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33 NORTHEY ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts ?' Department of Public Safety Massachusetts State Building Code(780 CMR) Ulf 0 Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 33 000A,%og S� SAkem MA 016110 —1 VW woa%L. A No.and Street City/Town Zip Code Name of wilding(if apph able) 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❑ I Alteration ❑ I Addition❑ 1 Demolition Please fill out and submit Appendix 1) Change of Use ❑ 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? Yes ❑ No ❑ Beef Description of ProposeA Work: -4ice1 44"6-0 o-Al covtjL N t of lxy 0 sae C'4VAA?u4 i Fi2� t 7 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 basemept 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 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ T R. Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Haza w rds to Air Navigation: MA Historic Conission Review Process: 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: Does the building contain an Sprinkler System?: Special Stipulations: C� SECTION_ 9: PROPERTY OWNER AUTHORIZATION Name and Addre s of Property Owner 'ih �ciot 331�oa�¢y S� Snlew. MR 014igo Name(Print) I No.and Strict City/Town Zip Property Owner Contact Information: Nat 04 Go jA, ASSOc. - - - Title J 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 property owner'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 0 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Cke,s GAnNi 931-�_ Yw 151742l Name(Registrant) Telephone No. e-mail address Re�stration Number 100non 021$6 µiC Street Address City/Town State Zip Discipline Ex iration Date 10.2 General Contractor Jekgjee Mas'rc¢ Company Name <i46., (Ix11 1lktk C'S 1- (U) 104385 Name of Person Responsible for Construction /� License o. d Type if Applicable 1 ®00.tS RV. WPSThaeD V1 q Old Street Address City/Town ' State 1 Zip! 118. 4`i1z133f 91H _65> _2323 SCK111 �cM4;(. Csl!. Telephone No. business Telephone No. cell - e-mail ar address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 5,000,00 Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact m nicipality 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 accur e o the b `y knowledge and understanding. (leis to dwttca 181- 3 4 �z / Please print and sign name Title Telep ne No. D e 100 r-NFL s-y- S�w�q� M4- 219 Street Address City/Town //��� State Municipal Inspector to fill out this section upon application approval: "`70_,0 ' -r//? Name Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot#for locations for which a street address is not available) 1 1` ze ' S4. S411 efy-, M A 0141`10 es;o1epi - l/3ooayve No. and Street J City/Town Zip Name of uilding(if applicabl For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ ,Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) ,�. CITY OF SM .M. -'LxSSACHusFTTS BUHML IG DEPART\t&N4T 120 WAsmNGTON STREET, r FLOOR TEL (978) 745-9595 FAX 7 740-9846 KINIBERLEY DRISCOLL MAYOR THomAs ST.PIFM DIRECTOR OF PUBLIC PROPERTY/BUMDI dG COSI,\QSSIONER. 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 ibis 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: SQR,)ice 1MAsTt?, name of hauler The debris will be disposed of in : ])isAaskce ASSCC.AAeS Lw . (name of facility) I Oc3, maple 5-F ✓ r, (address of facility) signature of per t applicant Lt l Z I IZ to dcbris fLdw CITY OF S.UI Eltii; ixassAcHus=s B1.II.D .NG DEP kRT% NT • 120 WASHINGTON STREET;Vo FLOOR 'ILL.(M)745-9595 FAx(978) 740-9846 KI\iBERLEY DRISCOLL THOMAS ST.PW-M MAYOR DIRECTOR OF PUBLIC PROPERTY/BI:II.DING CONNISSIONER Demolition Permit Sign-Off (Supplement to permit application) 1 hereby supply the following releases as part of the application for a permit to demolish the structure located at -r -s i�4 and shown on the Assessor's Maps of as being on Map # Block # Lot# The sixth edition of the Massachusetts State Building Code, 780 CMR, states in part: "A permit to demolish or remove a building or structure shall not be issued until a release is obtained from the utilities, stating that their respective service connections and appurtenant equipment, such as meters and regulators, have been removed or sealed and plugged in a safe manner." Utility to be Notified Notice Received hy Date Received Gas Telephone. Electric Public Utilities (Municipal) Health Department Fire Department Other - Other- Demolition debris hauler: 5 , Nla f, Location of licensed demolition debris landfill7���N Signature of Applicant Date: 4 z 12= Signature of Owner Date: This sheet must be returned to the Inspections Department along with a completed application for a permit, a site plan, and any other applicable information and fees. Denioperm.dot. • Massachusetts- Department of Pul-lic Safetq :Board'of Building Rcguiltions and Standards, '61►J Construction Supervisor^License 4x License: CS 104365 ` 'r STEPHEN CVZZIE RE �. 2 DORIS RD WESTFORD MA01886 c Expiratwn: 4/1&2014 .. � t f umrniaionu Trif: 104385�:. - The Commonwealth of Massachusetts ;Print Form .; Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Disaster Associates Inc.d/b/a ServiceMaster Address:100 Maple Street City/State/Zip:Stoneham, MA 02180 Phone #:800-649-6369 Are you an employer? Check the appropriate box: Type of project(required): 1.21 I am a employer with 50 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, M Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance? required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no CN employees. o workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name:Travelers Indemnity Company Policy#or Self-ins. Lie. #:UB-9946L529-10 Expiration Date:10/27/2011 Job Site Address: 33 NoAke St. City/State/Zip:4Ss1G+�L Y`lR 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 cer ' un er th d e enalties of Cerjury that the information provided above is true and correct. Signature: --- - - Date _ `1 12 1 2 Phone#: 17 $ I-4114u 0 33 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector r 6. Other Contact Person: Phone#: