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38-40 NORTHEY ST - BUILDING INSPECTION l2r -7o `Z\ e Commonwealth of Massachusetts 3 F( 11 Department of Public Safety + — Iassachusetts State Building Code(780 CMR) __ i ding � Application for any Building other than aOne-or Two-Family Dwelling (This Section For ffici IUse Only) - Building Permit Number: Date Applied: ll I Building Official SECTION 1: LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 3 - `lo "('H-.?r5k 'yej .eM mF. 01y? 0 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❑ 1 Demolition IT(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? n Yes ❑ No fS' Brief Description of Proposed Work: eJ k C lC-emrtJ-� G'r I - GGr o !�(\ ✓L C! --u ell f r2_ f •rcSS C + ' G rx ✓ Tr;lA 'G SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY - Check L, rm if an Existing euflding Investigation and Ev__aluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): G Proposed Use Group(s)i SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) �� p0 S (� Z!t� Total Area(sq.ft.)and Total Height(ft.) �ef,ex Q' SGl^j SECTION 5:USE GROUP(Check as applicable)" - - A: Assembly A-1❑ A-2 Cl 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-s❑ 1: Institutional 1-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1 R-2❑ R-3❑ R4❑ 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 ❑ He\ ❑ IIB ❑ 1 ILIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) • - Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public Check if outside Flood Zone Y Indicate municipal A trench wi of be Licensed Disposal Site required Qor trench or specify: Private❑ or inden[ify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way:/ Hazards to Air Navigation: MA Ili ton lammi si n R .i�+� I r�•�:-g: Not Applicable L3 Is Structure within airport appro area? Is their review con, ? or Consent to Build enclosed❑ Yes❑ ar No Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: I Use Group(.$): \ Type of Construction:� Occupant Load per Flour: Does the building contain an Sprinkler System?: 10x Y, .,.r\Special Stipulations: SECTION 9: PROPERTNOWNERAUT IORIZATION ' ante and Address of Property Owner M F) Ply x Name(Print) No.and Street City/Town ;Zip Property Owner Contact Information: MaC-C 1r, C°l2 Asa 76 q I Title 'relephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix.2) If buildingis less than 35,000 cu.ft.of enclosed space and/or not under Constmction Control then check here and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control NamRegistmnt) Teleph me No. e-mail address Registration Numbe c< �cdlrl� 5( - C, I t M — /� Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Ct,,,,cjes 1<olel.,T vl�c� �( k MVcx rarl Conn par Cl,bces (1a (v Name of Person Responsible for Construction License No. and Type if Applicable �i S s�-ccllr� s1— `5Oj-ems 0.15, a �aJ Street Address City/Town State Zip q,?$ joaQ -IM 3 C 12ntQ�� g �, � �_ll ,coal Tele hone No.(business) Telephone No. cell —�— e-mail address SECTION II:IYOKKIif:S'COMt'LiNti;1 IlON hNSURANX.J.AI'f1DAVU 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 $ p SrG G Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ h G6(i appropriate municipal factor)_$ 3. Plumbing $ pc o - 4. Mechanical (FfVAC) $ Note:Minimum fee=$i_�_(contact municipality) 5.Mechanical Other $ Enclose cheek S able to 6.Total Cost $ payable saO (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 jDate application is true and accurate toI the best of lily kilo ed'e and understanding. Please print and sin narrlie Title Telephone No. S t-MTO_C t �cl� M A ), 0 Street Address City/Town ,AJState Zip Municipal Inspector to fill out this section upon application approval: ��tr.-s6. r+V /It Name Date I �_ >ru CI"I'Y OF SiiuEm NPLSSACHCSETI'S Bull-DING DEPARTNff-NT �h ft xl 120 W.{SHLNGTON STREET, 3'FLOOR TFL (978) 745-9595 F.A-x(978) 7.30-9846 K.INCBERLEY DRISCOLL IYAYOR T'HONW ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BCILDLNG COWAISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �f t/ Please Print Legibly Name (nusine>.Grgan ization;Individual): C� c e��S K fur— �� Address: ��5� CGA( (ram City/State/7ip: ::5elie(l Me- G(q! a Phone S7Fs Arc you an employer?Check the appropriate box: . 'type of project(required): 1.El I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ v construction -. niploycLs(full and/or part-time)P have hired the sub-contractors 2M 1 pm a sole proprietor or partner- listed on the attached sheet.t 7• Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its , required.) officers have exercised their 10 R Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I,Mlumbing repairs or additions myself. (No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) t employees. (No workers' BE Other cmnp. insurance required.) •nnv appli..ml flea checks box At must also rill out the section chow showing their wotken'cumpensmion policy inliumalion. 'I Lsmenwtw-n whir submit this atndavit indicming they ae doing all work and then hire uulside contractors mtal snhmit a new atndavit indicating such. :t\nunctura thus chuck this box must attachuf an additional sheet showing fix none of the subtontnctotr and their worker'camp.pulley information. f uni un enrpluyer that is providing Ivorkers'contpeasatiarr inturuncefor my enrployeer. Below is the policy and job site infurmation. Insurance Company Name: I Policy b or Self-ins. Lit, N: I -Wo- 41�1 P)I g$ 7 RC -/, Expiration Date: 9 Job SiteAddress:k 3T —le nd(tl,t/ .511— CirylState/Lip: Se��!t-t �R G(ti'70 Attach a copy of the workers'compensation policy declaration page(slowing the policy number and expiration date). Fallttra 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 SI.500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of ' Iuvcstigutions of the DIA for insurance coverage verification: /flu hereby certi� he '' s wrd penulrler a crjriry that the injurnmllon provided''Gove is true and curreeL � Date' Phonc 1: Official use only. Do ooQvrite in this urea, to be completed by city or lows officiuf Ciry or Town: Issuing Aulhorily(cir'cle one): �r 1. Board of llcallh 2. Building, De'parnnent 3.Citylfnwn Clerk 4. Electrical Ltspector 5. Plumbing luspettor 6.Other Contact 1'ersnn:_ Phone it: ry,r CITY OF sm.Em. AXSSACHUSETTS t' ' ©DIMING D EPA R't?MNT 120 WASHNGTON STnET 3w FLOOR 'ML (978) 745-9595 Fmc(978) 740-9844 IU3tHEI2I.EY D2ISCOLL INLAma Trtoacis ST.Ptaslts DIRECTOR OF PUBLIC PROPERTY/at:mnLNG CONNISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Coda, 730 CMR section l l L5 Debris, and the provisions of NfU c 40, S 54; Building Permit k 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 �IGL c 1 It, S 150A. The debris will be transported by: (name ofhauler) The debris will be disposed of in C\OC SJ jt C Cl 1 (name of facdity) (aJJressoYtaciGty) _ signaturno 'Pei mitappficant�— ,life - - I -ew �o,n .a Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 132449 — _= Type: Individual Ti-i77 Expiration: 2/7/2015 Tr# 236049 CHARLES E. KNIGHTJR CHARLES KNIGHT 5 EAST COLLINS ST. �= SALEM, MA 01970 Update Address and return card.Mark reason for change. --- � Address E Renewal E] Employment Lost Card SCA 1 Co 20M-05/11 C�1zo tCoo�rrnzareu�ea �o�P/�Caaoac�xcueCt� License or registration valid for individul use onl Office of Consumer Affairs&Business Regulation g Y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 'gistration 192449 Type: - Office of Consumer Affairs and Business Regulation / xpiration E 2!7/2015 Individual 10 Park Plaza-Suite 5170 -- Boston,MA 02116 -` CHARLES E. KNIGHY`dR�j •- CHARLES KNIGHT 5 EAST COLLINS ST Y g •�,p SALEM,MA 01970 -- Undersecretary t Not valid without signature