24 PHILLIPS ST - BUILDING INSPECTION Cr- 9„03�
The Commonwealth of Massachp ,,0prs f
Department of Public Sa�PEC.?IONA
SERVICE
S:
Ulf Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than eopj IWW 20elling
(This Section For Official Use Only)
i
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street addres s not available)
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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❑ Alteration ❑ 1 Addition❑ 1 Demolition (Please fill out and submit Appendix 1),
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
LlCEFED .
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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) O
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❑ 1 H: High Hazard H-1❑ H-2❑ - H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ 1-3❑ 1-4❑ 1 M:-Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
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 ❑ IIB ❑ IIIA ❑ IIIB [3 ,IV ❑ 1 VA O VB ❑
SECTION 7:SITE INFORMATION(refer
rr�� p sal:to 780 CMR 111.0 for details on each item)
Water Supp y: Flood Zone Information: Sew D.s Trench Permit: Debris Removal:
rddjjA Check if outside Flood Zone Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ re rmit i xor trench or specify:
permit' enclosed❑
Railroad right-of-way: Hazards to Air Navigation: - MA Historic Commission Review Process:
Not Applicable Is Structure within airport a proach area? Is their review co p eted?
or Consent to Build enclosed❑ 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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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Name Street Address City/Town State " Zip
to act on the property ownef 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 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 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
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Company Name
Name of Person Responsible f r Construction License No. and Type if Applicable
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Street Address d City/Town State Zip
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Telephone No. business Telephone No. cell e- address
SECTION 11:WORKERS'COMPENSATION 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' suance of the building permit.
Is a signed Affidavit submitted with this application? Yes No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT F E
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=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ ` (contact municipality)and write check number here
SECTION 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 knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: i—
Name Date
1
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location(Please indicate Block# and Lot#for locations for which a street address is not
available)
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No. and Street City /Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
t he Commonwealth of'Massachusetts
Department of lndustrialAccidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): T. iA) • 14 .wa Va"/ lL/1 Q f ) )C_y e[ ��j(T�•
Address: /Z J3CX rrl�c� R T }
Ci /State/Zip: i 9 Phone#:
Are you an employer? Check a appropriate box: Type of project(required):
1.W1 I am a employer with_1 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).* have hired the subcontractors 6. ElNew construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
shipand have no employees These sub-contractors have
8.�Demolition
working for me in any capacity. employees and have workers'
comp. insurance.$ 9. ❑ Building addition
[No workers' comp. insurance P•
required.) 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.0 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp: insurance required.]
*Any applicant that checks box#1 must also fill out the wction below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information:
Insurance Company Name: CboY r7 3 I n S a ra h CQ Ca.
Policy#or Self-ins. Lie. #: W C U G q �5 22 Expiration Date:-42 l/ y
Job Site Address. (a t a y (2 h I l l I p—S s��2 a- City/State/Zip: SO U r✓+ A 17 ry
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$1,500.00 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 be forwarded to the Office of
Investigations of the DIA for insurance coverage.verification.
I do hereb enify under th s ud penalties ofperjnry that the information provided above is true and correct
SIP
i re: Date:
Phone#: N ( I
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit(License #
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#: