general contractor and 1 6• New construction
dmployees(full and/or part-time).• have hired the subcontractors
2.0 I am a sole proprietor or partner. listed on the attached sheet i r• CRemodeiing
.'hip and have no employees These subcontractors have H. 0 Demolition
working for me in any capacity. workers'comp,insurance. 9. Building addition
[No workers:comp. insurance S. El We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing ail work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [\o workers'Bump, c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.) t employees. [No workers' l7.❑Other
cutup. insurance required.]
•,airy applihsnt dust chucks box rl must Awt rill out Phil wctioo Wow showing their workcn'compensation policy inlbrrnotion.
'I Lvneuv oas who whnnit this amdavit indicating thcy ore doing call work and then him outside contraction mint mhrrtit In.a1YTJa,it indicting rich.
:("'-I Coln thor check this box own mxhal on additiurul shut shuwing the none of the subaunlrKWn and Phalr workcn'comp.policy infomutlon.
I am an employer that is providing workers'compensation insurance for my employees. Below/s the poHry and job site
infornradon.Insurance Company Name:��/`���
75
Policy 4 or Srlf--ins. Lic. 0: Expiration Date:
tub Site Address: �6-� k:iI;Z+ G-91A21 MA City/Slate/Zip:
Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under.Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a
tine up to S1,540.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
,)fill'to SIM(10 a day against the violator. Re advised that a copy of this statement may bu forwarded to the OI'lim of
Investigations ol'the DIA 1•or insurance coverage vcriticaliun.
/du/rerrby ceryfyrrnJure mV.J V n ter of perjury that t/re infunrrudun praviJrJ aqb ve tr true uaJ
iwd correct.rcorrect.( ') 1 `
im 1)
�� _
['Mine, � �SZ4�i b7
Ol/iciui use only. Do not write in this area,to he completed by city car town )jJhiuJ
I
City nr'I'usvn:
iIssuing Aulhurily (circle one):
1. L'oard u1 lleallh !. Ruildin, Department .1. Cityi town Clerk 4. F.leetriatl hrspectur S. Mmobing Inepeetor
(.other
i. Contact I'crtun:
Information and Instructions
.\lassuchusetts 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."
�IGL 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 sub-contractors)name(s),address(es)and phone numbers)along with their cerificate(s)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
he 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 Officlats
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Of the aftdavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permitilicense 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 currant
policy information(if necessary)and under"fob Site Address"the applicant should write"all locations 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 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 ctc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
]'he Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
0111ce of Iavestlgations
600 Washington Street
Boston, MA 021 l 1
Tel. 9 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
www.mass.gov/dia
CITY of S.u.Ear, Akss:tcfj[ sETTs
BULDLNG DEP.1RT1tE`T
120 W.IiHLVGTON STIMM. ym FZOOtI
rM (978) 74S.9595
Kl103FRLFY DUXOE.L FAx(978) 740-9946
,tiUYOII hicum ST.PtEt"
DIAEU08 0P PULIC P1tOP8p7Y/8(:Q,pL%4C CO-%O11SSlONE1l
Construction Debris Disposal Aftldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the Stata Building Code, 780 CMR section I 1 I.S
Debris, and the provisions of MOL c 40, S 54;
Building Permit p Ihis work shall be is issued with the condition that the debris resulting from
111, S I JOA. disposed of in a properly licensed waste disposal facility as defined by XIGL c
�n\Thhee debris will be
transported by:, )
I V)CICe .
(name u1 hauler) vv�i
The debris wi 11 be disposed of in
(no aortT rfacilltyl '
a r rulbly)
uynamre ofpermrt ipphcmt
life —