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9-12 POPE - BUILDING INSPECTION 13 9-- The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Build ng Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Onl ) Number: Date Applied: Budding Official:CTION 1:LOCATION(Please.indicate Block k and Lot N for locations for which a street address is not available) No.and Street City/'town Zip Code Name of Building(i 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 r\Iteration ❑ Addition❑ Demolition B�ease fill out and submit Appendix 1) Change of Use ❑ ChangeofOccupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 999— Is an Independent Structural Engineering Pcer R, iew re uired? Yes ❑Z_ No tt�.. Brief Des4riptio of Pro sed W rk: !� /l14±!wf 4.O/f, 2 0 oprc¢G 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 CNIR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing gbelow� No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(sq. ft.)and Total Height(ft.) 90 i SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ -F: Facto F-1 ❑ F2❑ 71: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ HL Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑S: Storage S-I ❑ S-2❑ U: Utility❑ Special Use❑and please describ Special Use: SECTION 6:CONSTRUCTION'IYPE(Check as applicable) [A ❑ 18 ❑ fIA ❑ 1I81-7 IIL\ ❑ II160 IVO VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each it Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public ff� Check if outside Flood Zone[I Indicate municipal❑ 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: -oinnux� n tt __cw (r x.cs; Not Applicable❑ Is Structure within airport approach area? Is their review m copleted? -. 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 do Sprinkler System?: Special Stipulations: T w. I ar 0 .. SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) a-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) If building is less than 35,000 cu,ft.of enclosed s ace and or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Resl2onsible 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 Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No. business Telephone No. cell a-mail address SECTION 11: 11t:11111-111 COA1ITM,,41'ItIN INSUIt.- CV'k\FH1)!\Vl I' 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 Estimated Costs:(Labor Item Total Construction Cost(from Item 6)_$ and Materials) 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ Note:Minimum fee=$ (contact municipality) 4. Mechanical (HVAC) $ 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERNIIT APPLICANT By entering illy name below,1 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 lily 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: Date Name i t ,< � 'j , The Commonwealth of Massachusetts r Department of Public Safety ➢U klassachusetts 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 a street address is not available) 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 ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy Cl 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: SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANCE 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)8r 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: FIi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage 5--1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION"TYPE(Check as applicable) IAA IB ❑ IIA ❑ IIB ❑ IIIA ❑ II[B ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: PP Y Public❑ Check if outside Flood Zone❑ Indicate municipal❑ 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: MA)list.ri. Cain In ci n I .i;w, Not Applicable❑ Is Structure within airport approach area? Is their review completed? 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 Loral per Floor: Does thebuildingcontainan Sprinkler System?: ' Special Stipulations: .-7 qr SECTIONS: PROPERTY OWNER AUTHORIZATION I Name and Address of Prot -r'ty Owner Name(Print) No.and Street City/Town Zip property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) C-mail address if applicable, the property owner hereby authorizes Name Street Address City/Town State Zip toad on the property owner's behalf, in all matters relative to work authorized by this building permit a2plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed s ace and or not under Construction Control then check here O and ski Section 10.1 10.1 Registered Professional Responsible for Construction Control 0 � e S �rltiN-4t72 t S 2S)Ce�a Mop, Q � A, Tclep orye No. a-mail add ess Registration Number p1 G it" 1 -1 G' Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Com any Nam A1v�Ph �v Nti ` Name of Person Responsible f Construction License No. and Type if Applicable �2 G 13r .rt�w �� �.n Street Address � City/Town State Zip 4�/T ,A/rC e a`7 11,t eei( Telephone No. business Telephone No. cell) e-mail address SECTION 11:NORM,.IF'C(JMf f\5r111O\ 1Ni5U I:A:M e Al'111IN tl' 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 Estimated Costs:(Labor ff ,,�� Item and Materials) Total Construction Cost(from Item 6)=$,et''2, al?V I. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ (contact municipality) Note: Minimum fee=$ ('c slit p� Y) -1. Mechanical (FIVAC) $ 5. blechanicod Other $ Enclose check payable to 6.Total Cost $ ,v rl D (contact municipality)and write check number here SECTION 3:SIGNATURE OF BUILDING PERMIT APPLICANT 7y,.enme below, I hereby altC' um r the Bins and penalties of perjury that all of the information contained in this andaccurate to the st of ry kn ledge and understanding. _ Zv/-gn n r� /title Telephone No. Date — & Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date CITY OF S.1LZN(2 "VL1SS-ACHUSETTS Of.'tLDLYC DEPA-MLE.rT 120 C0'".j' (;TO,V STUZr, Ya FLOOR `s It?L (978) 143-9595 <IUMMEY DRISCOLL FAX(978) 7•W.9346 AAYOR 1110stU ST.AERM DIRECTOR OF FLOUC PR0pERTY/8t:MnLVG CO�C�!!5�lO,YER Construction Debris Disposal Affidavit (required tur all demolition and renovation work) fn accordance with tite sixth edition of the State Building Coda, 730 C�1 iR s I.S Dcbris, and the provivns io of 1bfGL e 40, S S4; ection ! I ©wilding permit l;this wo is issued with the condition that the dcbrfs resulting from l l 1, S lSI J OA.shall be disposed of in a properly licensed waste disposal raoility as defined by 1vfGL o 1'11e debris will be transported by, JA^<-- s (17J1110 Ut'(IU4(Cf) The debris will be disposed Orin : (nantu of t'�cllily) n(pert app 1C.1hr / ilu_e5�._.._ I �! CITY OF Smzms N-ViSSACHliSETTS t BUILDING DEPARTJ(&NT y 120 WASHLIIGTON STREET,3se FLOOR T EL (978)745-9595 F.tx(978) 740-9846 NBEpj F.Y DRISCOLL THoN(ASST.PmM MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A l licant Information Please Print Le ib( Name(Business,Grganizatioruindiqdividual): Address: City/Statc/Zip: 41,1_ /D AeA PhoneM: Are you an employer?Check the appropriate box: Type of project(required): 1.Q.I'am a cm to cr with 3 a, ❑ I am a general contractor and 1 P Y 6. ❑Now construction employees(till-and/or part-time).• have hired the subcontracWrs 2.C] I airs a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have if. ❑Demolition working. for me in an capacity. workers'comp.insurance. Y P tY• 9. 0 Building addition (No workers'comp.insurance 5.'C] We area corporation and its. required.) offlectshave exercised their lo.❑Electrical repairs or additions 3.El am a homeowner doing all work right of exemption per MGL I LC]Plumbing repairs or additions myself.[No workers'comp. c. 152,)1(4).and we have no 12.❑Roof repairs insurance required.]1 umployca.[No workers' 13.❑Other camp.insurance requircd.], •Any appfleaut Thal checks box s t most alga fill uut the sectioo below showing their workers'compeowiun polity information. it /I b"uuwmnn who submit this anidavit indicting they am doing all work and then hire outside contractors must submit a Arse aflTdavit indicating such. :Contmons that 0wril this box must attwhod an addigumd shmt shuMns tha name of the sab•smninctan and Chair workan'camp,policy infomuaon. !aim on eaployer thatls providing)porkers'c ompetrsadon lasarancejor my employeez Below/s the pelley and fob site injornrurlom Insurance Company?lame: Policy A urSclf-ins.Lie.H: G'/2 © � 7��_ Expiration Date: 1112 1 ' /� r--. job Site AdJres� lZ PO/ P S City/StatU /Zip: �6 " !^-,e /1/ ,%ttach 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 NIGL c. 152 can lead to the imposition of criminal penalties of a tine 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 line of up to 525o.00 a day against rile violator. Be advised that a copy of this statement may be forwarded to the OI•lice of Investigations ufdte MA for insurance coverage veriticalion. /do fie y crrrlj er t/rep ns aoJ pen s ajprriary that the injonnallon provided above is true and correct. J: Dar! P u Ojjfrfal use only. Do not rprire in thin area,to be completed by city or town njjlclaf City or Town: Permlt/License d Issuing Aulhority(circlo one): I. Bourd of licallh 2. fluiWlnl;Oeparintant J.City/fawn Clerk J, Electrical Inspector 5. Plumbing lnspector 6.Other Conlact Person: . .. _ Phone q• i