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3-21 PARADISE RD - BUILDING INSPECTION
S O The Commonwealth of Massachusetts W Department of Public Safety MassachusetlsState Building Code(780CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) O 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) 3- Zf �r�;u Rd ICI-. �a-W a ; > - �3-Zi �� No.and Street City/Town Zip Code Name of Budding(if applicable) SECTION 2:PROPOSED WORK Edition of MA Slate C le used_ If New Construction check here❑or check a6 that apply ht the two rows below Existing BuildingefRepair Alteration ❑ Addition❑ Demolition O (Please fill out and submit Appendix I) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being suppliml as part of this permit application? Yes ❑ No ttj 3 Is an independent Structural Engineering Peer Review required? Yes O No Brief Description of Proposed Work: &alhepme,.t F Fu 11E M r.fief 0 / eddy__ SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANCE IN USE OR OCCUPANCY - Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O Existing Use Group(s): ProposW Use Group(s): SECTIONS:BUILDING HEIGHT AND AREA -. Existing proposed No.of Floors/Stories(include basement levels)&Area Per Floor,(eq. ft.) Total Arco(sq.ft.)and Total Height(ft.) SECTION S.USE GROUP(Check as a licable) A: Assembly ❑ A-2❑ Nightclub ❑ A-3 ❑ A-1 O A-5❑ B: Business ❑ E Educational O F: Facto 'F-I❑ F2❑ - H: High Hazard H-1❑. H-2❑ H-3 ❑ H4❑ H-5❑ 1: Institutional f-(❑. 1-2❑ 1-3❑ hl❑ M: Mercantile❑ R: Residential R-1❑- R-2❑ R-3❑ - R-4 O S: Storage S-I❑ S-2❑ U. Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) L\ ❑ IUD I 14\ ❑ IIBO I IIIA ❑ IIIB ❑ IV Cl 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❑ Indicdte municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: Private❑ or indentify Zune: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: 'JA I hitorii_ 14o�w�k_ Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No❑ 1 Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition ul Qnlc Use Gnmp(S): Type of Construction: Occupant Load per I'hntr. Dias the building contain an Sprinkler System?: _ Special Stipulations: (plat i_� a�i3 Tu 1�-UrnovQ1 i SECTION 9: PROPERTY OWNER AUTHORIZA"TION Name and Address of Property Owner NaJ Ct,,,,k S. Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title 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 thin 35,0M cu.ft.of enclosed space and/or not under Construction Control then check here O and ski Section 10.1 10.1 Registered Professional Responsible for Construction Control. 6-lvnn EICcfYi� -�nr;re�/u»» Name Registr cat) Td phone No. a-mail a Registration Number // R[rra; /1 Street Address. ty/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:1\.'ORKERS'COtvIPENSA1 ION INtiUltANCIi APFIUAvrj, 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 budding permit. Is a signed Affidavit submitted with this application? - Yes 0 No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and binterials) Total Construction Cost(from Item 6)_$ I. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical 5 appropriate municipal factor)=$ 3. Plumbing $ d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical Other - $ Enclose Y check payable a able to r,6 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. /14 fob�r9t�✓ SOP -ems /ov 1 3-/4 Please print all sign name Title Telephone No. Date i/ �rsn'k /2/ Oa 16D Street Address Cil /Town S,G,u_e� Zip Municipal Inspector to fill out this section upon application approval: Name Date Details Page 1 of 2 i t The Official Website of the Executive Office of Public Safety and Security(EOPSS) SEG. Sys. — S- LI C,. Mass.Gov Home State Agencies C_C� W t ozy Ur,ensee Details ullName: W P GLYNN ender: er Name: ir-a dress: ddress 2: ity: PLYMOUTH tate: MA ipcode: 02360 o nt U 'ted fates icense mit O: 0 4 License Type: Security Systems- S- License Profession: Regulated-Activity Date of Last Renewal: 5/7/2015 Issue Date: Expiration Date: 5/7/2017 License Status: Active Today's Date: 3/1/2016 Secondary License: Doing Business As: GLYNN ELECTRIC Status Chan e: L n Renewal nr icensee: vies- ernan ez, Melvin Relationship: Supervisor License No: CC-011934 Licensee: BRAMHALL, SAMUEL R Relationship: Supervisor icense No: CC-009409 icensee: CLARK, KEVIN W Relationship: Supervisor icense No: CC-009411 icensee: Demers, Aaron J Relationship: Supervisor License No: CC-012645 Licensee: DERKINDEREN, MICHAEL P Relationship: Supervisor License No: CC-009406 Licensee: LABELLE, WILLIAM Relationship: Supervisor License No: CC-011935 Licensee: LECLERC, RYAN R Relationship: Supervisor License No: CC-011936 Licensee: LOFGREN, DANA J Relationship: Supervisor License No: CC-009408 Licensee: LOUNGE, MICHAEL T Relationship: Supervisor License No: CC-009410 Licensee: PICKERING, JON D Relationship: Supervisor License No: CC-011937 Licensee: POOLE, DAVID E Relationship: Supervisor License No: CC-009407 icensee: POOLE, DAVID E Relationship: Supervisor icense No: CC-012415 icensee: REALE, CRAIG A Relationship: Supervisor icense No: CC-011938 icensee: ROBILLARD, JONATHAN D http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=191622& 3/1/2016 Details Page 2 of 2 f Relationship: Supervisor License No: CC-012435 Licensee: SCOTT, JEREMY D Relationship: Supervisor License No: CC-012701 Licensee: SPROUT, SEAN P Relationship: Supervisor nse CC-011939 Illne No Discipline Information ocumen um Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=191622& 3/1/2016