18 OCEAN TER - BUILDING INSPECTION (2) -7 2 G — 1 Lf L+ 9 y S(p$ 7— RECEIVED
The Commonwealth of Massac usetts
Ill� Department of Public 26 P Safe�jj,,nn y�R 11' U
Mussuchusetts State Building Code(7ft ,,,I7
Building Permit Application for any Building other than a One-or Two-Family i
(This Section For Official Use Only)
Building Permit Number: Date Applied: Budding official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address' not avail
-Tffr...�/iA ll,/�.Ci` SRU O( f-( 0 uqg lTon�v Hn�':nt✓rr
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 0 Repair 81 Alteration V�- Addition❑ Demolition ❑ (Please fill out and submit Appendix t)
CIi:inge.of Use ❑ Change of Occupancy ❑ { Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No t9, `
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ILJ
Brief Descriptionof Proposed Work:��Cou r�'/'� 2 $-r ' o, >-�a -�-T' ( _f (Z ✓t�o� d�,)L
0. I b�'YFc,.e o,-- .,_. ve/.f k- 3 I-.,'�.e 1 (��-( I u1 � rb� h a,s<�'.f-,e I' w 1'f-� 1 b•e d�a v�l
s t.�o'✓� A.- n 4—r� c.�es�. k , Nu C4 mil` Y-1
SECTION 3:COMPLETE THISSECTION 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 CNIR 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)&r Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-t ❑ A-2❑ Nightclub [IA-3 ❑ A4❑ A-5'0 B: Business ❑ E: Educational Cl
F: Facto F-t❑ F2❑ 1 El: Hi h Hurd H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional,)-t❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑- R: Residential R-111 R-2❑ R-3❑ R4❑
S: Storage S-'1 ❑ S-2❑ U: Utility❑ 'i- Special Use❑and please describe below:
Special Use: -
___ SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑---- IB ❑ IIA ❑ I1B ❑ Hu, ❑ HIB'❑ 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: A trench will not be Licensed Disposal Site'f�
Public 1� Check if outside Flood Zone W_ Indicate municipal required SLor trench ors ec p' fy:
Private❑ or indentify Zone or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: tii,\.J,-i� r n c-ipuni si n tt c_q i n ids:
Not Applicable f� Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No K Yes❑ No 43,.
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Tvpe of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: W Special Stipulations:ul
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Prb"pec-ty;O.ivhar
I III"Name(Print) p No.and Street City/Town Zip
Property Owner Conlact III ifomiation:� 0101 / I
4-78 65-7 if If?_ r-h'�wy✓ICF
Title Telephone No.(business) Telephone No. (cell) a-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 s ace and/or not tinder Construction Control then cheek here and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
144N^( � ty tjo✓ �Y
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address fi City/Town 1 State Zip L
q7 y'j _ U�7 l Z r�Tw o ilk COY1C.�n�, .ul
Telephone No. business Telephone No. cell e-mail address
SECTION 11:l\1ORKERS'CONII'I?uSA HON INSURANCE AFF'IDn\b'I'I 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 12rNo ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor 6 2 ?a
and Materials) Total Construction Cost(from Item 6)_$ z
L Building $ d D 0 t7 Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ 2 l b0 appropriate municipal factor)_$
3. Plumbing $ /O o a p
a. Mechanical (HVAC) $ Note: Nlinimum fee=$ (contact mn�ci ity
S. Mechanical Other $ Enclose check' able to
6.Total Cost $ 6 2- payable
(o � (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 e be t of n nowledge and understanding.
r✓ Z\� 'f—�i r ��7 ef7f s 'l �t r 4Z 3/z ,/ y
P se�,,t�r t and sign m me "Fittlltee Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
)
CITY OF S'UEm, A-1SSACHUSE17s
13L=LNG DEPART\LENT
120 WASHLNGTON STREET, 3w FLOOR
�h TEL (978) 745-9595
F-jLX(978) 740-9844
IC!\tBERL.EY DRISCOLL
�UYOR Trgo,%LAs ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/St:ILDLNG CO\W(SSIONER
Construction Debris Disposal affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition Of the State Building Code, 730 CMR section 111.5
Debris, wid the provisions of ivIGL c 40, S 54;
Building Permit A is issued with the condition that the debris resulting From
this work shall be
l 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by rVIGL c
The debris will be trans�portcd by:
1 (rainC Ut h�Ullfl
The debris will be disposed of in : p
(. (naine of facility)
(address of tacility)
s' natureofpermitapplicmtt --
'We
CITY OF SAL.ENI, 2)INSSACHUSETTS
�p o
BUILDING DEPAMIEIiT
120 WASHINGTON STREET, 3w FLOOR
a TM (978) 745-9595
F.ax(978) 740-•9846
KINfgFRT F.Y DRISCOLL
MAYOR THOh41S ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUI DLNG CONNISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t rlicant Information /�� Please
ee(PPrrint Legibly
Name (13utiness:Orsanizatiorvindividual): -,M l f V ,0 Vte-r
Address: r� �7 ��
City/State/Zip: ^I�eV /" V� C( fl) Phone #:
Are you an employer?Check the appropriate box: 'rype of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
niployees(full and/or part-time).* have hired the sub-contractors
2. am a sole proprietor or partner. listed on the attached sheet,t �• �-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.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself. [No workers' Gump. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
camp. insurance required.)
•Any applicant our checks boe pl must also fill out the xcGen daowshowing thclrworketi compensation pulicy inli,rmation.
'I(omeowm.•n who submit this affidavit indicating they arc doing all work and then hiro outside contactors mtut submit a new affidavit indicating such.
=C,,ntmctoo thus chcak this box must aaachod an additiowl shot showing the mmnc of the subtantndon and their workers'comp,policy inrar t ation.
i am an employer that is providing workers'contpensatlan insurance for my employees. Below Is the policy and Jab site
information. 1- R
Insurance Company Name: ✓�U_4
Policy#or Self-ins. Lie.#: G t� ?`f �' Expiration Date: �/�
lob Site Address: ! DG24"_ "—`� City/State/Zip:5 °Zf-—, //0
Attach a copy of the workers'compensation policy decWatlan page(showing the policy number and expiration bate).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminai penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as weal as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the 011ice of
Investigutions o)•the DIA for insurance coverage verification.
I rlo hereby c ❑fy ui el,;d e pg and penalt/es of perjury titan the information provided ab/ove is true and correct.
Sinn uurt �r e ., Date: 3 ` 7
L. U /J C
Phont 1: � � � 1 I,
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitA,lccnse
Issuing Authority(circle one): � -
1. Board of health 2. Building Department 3.C'ityfruwn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ .. _ . .._.. ...._ Phone
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