58 PERKINS ST - BUILDING INSPECTION (5) t
1 The Commonwealth of Massachusetts
Department of Public Safety
1� Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
" (This Section For Official Use Only)
Building Permit Number: Date Applied. Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which astreet address is not available)
SR RK&6 15j 5-01hn Mfg
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[ Repair(,I Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ I Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ Noll,
Is an Independent Structural Engineering Peer Review required? I Yes ❑ Nox
Brief Desc iption of Proposed Work: 041- 1�2D b,f yw d 49,MK
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.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❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ I-2❑ I-3❑ [=!❑ M: Mercantile❑ R: Residential R-111 R-2❑ R-3g R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
c SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 1110 IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ I IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Dis osal Site❑
Public Check if outside Flood Zone l,Indicate municipa A trench will not be P
required I>S(or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: hln I nstc rid Gnnnnsinn ltgyn _7 r> r,}s:
..........
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed Cl 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:
y t
SECTIONS:.PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
172%IT91/ 00 u ,I
Title Telephone No.(business) Telephone No. (cell) e-mail ad ress
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 budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft of enclosed space and/or,not under Construction Control then check here O and skip Section 10:1
10.1 Registered Professional Responsible for Construction Control -
G fry �Dfcsfy q--5m ^�� vtGt C
Name(Registrant) Telephone No. e-mail addres Registration Number
�/4a,,�po�RV �I�Pdn A&�_
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Respo sible for Construction License No. and Type if Applicable
�i lo�r�n
�
Street
�Adddress City/Town 1 State Zip
e � J
Telephone No. business Telephone No. cell e-mail adc s
SECTION II:\VORKF.RS'COMPFNSA'FJON 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)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (coat n rrtR'fpality
5. Mechanical Other $ Enclose check payable 0&,- G
6.Total Cost $ al y
Q7J (contact municipality)and write check number Here
SE ION 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 the best of my ko nw! ge and understanch .
Please print and sign Ham_g Jitl� Telephone No. Date
� � ll 1?n 1
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: Vu4wl1
Name -Date
y �....... ; r. w. ,..ma,^:^.o ..e.,...�"�a+,�.�ew.. ^Y�. w'.....a`^5�--'��..... Mw' N'a�++°+'�'•.""'p'"'""g
rt- tt � 5 ya _;o- J•jr ue.'t` � � y v,�. � • y r , f
fit ...
CITY OF Slur-IlN I,;NUXSSACHUSETTS
BtiILtDL�IGDEPAR-PIMNT"
]20 WASHIINGTON STREET,34
'FLOOR
° Tom (978)745=9M
\ FAX(978)740-9846
ICI\tBFRi F-Y DRISCOLL THOMaST.PMM
AYOlt DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMMIONER'
Workers' Compensation insurance Affidavit: Builders/6iitractors/Electrieians/Plumbers
4 nlicanf infortnation Please Print Leeib[v
Name(Susitiess/Organi:atioNlndiviidual): to
Address: 7 L rA Ufnq R b s S
City/State/Zip: gf('I//1 orl2jD Phonell:_J�
Are you an employer?Check the appropriate box: Type of project(required):
I. I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full anNorpai�-time).• have hired the subcontractors; '
2.❑ lamasole'propnctororpartner-
listed on the attached sheet* �• ❑Remodeling'
ship and have no employees' .` These sub•contractorshave S. _Demolition
working,for me in any capacity., workers'comp. insurance. 9• Building addition
.[No workers`comp.insurance 5. We are a corporation aril its 10.❑Electrical repairs or additions .
required.) officers have exercised their
right of a em non MGL, I I.0,Plumbing repairs or additions g
3.K I am a homeowner doing all work Gh P PG
myself.[No workers'comp. c..152,§1(4),and we have no 12,0 Roof repairs_
insurance required.]t employees.[No sackers' 13.❑Other
comp.insurance required.!
-Any oppliran that chtxka has Of mout gists rollout the sectim bclowshowina their wmken'compenwion policy information. t .
t I laseowners who submit this affidavit indicating they am doing all work and then hln outside contncumo must submit a new affidavit indicating such
:Cantrxtom!hatch«k.lhis box now aewhed an additional dhwt showing the name of the nob�contracton and thairworkess'comp.put icy information... `
am an employer that Is providing workers compensadon insurance jar my employees.' Below Is the polity and Job site
information;
insurance.Company Name: '
Policy N or Self-ins.Lie.M. Expiration Date:
Job Site Address, City/State/Zip:-
Attach a copy.of the workers'compensation policy declaration page(showing the policy nurnihor and expiration date).
Failure to secure coverage as required under Section 25A ofMGL•c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may bo forwaided to the Office of
Investigations-of the DIA for insurance coverage verification. f
I do hereby certify undetthe pains and penalties ofiterjury that the information provided above is true and correct.
,9 ,n..,.,,_. pate•:':P cone d•
Ojjh*1 use only. Do not write in this area,to be cumpleted"by city or town off ew
City or Town: Permit/License is
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.Cityffown,Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone 4:
{
�. CITY ofS.U.Em2 NL SS.,�wHtrsErrs
BL:=LNG 0EA%,tT.%ONT
1_'0 W.u9HLNGT ON STRE&T, 'O 3 FLOOt
ILL (973) 745-9595
Klmo& i.EY DRISCOLL RUC(978) 7.10-9345
NUYoR 'f 1O.%tUSr.PtERRB
DIZECrOR OF PLOLIC PROPERTY/BCtLDLYG COSL\tISSIO.YEB
Construction Debris Disposal Affidavit
(required the all demolition and renovation work)
fn accordance with the sixth edition of the State Building Coda, 730 CbfR section 111.5
Debris, and the previsions of,MOL a 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
1, S 150A. facility as defined by,tiIGL o
t l
The debris will be transported by:
�iif > >isQ QI
(Hama ut'haulcr)
The debris will be disposed of in :
1 ►F� w�S��D;s sue_
(name of facility)
(.nlJcest ar ta,ility)
i�
vgnamre of permit applicant