27 PARADISE RD - BUILDING INSPECTION The Commonwealth of Mgt
Department of Public S l(S' YW SERVICES
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than ZQprt&kr2fyo-AVn4DyW&elling
(Phis Section For Official Use Only)
Building Permit Number. Date Applied: Building Official:
SECTION 11.:LO,CCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
Ojj nF�l'1 I�1�7[7 1�L1�1 N ADAS6 R A2 Ai
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
E)dsting Building Repair Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Iff
is an Independent Structural Engineering Peer Review required? Yes ❑ No Rol
Brief Description of Proposed Work W
P-+6rn_oy� INgi7n urn y o NO
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 HIIGHT AND AREA
Existing - .. - Proposed.
No.of Floors/Stories(include basement 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❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
L• Institutional I-1❑ 1-2❑ 1-3❑ 1-4❑ M. Mercantile❑ R• Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use: -.
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IN ❑ VA VB ❑
SECTION T 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 trenchwill not be Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify:
Private❑ or indentify Zone: - or on site system❑ permit is enclosed❑
Railroad rightbf-way:. T
- Hazards to Air Navigation: MA Historic Commission Review Process:
- Not Applicable❑ - Structure within airport approach azea? Is their review completed?
or Consent to Build enclosed Yes❑ or No❑ Yes❑ -No ❑..
SECTION 8:'CONTENr OF CERTIFICATE OF OCCUPANCY- .. .. -- .. ..
Edition of Code: ' Use Group(s): Type of Construction:. Occupant Load per Floor: "
Does the building contairi an Sprinkler System?: Special Stipulations: -
se�v�
to F C,i C-C_ .
SECTION 9: PROPERTY OWNER AUTHORIZATION
_ oName and Address of Property Ownerer.•� rsu
op
Name(Print) No.and Street Q�� City/Town I Zip
Property Owner Contact Information: t1U w�.
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)
bu ilding 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 Res onaible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
102 General Contractor
Company Naamll
uA^�M t.1.G
C'S-D�341pFr0
Name of Person Responsible for Construction License No. and Type if Applicable
PId.15O)C 131 iN yM—NowI
Street Address City/Town State Zip
Mb --%9A (tea 13 - O413 S-40% [sw dD +fir MOA, CM
Telephone No.(business) Telephone No. cell e-mail address
SECTION U:WORKERS'COMPEN5ACION 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)_$ 6df_ 0o
1.Building $ Building Permit Fee-Total Construction Cost x r7 (Insert here
2 Electrical $ appropriate municipal factor)
3.Plumbing $
4.Mechanical (14VAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 1 :SIGNATURE OF BUILDING PERMIT APPLICANT
By entering M name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
ap licatio i is I and accurate to the best of my knowledge and understanding.
�6l) 4p�nlSmN _ M5H�E4Z , 3�4-4o 3®I®r 7twi
Please prin d siRrt name , x itle � elephone No. Date
rM.
Street Address �l' F+`City/Town State Zip
Municipal Inspector to fill out this section upon application approval: 4
Name IV Date
aCITY OF SiUEN2 4 \WSACHUSETTS
BunmiNG DEP ART%1E1NT
1'_'O W�SHINGTON STREET,3w FLOOR
TEL (978)745-9595
FAX(978)740-9946
KIMBERi E.Y DRISCOLL THOMAS ST.PIFRRB
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING COWNfISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information p� Please Print Le 'hl
xs ga Name(BusinslOrnintionkllndMdual): I Y J�rj iu z,
Address: ff . r Ox �� I ,fin
City/StateiZip:►f totiT q�1.1_�Phone li: tp3"Tt 0'3 G&
Aree u an employer?Check the appropriate box: Type or project(required):
IM t am a employer with 3_ 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).- have hired the sub-contractors y
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7. M Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
workingfor me in an capacity- workers'comp.insurance.
Y P tY- 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 I I.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.0 Other,
comp.insurance required.]
•Any applicant that ducks box 91 muse also N nor the section below showing their workers'compensation policy information
1lo moe me who submit this affidavit indicting they are doing all work and then him outside wntrmaas mast submit a rxw affidavit indicating such
:Controcwm that check this box must attached an additional sheet showing the mane of the subtoottapon and them workem'comp.policy information.
I am an employer that Is providing workers'compensation insurance for my employees. Below is the polley and fah site
ittformatioiL
ea
Insurance Company Name: ` - �'1
Policy 4 or Self-ins.Lic.M V515-�o��r5 I A,A/� Expiration Date:
Job Site Address:7�l96 `iIIF A— 1t W A City/State/Zip,
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 S 1.500.00 and/or one-year imprisonmenr,as well 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 thata copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certify ur er d aims and penalties perfary that the information provided ab ve' true and correct
• a t re: '� AlPC �! LI,G Date• I
Phone
Ofliciol use ordy. Do not write in this are4 to he completed by city or town offtciai
City or Town: PermitllJccme#
Issuing Authority(circle one):
1.Board of Ileallh 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
i
CITY OF SAI. &M, INLkSSACHUSETTS
Bu LDLNG DEPARTMIRNT
�.< 120 W ASH NGTON STREET,31p FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
KI�fBERLEY DRISCOLL
TMAYOR THO&LAs ST.PmnE
DIRECTOR OF PIBLIC PROPER'rY/Buii DING C0\L%as$t0,iER
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
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
4`? �>� - & r�v�ri MA
(address of facility)
ignature of permit applicant
date
dcbrimftdm
No
Ju1211401:29p Bill Johnson—NPCM. LLC 603-6724262 p.t
ZZ -7
The Commonwealth of Massachusetts
4 %"y Department of Public Safety
�. Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a Om or Two-Family Dwelling
(T ids 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)
a7 H't11yL56 N�em A006�2�
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION Z PROPOSED WORK
Edition of MA State Code used If New Construction check here D or cbeck all that apply in the two rows below
Existing Building Repair Alteration ❑ Addition❑ I Demolition (Please fill out and submit Appendix,l)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of tlris permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ \'o v,
Brief Description of Proposed Work:
�EMAoyi t91 ISZ70 I16t V t
SECTION 3.COMPLETE THIS SECTION IF EXISTING BLILDING UNDERGOENG RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNfR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement 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 C Nightclub ❑ A-3 ❑ A-4❑ .A-5❑ B: Business ❑ I E: Educational ❑
F: Facto F-1 ❑ F2❑ M High Hazard H-1❑ H-2❑ H-3 ❑ H4 D H-5❑
I: Institvt5onal [-1❑ I-2 D 1-3❑ ]4 C 1 R: Residential R-I❑ 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 ❑ IIA ❑ HB ❑ ILIA ❑ IHB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SYM INFORMATION(refer to 780 CMRTI .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❑
PP y. 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: Hazards to Air Navigation: \iP,t fil:ion;(_aumYS5;"u a•vic;',oc'
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed C 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:
Jul 21 14 01:29p Bill Johnson—NPCM. LLC 603-6724262 p.2
SECTION 9: PROPERTY OWNER AUTHORIZATION-
Name and Ad ess of Property Owner u /00
� Z kywrou mac. W— s yY1 A
Name(Pratt) No.and Street V1,,,�.c City Town Zip
Property Owner Contact Information: Ak)P47_ T�
Me MfN "04 K? o�6 - H
Title Telephone No.(business) Telephone No. -(cel[) e-mail address
If applicable,the property owner hereby authorizes
Name - Street Address City/Town State Zfp
to act on the properry ownees behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
f building is less than35,000 cu.ft.of enclosed space and/or not under Construction Control then check here0 and ski Section 10.1)
10.1 Registered Professional Responsibie 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
0 .M l,lG Sce>roC F. Soa�lasz�l rC� t34* —
Company'Name
Ss,$-rt�c+�llP.r�oly
Name of Person Responsible for Construction License No. and Type if Applicable
P,d,�a 31 1Me rc-U �3 S7
Street Address Citv/Town State Zip
3- S _2i MISON AD ORANbIM c�
Telephone No.(business) Telephone No.(cell) _e-mail address_
SECTION II: 1ta.F:Si� nl-h'iSXt!On iCSL r,^,:� _t aF n;;\ypi. -G.L.c152.§25C6
A Workers'Compensation Insurance Affidavit from the NIA 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 c
and,vlaterials) Total Construction Cost(from Item 6)=$ 6d'000
1.Building $ 00 Building Permit Fee=Total Construction Cost x 2(Insert here
2.Electrical $ appropriate municipal factor)-I
3.Plumbing $
4.Mechanical (HVAC) $ Note: hlinimumfee=5 ?.!rw7 (contactmumcipality) I
5 mechattical (Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 1 :SIGNATURE OF BUILDING PERMIT APPLICANT
By entering name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
ap licanc ra and accurate to the best of my knowledge and understanding.
I -�-(J• �bt sm�l m611148az r -4
ftorPlease prin a nd si- name `f itle .` Telephone No._ - Date
Street Address City/TownNState Zip--�
Municipal Inspector to fill out this section upon application approval:
Name Date
Jul 21 14 01:30p Bill Johnson-NPCM. LLC 603-6724262 p.3
CITY OF &U-. N15 1Lx ACHUSETTS
BL:=NG DEPART\fEINT
12O WASHLNGTO.1 STREET,3aa FLOOR
TEi_(978)745-9595
FA.e(978) 730-9846
KIJiBERLEY DRISCOLL
MAYOR THOMAS ST.PWARE
DIRECTOR OF PUBLIC PROPERTY/BUIIl CO.%af3SSIONER
Workers' Compensation Insurance Affidavit: Builders)Contractors/Electricians/Plumbers
Applicant Information Please Print Lelzibly
Name(nusin zsOrSanezatio vindiv durl):�+���� fi
Address: �.rA0. �x
City/State/Zip:�[►p"Tga1.1 .f��L( Phone#:_ n3-4 L0
` Aree v a an employer?Cheek the appropriate box: Type of project(required):
{ 1 t am a employer with._3a____ 4. 0 1 am a genaul contractor and 1 6. Q New construction
employees(full and/or parr-time).• have hired the sub-contractors r
2.0 1 am a sole proprietor or partner- listed on the attached sheet i 7. Lit Remodeling
ship and have no employees These subcontractors have g- []Demolition
working for nu in any capacity, workers'comp.insurance. 9. '�
its Building additionaddition[No vio:keri comp.insurance 5. We arc a corporation and
required.] officers have exercised their 10, Electrical repairs or additions
3. 1 am a homeowner doing all work rigln of exemption per MGL 1 I.Q Plumbing repairs or additions
myself.j\o workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs
insurance required]t employees.(No workers' f 3.[]Other
comp. insurance renuired.]
•Any apptie ut elude checks brae rl must also Ca out the&serum below showing then workers'eompcsarion poucy infumtanoa
I iamurwnees who submit this ahSdavd indicating they arc doing all work and thm him outside contnstooy muss rdbmit a new affidavit indicting udh
Cnmtzeton that chock this box rntxa xuackd an ooiticsed aheet&),owing tf<name of'he sub eantrxwn and eheir workers'comp,policy iofarnution.
I um am naploper that is providtag nerksrs'romperuatiaa lnsarance for my employees. Below Is the pocky sad jab site
informution.
Insurance Company Name:_ ,
Policy#or Sclf-ins.Lic.#: 1011b 11�5�A7R5 t Expira
� tion Date'
Job SiteAddress: �l96 71.1t�^ Iy)A-city;s,ate/Zip; � tAA
f
Attach a copy of the workers'compensation pocky dectaratlon page(showing the policy number and expiration date).
Failure to socurc coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,5W.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 5250.00 a day against the violator. 13e advLud that a copy of this statement may be 1,1orward6d to the Office of
Inwmigatiuns oran,DIA for insurance coverage verification.
I Jo hereby certify m rr uias and/pen/jo6i�rrKj fpperja(ry�thaaI(be iuformadon praviddd ab ve i ruse and correct
S n[;) ire: - Necc /'! Dater
Phnn #:
Ojrriai ase urdy. Do not write fa dris urra,to be cmupketed by city or town,offiriaL
City ar"fawn: PermitflScense
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.City/fawn Clerk d.Electrical Inppector S.Plumbing Inspector
6,Other
Contact Person:_ _ ___ Pbone#:
Jul 21 1401:30p Bill Johnson-NPCM. LLC 603-6724262 p.4
CITY OF S.U.E.tii, NWSACHUSETrS
Bu=NrG DEPARTSLEVT
• 1 120 WASHNGTON STREET, 3' FLOOR
a T EX- (978) 745-9595
FAX(978) 740-9846
ICINfBERLEY DRISCOLL
1AWOR THomAs ST.PIERRE
DmEC[OR OF PS BLIC PR0PE1tTY/BU11Z\G CO\MSS1ON ER
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
111, S 150A.
The debris will be transported by:
'DyjAWG U NQV6,
(name of hauler)
The debris will be disposed of in :
(name of facility) �j
4' �t5w1�' ST - & Psi/a?(, ro f
(address of facility) I
,gnahue of permit applicant
71ZLI.14
irate
Jchma;�Jew