29-31 PARK ST - BUILDING INSPECTION 1 The Commonwealth Of Massachusetts
Department of Public Safety
'\ S •,,,j ..\lassorhos"114SLllcliui[diIIgC...It,(7SIIC.\IIt)
lluilding Permit Application for any Building other than a One_ur"I'wo-Fancily 1 Iling
(Phis Set Iion For Official Uke oilly)
U,ue.\ppl ied: "_--------- -- Bu ding Off 1,11:
SECTION L-LOCCA HON(Plea
asse indicate Illuck II and Lot p fu locat 1 for t ich a st J ,v a--
29 -31 _FLZK_s4 _.. ._.._. �5wN.-. ___ _ __ _
,No. ,md Street Cily /town /ip Cot1 Name of Ili If uppli,ahlc)
SECTION 2:PROPOSEI V0I4K
Edition aI MA State Cade usvd _ ."_- If;New Construe tiun,hcck here O or nccrk all Ihat,lpi,lr in Iho Iwo rotes hvlow -_
Fisting Building❑ Repair AltenlliunA :\Jditim, 0 Dentoltlion O (I'Iease till out and Submit.\pprndis l)
Change of L'se ❑ Cluutge of Oceupinev ❑ Other ❑ Sperify:-- -_---- __
:\rr building plans and/ar construction JlkUlocots being vupplied,Is part of this penult application?i
----- --
Is an Independent- ruttural Engineering Peer Review rt•quirc•d? NoBrief Dvsrriptiuniffl1rop -Sed 11'ork:.--.
--
SECTION 3:COMPLE FE'THIS SECTON IF EXISTING BUILDING UNDERGOING RENOVAtCHANGE IN USE Olt OCCUPANCYCheek here iton Existing Building Investigation and Evaluation is enclosed (See 7,40 C;\IR 4) ❑
Existing L'se Gnnlp(s): Proposed UseSECTION 4: BUILDING MIGHT AND AREA
Existing
No. ut Flooa
ude basenunt levels)h Area Per Fluor(sq. It.)
total:1n•a(sq. tal Height(it)
tiEC1-ION 5:USE GROUP(Check as a livable)
A: AssembA. 0 :Nightclub ❑ A,1 ❑ A-1 ❑ :\-i❑ B: Business ❑ E: Educational ❑
P: FactoP_'❑ II: Hi h flalard 1l-1 ❑ It-2❑ ii,\ ❑ 11-a❑ II-i❑
I.
Institutio2❑ I-3 O 1-� ❑ ;\I: Mercantile❑ li: ItesidenNal R-I❑ It-'_❑ 12,1❑ li-�
S; Storage SI ❑- S-_❑ U: Utility❑ Special Use❑,unl please describe below:
Special Use
tiFCHON 6:CONSTRUCTION 1"YPF. (Check as applicable)
IA ❑ IB"❑ Mil ❑ IIB ❑ ❑IA ❑ IIIB ❑ IV ❑ VA O I'll o
-_- SF(`TION 7:S I I E I NFO R,\L\PION(refer to 7.4U C.\IIt I I LU for details on c,rch item)
Water Supply: Hood Lone Information: Sewage Disposal: 1'rench Permit: Debris Ftem"Vali — -
Publir 0� Cheek a aobld"IIo,+J /_anc Cl Inditme oumi,il"dK .\ In•n,h will not he Li""nv"d ❑
Pnc.00❑ „r indemil\. An illn•yuin•d ❑nr Iron,h or, nr If\
pen_nrt is"m IosrJ❑
It ailn,aJ right-„f-w,ty: I latards to.\ir.V.w lgation:
�lru,tnmoohm.w1wit.q•pm...h .in•u.'
I Is th"Ir""clew„vnld"Ir,l'
.,r t ❑ I 1",❑ ,-r.\'„ lr,❑ \a ❑ I-
_______ tiFC IIU.V 9: CO.V I I T I lF('h1(IIPIC.\Ili OF U('CCI'.\NCY
d,Wv„a I, ( .r(;nntl'1,) It ia , lC ,n.lru,Invl thu;ltwl _---
Iy ,, Ihr l•u JJin{I,• ;o.un.m �i,nu Alrr tit slr;n' ti
i per i.il '�hpul.l h„in
SR I ION 4; 1'RUI'If ITfY(11VNFR AUI'1Il1RIZ,\IIUN
ollro1wrh Ow nor d �-1f�
L3G2. 2,r, { �s __ 5 D e s� �3> 21 { g,esw�y. ;F;
Nmne(Print) _ _.. ` No, and titreto city/rnwn
Properly Owner Cntta,t bdonnation:
- - L;E��Qrt�(kv�isSQ�'yl�• awl
I isle relnphone No. (business) relephone No. (a•II) c-, ad address
II eppli,aldc, the properly owner hereby aulhorie.es
N,unc street Address _city/ Town slate —_Zip_.—
w art on th=I)erty owner's bohalf, in allanattecs relative lu work authorized b1 this building, +ermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 21 _
If FuilJ in+is Icss th,m ti,Ugl iu.ft.of enclosed s•nee and or nut under Construction Control then check here O and eki +5v01III 11)1
Ill.l Re+istered Professional Responsible for Constructlun Control
Tele hone No. e-mail address - Registration Number
Name(Registrant) V
srect Address City/Town Sh,lo Lip Discipline Expiration Date
lo.2 General Contractor
CuntlName
1_)t N C5 1� 11� ----�
Nano of Person Responsible for Cunstn,c Urn License No. and Type if Applicable
y;I,e1t- ss City/'rtrwn St ue Zip
rate +hone No. 11,112
ness Telephone No. cull a-mail address
SECTION 11; 11, v<1.rtz,, I t IMIT" ,.,\1 ins IX•t 1,,A\t I .\I 111 I,'A I I M.G.L.C. 151 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed end
submitted ,with this application. Failure to provide this affidavit will result in the denial of the Lssuance of the building permit.
Is a si+ned Affidavit submitted with this application? Yes O No ❑
S ECHON 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and \laterials) Total Construction Cost(from Item fi) 'S_ --
I. Building S Du ild ill Permit Fee'Total Construction Cost s k• (Ins art here
'. Lleclrical S 3 appropriate municipal factor) '3 5�
1. Plumbing b 5 Conrail nnuti,i ,alih'
Nate: Minimum fee'S--( { )
!. \Iechaoi,al (Ilv.\C) 5 `
i. Me,hani,al (Other) ti I'n,lose ,he,k p,w'able to —
r,. I, I'll C,Ist > 12 (,nnta,t »urni,iVA ih'1 and ,,rite rha,k number here
SECTION 13: SIGNA LURE OF BUILDING l'LR\ITT APPLICANT
Iiv entering Con name below. I hCreby .fittest Wild or the pains,Cod pcnalttvs of perjury that,ill of tile infanuati,m,ont,Iinrd in this
,Ippli,.Ition is Iniv.find ai,tIrale to the best of Illy vdg•,Cod »nderstandiilg
�- pd r{CYS_. S QrJ:w� �Mny� L✓ aq. 3y f6j(). y�q
I I'Ir.Ise pru,t .I n,l .q;n na mr
fltl,• Telephone Nn l>,Ity
5 s{ 3➢k Z3 Clle,
-I reel rr s rn„n SIP
\ltu,i,i j,.II luspedur hr fill out thi.v sediom upnn .,pplicali in approval: .. ._._ __ .. ..
Nance +.Ite
C[TY UE Sa1L. IN11 N WSACH US E-ITS
'1J OCILOING DEP.IRC>tE.�r
120 WASHIINGTON STREET 3o`FLOOR
TEL (978) 743-9595
F.k.'c(979) 7)6.98.16
,<1.%10E1i2_EY DRISCOLL
LILYO Z TTIOSL\3 ST.P1EQR8
DIRECTOR OF PL'OLIC PROPERTY/9L'rimtNG COJ6IISSIONER
Workers' Compensation Insurance,%ITTdavit: UuildersjCuntracturv/Electrlclan.yPlumhen
knlrlleant information � � Mane Print Lelihiv
NainellhuitwsOrgamntiarvIndividual): U9 ,rnQeAIc'S
Address: 5 '_QhiXc&C. � lax 20 a
City/State/Zip: JttrL MM , OVA ls Phone* QU —235 —ICAO _
Are you in employer'.,Check the approprla a Get Type of project(required):
1.L] I am a employer with a. I am a µunural contractor and I
dnlpinyees(tiall and/or part-time).• ave hired the subcontractors 6. 0 Now cunstntclian
2.❑ I am a sole proprietor or pasincr. listed on the attached iheeL : 7. 9� Remodeling
.hip and have no employees These subcontractors have N. C]Demolition
working Air me in any capacity, workers'camp.insurance. 9. Ouilding addition
[No%vurkcn'comp, insurance I. ❑ we are a carporation and its
squired.) officers have dxereised their 10.C3 Electrical repairs or additions
J, 1 ain a homeowner doing all work right of exdmptiun per MGC 1 I.❑Plumbing rcpuin or additions
myself.(No workers'comp. c. 132,110h and we have no 12.0 Roof repair$
insurance required.) t employees. (No workers'
sump. insurance required.) 110 Other
•.\ray applkt 11W rhmsta but A mesa at"till out the aeetiue below ahowine their workrn'compsnsnlun pulpy inlHrmudoa
'I honauwntva who,ubntit this adlMvil indicating they an doine all sure and then his W,,i k eallaa..n mall n,hmlt s new.ulldavil indiaine tacit,
t'�mmown than Owls this box muss IDochod an a,W,aurwl.hest ahuwlns the nano of the nat►euntnctun and their wtotem,comp.pulley InPormadoe.
/urn un nnpluya rharli p�opf✓!nX tvorkrn'cumptn.rodan Gr.rurarree�or my emp/uyrrs, Bdow/i rlu policy and job silo
in/uumallon.
lttetlQtilee Company Name:
I'uliry d or Self-ins. Liu, d: Eapiratian Date:
Jub Site Addruss: cityistatelzip:
.\each a copy urthe workers'compensatlas policy ddclaralloo Me(showing the polity number and expiration date).
Fsilura to mcura cuverage as required under Section 2L\ut',%fGL e. 132 can lead to the imposition of criminal penalties of a
rirc rap to 11,500.00 andlur mu•year imprinnnatenp as well as civil penalties in the form of a STOP WORK ORDER and a line
ar up to 5230.00 a Jay rgainst rite viulmor. Ile advi.eed that a copy of this aatcmunt may be turwar&J to the Oliica of
in re�tigatiuus,al the OIA 11)r insurance cov raga waiicatiun.
/do/,ruby terri ✓arrrhr a' rmt✓ptnv(dr.r r/pyrjury r/cur rht in�unnurlwr pruvi✓a✓ubuvr it trot.nr✓iorrrc6
Ul/idol,r,e,,,dy, /ha.ng nvirt in llriv rrr,r, tal.�t rmopleted by city ur lawn,r,/j/rivi
City•rr I'uwo;
I•,trio;.\ulhorilr (circle one): _.—_. . .___
I. !Lr.ud nl Ilualth !. Iludding lh•p.tr lotto( 1. ( ity,'rnu❑ Clerk I. Etcctric.it hopetwr i. Phnuhin:; In,pre for
4. tLhcr
CITY of: S.l(zm, Akss,kCHUSETTS
13LMDL4G DEP.1RTtE\T
I'O WASPILVGTON STXW. 1'O FLCCItI
K \OERLBY OAISCOLL Rix(973) 11a.9W
,ti A YO R n1G.uw ST.PcaUS
0I29T0a CP pL atic PRopeATY/st;mnc1G CO\Olts3tOV EA
Construction Debris Disposal Alfidavit
(required for all demolition and renovation work)
In aceerdance with the sixth edition of the State Building Code, 180 C4MR section 111.J
Debris, and the provisions of MGL a 40, 3 J4;
Building Permit al is issued with the condltlon that the debris resulting from
Ihis work shell be disposed of in s properly licensed waste dlspossl facility as defined by tbIGL e
I 11. 3 1 JOA.
The debris will be transportcdlby:
.0
7;S 0o6g l
(nne ufhaultr)
The debris will be disposed of in :
(n�mt of dciliry)
1 dOre o a r f�„I,�y►
o �erm,t pph�rnf
Jun
` '=• ,NI:tssachusetts - Delimit-ent of Public SafctN -
1aw Board of Building Regulations and Standards
Mill Construction Supervisor License
License: CS 97113
JEFFREY QUINN
18 ARLINGTON AVENUE
BEVERLY, MA 01915
o—
� Expiration: 9/26/2012
('nmmis.iuner Tr#: 4425