23 NORTHERLY - BUILDING INSPECTION cOH,1„Dl„vedtrn Of Ntassachusetts
I Department of Public ti,lfety
It iskl is St.11r liuil,h ng Cods( RII I'.\IIt)
Building Permit Application for any Building other than a One.or l'Wo-Family 1)welling
(I his So(lion For Official Use Oniv)
liuildiult Prnnit Number _ _ _ Dale.\pplied: ._. ._..._ Building Oifirial: _
-- tiFC'I TON 1: LOCA LION B'lease indicate mock M and l.uf N fur locations for Which a street address is not.Iv JilJble)
�3 _No t eel SAtl-evion _
No. .ind Slrrat r Cify/fo%vrl /ill Code Name of lituldilig(if 1pplirablc)
SECTION 2: PROPOSED WORK
I ,1111"ll of \I:\Stah•Code used . .. if.Vole Gnl.atruetiun rhvek here❑ur i hrek all Ihdt a , ,
f! I\' in Ibc two nnvs beh'W
F\istilfg liuilding ❑ Ropair O Alter•Ition ❑ Addition❑ Uemolilioo Cl (Pl,•aae till uut.uld xlbnlit.\ppendis I)
Chani;v of Use ❑ Change t If Orr upallcy ❑ Other
\ry building plans anJ/ it Lou..I rut lilit tit klllllvll1.4 beillg Sit pplle,l,ls p.lrt of this permit application? Yes ❑ NoIs Jo 6ldependcut Strudur•d Engineering Prer a icw rcyuired? Yv.Y ❑ No ❑—/
lirict Destriptimi of Vruptrvrd Work=.._� �(f/�r//1/` %it/ _�Zo��/�Q�' �A/t,� S""Y4/. /^f•
SECTION J:CONIFL6fE THIS SLCI'ION IF EXisTING BUILDING UNuIiRGO1NG RENOVATION, AUDITION,Olt
CII,INGE IN USE OR OCCUPANCY
Cht•rk here if•nt fsisting Building Investigation Jnd Evaluation is enclosed (See 7,41)C.\IR
F\isling Use Grutlp(s)t
SECriON at BUILDING MIGHT AND AREA
Existing Proposed
No,of Flours/Stories(include basement levels)h Area Per Fluor(sq. it.) U
I'utal .\rva(sq. ft.)and rotai Height(it.) 20G0
S F.C""PION 3: USE GROUP(Check as a IicJbir)
A: Assembly:\-I ❑ A-20 Nightclub ❑ ,\,1 O :\-all A-i❑ B: Business ❑
F: EJucatiunJl ❑
F:
I: PIcto _ ItIII IHazard If-] K: H•2❑ it-3 ❑ II-4❑ -30LI f ResdntiJ R-I❑ ft-_❑ t,t❑ t-4 O-I ❑ - I,tO I aInrtihdidnJlI nHlc❑
S: Sturige S•I ❑ S2❑ U: Utility❑ ti eciJI Use❑and lie,l.kv dcxrl by I,Inv,:
';jWL ml Use
SECTION fi:CON;tiI'RUCr10N 1'YI'F. (('heck as a+ likable)
I.\ ❑ 111 ❑ IlA ❑ IIB O III:\ ❑ Hill O IV ❑ %'A p % it (3
NIA`fION 7: SfrF INPORMA F ON(refer to 790 C\llt I111.0 fir detids on each item)
1Va ter Su pp ly: 19uud Lune InforinJtiun: Se Wage UispusJl: french Permit. Hebris Renurvil:
Public Clcl:: ,k itouhldv I-lood Lon"❑ Ill,tan.•nu111a ip It❑ \ Ircn,It %kill not lie I Irru,rd 1)ly,sol gilt•ClPm.11o❑ „r md,rdill' /rah•. err loin-d ❑r,r ln•mIt or.pr%itt..
.. nr„n ale.\.Ion ❑ I,rnnu i\cm lord ❑
Itdilnra,l righ Lui „'•'Y Ila/ar, to.— .\ac i..niun: q
\, 1 \I,Idn.rl4r❑ h �umt�r�nrtlnn.m It.r r kh.u'ra' . .
1'" PP "• 1,Ihtvr I lit
,rnrl,Ir trJ'
rt ,v�rw h,Mudd rm lt,.r,l t7 1r, ❑ „r\'trO lr. ❑ \ , L
tiFllfU.V ,Y; CU.VII..VI (IFLI-It IlP1C'.\rF UP U( ( LI'.\..V( Y
I Jill, I , l l ylv ( .r
1' lope.,I t, u.Irm tern ,`tr ul,.ml l , .id
14r . Ihr bnJJinl;„ nl.un.w `,I,rin Ale r�%yrm' `-Ion rd ' Iii•ul.iln,n.
I
- -
`,I.CIll7N I I'It171'T111Y IIIVNrR \Drill lltlL,\-I ION
um niJ .\tLln ss nl I r hrrlt lhs ntr /` CI .. . �r /Y.�
af
IC t�.r.v __�/ . Q-� Cil\i (own /ip
Nam (I'mit) Nil ,lilt[Strccl
I'roprrtY 0%,nerr Clin�ttae,t 6tft,nnafion: d � �_-
� "J v_�'C.._ ---- -- 5-_.—_•.—C1._— '- o-nlail ,ttldress
ItltphonCNil (husincss) rvlrpluureNo. (a•II)
11 tppliceble, the pn+prrly owner htrbt aulhvu u ��- r/ ✓
_ City
Nance Street Addn�ss /roty� _. titil Lip
lo,trtoo the pra+rrty owner's behalf, in all m.ttter.s relative to work aulhoriacd by this buillin7t Vcnnit annlicatiun.
SECTION 10;CONS-I'RUCrION CON I HOL(I'lease fill out Appendlx 2)
If t+u ildin•iv Ics.+than 13.0011 cu. it.A vndosed s•ace enJ or not under Construction Ctwtrol then check here 0;utd skit 5vchon to.l
1().1 Ite•istered Prufessiunil Responsible for Construction Control
rcle bona Nu, c-mail address Registr t( Number
Nante(RC};istmnt) p Yn Of t o I GS
/V26aJ 3�✓ r`� �� (2a c..--)(� _ Discipline L\plr.i urn Date
---�--- city// 0_ St,tic Lip p
Strict Address Y
10.2 General Contractor
err y sr�rf� a.�x � 1�l,vsT UGC'- -1
Conivan ,Name
License No, and Type if Applicable
Name of Person Responsible for Construction _
ti r\ddress City/Town State Zip
lrcev/7 le-
-mail address
------
rcit, +hone No. Itunticss
rile+hone No. mil e
SECTION 111 ttt �i;•.rl<:r i r�\Irl v,)nt+� I V,I n;.)�I I AI l u��'.\'u M.G.L.e. 152. 75C 6
11
A 1Vorkers'Cumpen twtion lulu ranee Aifitlav it from the \IA Department of Industrial Accidenb must be corn pleled end
submitted teilh this application. Failure it,provide this affidavit will result in the denial of the issuance of the building permit.
Is a si fined Affidavit submitted with this a lication? Yes 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and \laterials) rural Construction Cost(from Item 6) '
I. Buldin S Building Permit Fee `Total Construction Cost x ____(Insert Iten
'. Eicti'Iriial S apprmpri,ite nunticipal Ltctor) 'S
4 1'Iunlbing nt fta%
\Icch nuuticln .
Note: \lininnnn fee ' S_—__ ctnl
(
1. anical (IIVAQ S
i. ALt hanical ([[heel Fncluae check payable to �
t. total cost 'S Q (coolact nuutictp,lity)end tvritc check nund.er nrre -._. .. . . . .
SLCrON ):SIGNA I UIM OF BUILDING PLIMIrr AI'11L c, N*r
lit rntvriml, 11.\ n.unu below. I hcrcbv •otest under the p,�in.c.uld pvn,tlties of prrju ry that all of the uli nnenon cont.unrJ in Ibis
•'pPlic el it'll iv it -0011 act orate to the of my kno"I'd)le.owl till erst.utding.
'F e I It I'l • \0 11a1e
I'Ir.ie• print .ntd „7;n n.tmr
liLJ/�C /—
\Iwti:ip.tl lo,pecoir to till out this svctinn upon ,ppliialion npprncalo I+.ilr l
\.mu•
i F CITY OF SALE,%1, , L-1SSACHL;SETTS
BluazmG DEPARTMENT
120 WASHINGTON STREET, 3w FLOOR
TEL. (978) 745-9595
FA.Y(978) 740-9846
KI.%tBERL.EY DRISCOLL
MAYOR. THONLks ST.PiERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONL�IISSIONER
Workers' Cotnpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information q / Please Print Lepib►v
Name(BusinesaOrginizaiiomindividuaq: r 1 y Gf 7 Gam./
Address: 21 G
City/State/Zip: PI Z, / °� honelt:
Arc you as employer?Check t • propretoe box: 'type of project(required):
I. I am a employer with 4. 0 I am a general contractor and 1 6. New construction
employees(full and/or part-time).' have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have If. ❑Demolition
working forme in any capacity. workers'comp. insurance. 9. 0 Building addition
(No workers' comp. insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'cutup. C. 152, g 1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. (No workers' 13.0 Other,
camp.insurance required.)
-Any applicara dvat chucks box of must also till out 1hd uctiuo bdow showing their workers'compensaion policy infurmatiom
'I hwteowners wha suhmil this alliMvit indicating they ate doing all work and then hire uuridtecammetms most submit a new afetdavil indicating such.
=Curnmown that chuck this box must attachod an additiorwl sheet showing the name of thb sub.nmhacton and their workers'ramp.policy infommtion.
l um as employet that is providing workers'compensadae insurance for my ernp/uyeex Below/s the policy and Jab site
informadz;m
Insurance Company Name: / i ��/S C�
Policy u or Srlf--ins. Lie.N: ? WA L 10� / Expiration Date:
Job Site Address: �J �y�Ir `f ! Ciry/State/Zip: /✓/��� ��
Attach a copy of the workers' compensatlon pulley declara spoke(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 of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a line
of up to S'_50.00 a day against that violator. Ile advised that a copy of this statement may be forwarded to the Oliice of
Investigutiwns of the DIA fur insura cc coverage verification.
/du hereby c•rrrij pains unJ es o rjury r/mJ r afonnotfaa pro vidrJ above is iru unJ carr el
slim t ` - a 11
Phone
Official use wdy. Do not Ivrile in//its area,to he completed by city ur iowa aIJicirrl
City nr'1'utrnt _.. Permit/hlceme
Issulag.Autharity(circle one):
1. Board of Health 2,Building Ilepartineat 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.0dicr
Contact Person: .. .._ ___._.._. Phone It:
(
' CITY OF S UI EtiI, i LA ssIkCHusETTS
BuiLDLNG DEPARTMENT
N 130 WASHNGTON STREET, 3AD FLOOR
TEI.. (978) 745-9595
F.Ax(978) 740-9846
KINtgFRt RY DRISCOLI
MAYOR THo.Nw ST.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BCILDNG CONI]MISSIONER
Construction Debris Disposal Affidavit
(required for all 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 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
1 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signatu of permit applicant
date
JcbrismYJx