32 PERKINS - BUILDING INSPECTION The Commonwealth of MaVas Department of Public SafBuilding,Code(Building Permit Application for any Building other thanFamily Dwelling
(This Section For Official Use Oily)
Building Permit Number: Dale Applied: _ 25/121Building C f'vial:
SECr1ON 1: LOCATION(Please indicate Block F and Lot p fur locations for which a street address is Rdf available)
No.mid Street City/Town Zip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
Edition Of\IA Stale Code used._'+t" If New Construction check here❑or check all that apph•in the two rows below
Existing Building er Repair S,., Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and subunit Appendix 1)
Change of Use ❑ Change of Occupancy Cl Other ❑ Specify:--- _
\re building plans and/or ronstruitiun dik'uments being su pplicd as part of This permit application? Yes ❑ No —--
Is an Independent Structural Engineering Peer Review rvyuireit? Yes ❑ „No. t(.. _
Brief Description of Proposed Work:. �e Pa:� (_, 1%
rireoc .. f' :, x�.w r44t).S Ira^�)v5�r3 i•la��a�
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 euclused(See 780 CNIR}I) ❑ .
Existing Use Gnnnp(s): . --- Proposed Use Group(s):- —
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flom:s/Stories(include basement levels)dr.Area Per Floor(sq. ft.) ,3
Total Area(Sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A--2❑ ,Nightclub ❑ A-t ❑ A4 ❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ 4L• Ili h Flazard H-t ❑ H-2❑ 11-1 ❑ LI-4❑ f-1-5❑
1: Institutional 1-1 ❑ t-2❑ 1-3❑ 140 M.- Mercantile❑ It: Residential R-10 R-'-❑ R-3❑ R-h❑ -
S: Storage S-1 ❑ . 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION b:CONs rRUCTION 1-YPF-(Check as applicable)
IA IB ❑ HA 118 ❑ MA 1118 ❑ I IV 1 VA ❑ VB ❑
SECTION 7:SI'1"E INFORMA'TION(refer to 78B CNIR 111.0 for details on each item)
Water SuppI Plead Zone Information: Sewage Disposal: 'Trench f'ennil Debris Removal:
Public 0 Chick if oulside Hood Low Indicate ouunicipal A trench"' I not be Licensed Disposal Site❑
rvquirad ®or trench or specifv1
P riv,ue❑ ur wth-Wify lone: ___-- or on Site S�Slenn ❑ permit IS cnc lilted ❑ Ne
Railroad rigln-of.; r Ilaiards to Air Navigation: v � i,� i I � I .,. .
N, Appliidble IS Gtructur•within,iirp, t.nl + each aria.' h Ihr it recir r� i+ mplrleJ'
or(.un.ent to Build c lit loted❑ )l oS❑ or.No( YcS❑ No ❑
SI.Cl'[ON 8:("ON I ENT OF CFRTll9CA'I'F.OF OCCUPANCY
I!ditioo lit Cale: - . .._ L w Grou p(s): _ .. _ . - I\pv nl Gmslrui time: lk�up•unt Loaf poi Iloor
Poo, Ili,-buildi❑g cocain,m 7Prinlder Sc,trm?:
SEC ION 9: PROPYR'IY OWNlilt AU I'IIORIZA'IION
Name and Address of Frupr tN'Owner
Name(Print)._ --- _—. No.and Street City/Town Zip
ProperlV Owner Contact Information: 1
I'itlr telephone No. (business) telephone No. (cell) e-coattail addr
If,applicable, the properly owner hereby authorizes
_-_--- Name Street Address City/Town --- State Zip
to art on the property owner's behalf, in all matters relative to work authorized bV this building permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
1f till ild illg is less than 35,1XV cu.ft.of enclosed s pace and or not under Constriction Control then check here C3 and ski p 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
cam- "k'(
Company Name ---f
`^''N v�,'�
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zi
9 ��
Tele phone No. business Telephone No. cell a-mail a a ress
SECTION 11:Nc,yarl:>'('AWt',i•.:N I ION-I,N:a ll:. .\i.'I .)rlil'AI'll M.G.L.c.152. ZSC 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 a lication? Yes O No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S.— O�c'� c�O
1. Building S X O O O U Building Permit Fee=Total Construction Cost,,(_(Insert here
2. Electrical $ appropriate municipal factor)=S
1. Plumbing $
+. \lechanical (HVAC) S Note: Minimum fee=S__(Contact muniripelily)
i, .\IvC11a11i0l (Other) S Enclose check payable to
li.Total Cost $ 10 O O v (Contact numicipality)and iv rite cluck nuniber here
SEC HON 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Itv entering nay more below, I hereby.11tcst wader the pains and penalties of perjury that all of the information Contained in this
application is Irue dod act orate to the best of ma' knowknowl upderstanding.
I'Ie,tse print,cod sign n,une title IJcphoneNo. Date
titreel Address - CiIN'/ town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
<; CCCY OF Sm.Em, NWSACHUSE"ITS
v OI:ILD4\G DEP.tKC>lE\T
it
120 WASHLNGTON STREET, 31D FLOOR
TEL 978 145.9595
•� Ful:(979) 7•10.9846
�-1\113 Rt FY DRISCOL-L
�L�Yo A TNO.MS ST.PIE"s
DIRECTOR OF PUBLIC PROPERTY/BUnDf\C,CMNISSIONER
Workers' Clnnpensation insurance Affidavit: Builders/Contructurv/Electricl•rnsit Plumbers
knolicant Information Please Print Lea_ihly
Mimi: Urg,tnuatiam lmtiviihtall: �...._ �a� �- I �.
Address: ac> L.✓os
CilyiStatc/Zip:
Are you an employer!Check the appropriate bolt Type of project(required):
1.❑ 1 am a employer with a. 0 I am a general contractor and 1 6. 0 Now construction
Ipinyees(Alit and/or part-time).• hive hired the sub•eantractars
2.&lam a sole proprietor or partner- listed on the attached nhect t 7• ❑Remodeling
ship and have no employees These sub-contractars have S. ❑Demolition
working Air me in any capacity. workers'comp.insurance. 9. C1 Building addition
[No workers',comp.insurance !. 0 We are a corporation and its
rcyuired.j officers have azerciscd theft
10.❑ Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exdmptiun per MGL I I.❑ Plumbing repairs or udditions
myself.(No workers'sump. c. 152,§1(4),and we have no 12,0 Roof repairs
insurance required.( r employees.(No workers'
cump,insurance required.j 11,0 Other
nny applh.:ud due ehwhs hod el mull Aw nit ow the wcliva West she wine their winters'eompenodun puticy mnumallon.
'I huneuwixv who.uhnid this alltdavil indicuing Ihey we doing ill work And then hire uunide...1"'me mild mhmil a new allldavil indicating w h,
:r.muxtors that chask this boa muel ouch al ae Additiwwl.heel thawing the nwno of the rub4onimtom and their workers'comp,policy Inremvdoo.
fain on employer thuNf pruvldlnR Ivorkers'cumpruradun lnsnrance/or my employers. Belli Is thrpollgt and/ob site
injorarmlan.
Insurance Company Name:__....-._
Policy 4 or Selr-iiu. Lie. M.: Enpiration Date:
Job Site Address: City/$WldZlp:
Attach a copy of the workers' campensatloo policy declarullan page(showing the policy number and aspiration data).
Kidum to xcuro cuveragd m required under.Sectian 21A of MGL e. 132 can lead to the imposition of criminal penalties of a
tire up to 11.500.00 undlur one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and d Ilse
ar up to 52I0.00 a day Against Ilia violator. Ile advixed that a copy of this maicmcnt may be iurwurdcd to ilia Oitico of
I,ivc,tigAuni ufnic !)IA tar insuranco eoverago veriiicatiun.
1,10 hereby certify folder the pulls asiiiddppeaohlrs�rf pe ury flint th ifi�unnmlmr proviJrJ�qu/buv is true lord cafreet
1t.:I•.l lltrc: 7—p — c-1 ; I).iR I
01 iciul ti ie"nay. Oa trot tvrife in thi.v area,m he c moplered by city ur tows,i ltia!
City iflbiva:. ._, Pcrmitil.lccneei
h+uin-Attlhurily (circle ant):
1. Ilourd of Math !. 111ildli ty I)epio novel 1. ('i1p rnivn Clerk 1. Eleetrlc.11 1n+peerir i. Phunhini; Itlipeentr
G. 00wr
CITY OF S.1L Nry 4tiL1Ss.ICHUSETTS
JL'tLDOiG DEP.IA-nzNr
I'0 W-UJILNGTON ST> V, 1'O F200A
r2L (978) 145-959S
KI1 BITAr Y DRISCOLL P,kx(973) 144984
MAY04 MO.wf ST.PMXXA
OfUCTOROPKNICPROPEATY/3"nLNGC ANISSIONEA
Con9tructlo13 Debris DISPOSal Affidavit
(required rot Ill demolition and rcnavation work)
rn accardanee with the sixth edidan of the State Building Cade, 180 CMR section 1 I I.1
Debris, and the provisions of MGL a 40, S 14;
Building Permit Af is issued with the condition that the debris resulting from
111, S I JOA.
this work Shall be disposed of in a properly licemed waste disposal facility as defined by MGL c
The debris will be transp/`�'orted by:
J I - z A n -- -,f i
(name Urhouldo
The debris will be disposed orin :
lddrefa arr�, (,iy)
yrt�mrsuf;ermitipphcint
3 _Z