5 PRESCOTT ST - BUILDING INSPECTION (3) J rS !
The Commonwealth of Massachusetts
CH������''' Department of Public Safety
// Massachusetts State Building Code(780 CMR)Building Permit Application for any Building otherthan a One_-or Two-Family Dwelling
(This Section Fo Offic UPoly) _
Building Permit Number: Date Applied: uilding Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street S C Town 5 Zip Code Q 1 q� Qame of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑qr check all that apply in the two rows below
Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1.)
Existing Build Tng 11 Repair 0
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
1 Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work I '
G n +
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❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1 R-2❑ R3❑ 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 ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
LWater Supply: Flood Zone Information:- Sewage Disposal:
Trench Permit: Debris Removal:
A trench will not be Licensed Disposal Site❑
ublic❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify:
ivate❑ or indentify Zone: or on site system❑ permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: -%I,% Ili I nc C0111111,111011 I'gyi I ro,r.s:
Not Applicable❑ Is Structure within airport approach area? - Is their revnew,connpleted'onsent 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 OWNE UTHORIZATION
Vame a'd Addr•ss of Property Owner
v5
Name(Print) No,and Street City/Tpwn Zip
Property Owner Contact I o mation:
Title Telephone No.(business) Telephone No. (cell) e-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.it.of enclosed space and/or not under Construction Control then check here[3 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
S
a ie(Regi;,l. tFJ' Tel tto Io. e-mail addrsl f ,r ti /ry Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contrac r
r� co5
Company lire
01 � , 17
IVagie of Person�e ponsiaLe for Consl�uction C License No p agdpe if Applipab�e
Cu r (�
Stree) A INJU
d
res_ s I Sty/Town State Zip
Telc hone No. business Telephone No. cell e-mail address
SECTION 11:14U1 KFNS CUNT F-NSA'110\'IM"UR.At\CH AI TIDAVrf 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 ' suanc he building permit.
Is a signed Affidavit submitted with this application? Yese
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE -
Item Estimated Costs: (Labor 6 GlJ G,
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 rue and accurate to the best of nr knowledge and understanding.
P : print and sign na rc Title T n Date /
Street Aij(iress City/Town fate p
(o �
Municipal Inspector to fill out this section upon application approval:
Nam ate
CITY OF S,Vt &Nf. AAss.Au-iUSETTS
BLUZLVG DEP.IAnmST
110 W.ISHLYGTON STREET, !1a FtOOA
I-EL (978) 745.9595
KIJ®EALEY DAMOLL FAX(978) 740.9M
MAYOR 2} clmuST.Ptatus
DIREcron OP PLBLlC PROPEATY/11LADLNG CO\L<115stOVEA
Construction Debris Disposal AflIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting from
This work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported b
Nick Or1 �� �
(name of hauler)
The debris will be disposed of in
(name or fanI ty
(JJJ aoYfJeili�y)
C `yZ— - 1 siynJmte orp mit 3ppliunt
/v IJfC
SAZ�% CITY OF SALEtiI
PUBLIC PRUPRERTY
DEPARTMENT
11W.nflY InIN"it
\INIM
I I.^ WAN tItAG 1 U.�i 18 CLI- Al 3.111•.11, M.1 11 V 1 I r S177�
11:1, )7s" l3 93n3 a F 1x v7aJ/4'Ia46
Workers' Cumpensatlon Insurunce U1lddvit: Uullders/Cuntracturs/Electrlciyni/Plumbers
1 dlcant In urmallon
L Plea. Print Le •hl
Vc11T1J I Ilual'u;ayl7r;lanu.tin'vloJ'rnluull: 1 l co
�llllrc5.Y: �f� l/1 \ AV
Ciiy,Smrc,7ip: C. Monei/: S
.\re)nu mr vngrloy@r?Check the eppruprlate box:�I 1.❑ I -fill a cmpluycr with d. hyM It(NrrJecf(required):
❑ I nm�gcncrsl coulraetor and 1
'•�vulpluyces(full Jn,Yurpsrt-finis).• huvu hired the sub•cunfraelurs fr' new eunstruetiun
1 Jill a sole prnprictrw or partner• listed on the anached sheet t 1. ❑Relnaleling
ship and have no empluycvw These sub-contractors have
wurking tilt me in any capacity. workers'camp, insurance. tl' ❑Demolition
I NO wolltcrs'cutup, insurance 3. ❑ we ars a col7aorelion and its 9, ❑ Building addition
3. nquircd.) )"'cars have caercis rep
ud their 10.0 Electrical airs or additions
❑ 1 and a homaulrner doing all work right of c.aemption per A, A 11.0 Plumbing repair,or additions
myself. Iii•o workers'comp. - C. 152.11(4).and we huvu no
nsurance required.) t employees.(P'o workers' 12.0 Rwrfnpairs
comrk insurncu nquind,J 1 3•O Other O n
•\nr.,,phau,l tl'W cheb ew rl mop:Jw lill wa'he Wtims fxbw awwuq'time'rwhua'cWl,ernualwl Iwliry ndiulnpiuq
'I I.n lwmn he,uy,lal this alTdavir in,llw1ine'hry 416 Joinopi _
f•'nlrwu,n IAp ahrc6 this a•s,salt Jlt;tar.0 addiliu.Il.twr1 Jlnw s ite na M al ON rimitride W.eerrr rarlun and 1111re tmuviur 4 a"'IrlJeril inJiu,lin w_ s let.
/utu un cutpl@yrr'hut it prvyjJlnr IvurArrs'rurnpenrnNon Lrrurrrnaojui my nnp/upreti Br/err/s rh�/I y un%uI s
iujunnufGrtn K �(
Insurance C'umpauy .Name: `v
Irulicy Ir ur Sulf•ins. Lic.H;
EApirallon Date: 6
JabSile.\ddrem: GG S� (( �
Ip
.4ltuch a copy of Ih@ workers'cuinpematlan pulley declaration pug@(show)g the policynumbur and cap ratlun dare).
I;Jlluru 10 sccurs cu%cruge as required under Section 23A ui'MCL c. 152 cis lead to file imposition oferiminal Penalties of a
line up ra it 5110.00 JnJiur uue•year impri.vanmcnr, Js well as civJ Ircnuhiu in the lunn ol'a STOP WORK ORDER lend a fine
,+i up rn i250.00 a Jay.Igain>.t the v6Naror. Ile advi.,cd that a copy irthis mulcmcm may be turwarJeJ to the uOice uC
lit\'�plt�Jllunllor'nshrJlxc c,;rcrJ3c lci ific Jlwn.
/du/ra•rrhy A.rrli[y rutJa'r 114 1minr'md prnuAiry u/per/rrry r rr irrjunnr7/ote ruviderl r .- Y gd{rr r s bum a rorr• R
� I
Ir1%/Iciu/nsr un/y. /)a,Inn Vrire in Mgr urea, 10 Ae ruutp/rled by city of town u//ividi
(71r a♦ town: -
i - Pennirtl.lcvnre 0
L.uing .\ul Nitrify (circle noel:
1. IL'arJ „(IfrJlfh 2. Ihuldin� Ilcp.lnun•nl I. (;i1).'falrn Clerk J. L•'Icatric.tl lu,pcctur ;, plumbing Imyectar
G. 17ther
i
-
-__ I'Aune 17 i
Information and Instructions
v s teen m the service of goober un,ler any conlnct of hire,
\LIN•IC IIUSC{I)(JC nt(JI Law,ChJpler I72 rcyulres all enyrloyen to provide workers wmpen+Juno 1�1( heir enip oyces.
I'unu:utI to!ills,u11s1a, in rmpluraa is detined Js"...e cry P• .
..
.Press or implied, oral or wraten. or
Jrtnanhip,assoeunoo,corporation at uher legal cnnry. Jor themore
�n employer 1+detined L"an Individual,P' to in griployees. However the
t the I,Kegu,nil engaged In a joint enterprise, and including the legal represaly, ,playing
la a deceased employer.
I ,;cover or lrubige uI an ntdrv!dual. p
rrmershnp, associauoa or other legal entity,emp Y a of the
roman to three
maintenunea,cunsuuclion or repair work on wch dwelling house
owner of a dwelling house having not more than three Jparanenn and who resider!harem.or 1 e occupant
.Iwellir house of goober who employ. pa
or ,m the around+°r building appurtenant hereto shill not because of such employment be deemed to be m employer.'
�IGL chapter 152, d'_5C(6) also states that"every state or local Ileensing dings I shall withhold the issuance any
or
Itruea with the Insurance coverage reaulred.'
rtnel•al of a Ilecnse ur Par[need
d operate a businesse Of are to construes buildings In the Insurance
coverage
c I e r911vi11Ins+hall
applicant wile has not produ;ad Acceptable5( )>IJ esrlNeither he onunonwealda not any of its p
AJdiuunully, -,IUL chapter I5_, S- ( 4
enter into any ontract Ytu the Parfomwnca ul'public work until acceptable evidence of CunnPliartce with the msunnca
requirements of this Chuplar have been presented to the contracting authority."
s
Applicants the boxes that apply to your situation and if
es and bona nunrber(s)along with their CartiAeuta(sl of
necessary c:ls !ill out the worker' c t0r(s)sari al.$). ddret*m'and p,by checking LLP)with no employees other than the
insrae' supply u Liability
C rylp nice (. ).
worker' cortlpanaetion'oil -ttad if a eP or LLP door have
insurance' Limited Liability Companies(LLC)or Limited Liability Partner W
not required to
members or Purman, are required.
Be advised this affidavit may be subtnittad to the Depurtmant of Industrial
employees.a policy is req ' Also be sure 1e sign ued Jule the uftldevn theTil Department Ofshould
.\Ccidents for confirmation of insurance coverage.
�Cron for the permit or license is being requested,not the Ihp
ba rctunled to the city or town that the app uestions regarding the low or if you an required to obtain a workers'
Industrial,\ccid,fnte. Should You have any y
eotnpeinsation policy.Please Call the Depurterrent Ile the number listed below. Self-insured Companies should enter their
elf•insuranee license number on the a ro riuto lino.
city or Town of"Clals
you to !ill gut in the le era the otilce of Investigations has to contact you regarding he applicant,
Plcnsc he sure that the affidavit is complete and printed legibly. The Department has provided u space at the Uom
Uf the affidavit for y
hcations in an given ear, need only submit one:diiduvit indicating curtest
please , sure to till in the pekiut in
e n t the 1 which will be used as a reference number. In addition,an applicant
nhat must submit multiple pennitlicmule apP '
policy information(it nacesaary) and under"job Site Address" h ma(phednbr lu ensue►eowe may beprovided to thuna in e
ur
town)•",\copy of the ulilduvit that has been orticiully sump'
y y Y
permit not related 10 any business or commercial venture
applicant as proof hu a valid aiflduvit is on file for Nature Pmmits or liCensas. A new attiduvit must be flue out each
y ear. W here a hums owner er citizen is obtaining'.license s P
(i.e. o dog Ucen.+e or permit to burn leaves etc.)+aid Person is YOT required to complete this affida uthJle.ln uasuans,
I he Alice„1 (ave+tlgatlun* wuuld like lJ diunk you in advance fur your Cooperation atld should y Y 9
plead. du nut hesitate to give us J cJll•
lephuna a
nc� U.p.1(Imeltt's addre+., toTh Comntlonwealth of Mamchusetu
()apartment of Industrial Accidents
OUke of[nvadQatlana
600 Wilishin6ton Street
Boston, MA 02111
T al. 0 617.727-4900 ext 406 of 1.877-MASSAFE
Fax M 617-727-7749
;.try Id www.mau.gov/dia