10 PRINCE - BUILDING INSPECTION G A- 2 q �
,. lr
;The Conimonwealth'of Massachusetts" '
h y Department of Public Safety
\ Massai lwsrtis Slue llui Id ing Code(7#II LAIR)
Building Permit Application for any Building.other.tl>_an a'One-or Two-Family Dwelling
('Phis Section For Official Use Only)
Building Permit Number ___ __ _ Date Applied: .__ Building Officiate
SECTION 1:LOCATION(Please indicate Block B and Lot q for locations for which a stree a s In Ilab )
No. and Street City/'Town Zip Code Name of II ding(if appli(able)
SECnON 2:PROPOSED WORK
Edition of MA Slate Code used.__ If New Construction check here❑or check all thet apply in the two Ales below
Existing Building Repair❑ Alteration 9 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:Are building plans and/or construction dlx'uments being supplied as part of this permit application? Yes O No _---
15,m bldupendent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed%fork:.__
_-- 9; IP1T —CL W 1. 7 E 3 TN200 L-i
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,.ADDCr10N,Olt
\ CHANGE IN USE-OR OCCUPANCY
Check here if an Existing Building Investigation.and Evaluation is enclosed(See 7ri1a CkIR.34), ❑
Existing Use Criup(s):ns:. - 11 + . a, 1 ., Pritpused Usc'Grou'p(s):
SECTION 4: BUILDING MIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) 4 Z�j} 6 t9
Toted Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly°AYC3, A42.13 Nightclub ❑ A-1 ❑ A—1❑ A-5❑ 1 8: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2 Cl 1T: Ili h Ilazard H-1 ❑ .H-30 11.3 ❑ H-4❑ 11-5❑
1: Institutional 1.1 ❑ 1-'_❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential 'R-10 R-2❑ R-1 11-4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑'.in,] please describe below:
Special Use •' ' '`•% �,•
SECTION 6:CONS'TRUCrION TYPE(Check as applicable)
IA ❑ IB ❑ HA ❑ 116 ❑ IFFA ❑ [fill ❑ IV., ❑ I VA ❑ Vil ❑
SEC"LION 7:SITE INFORMATION(refer to 780 CMIt 111.0'for'details oA each item)
Water Supply: Flood Zone Information: Sewage.Disposal: Trench Permit: Debris Removal:
Public?94 Cheek if outside I:Inod Zone❑ Indicate municipal❑ A tryndl hill nut be Licensed Disposal Site❑
required ❑or trench or spu A, ...
P,riraly❑ or mdsntih 7unc. nr on site cc stem❑
-r'• , --=n :,� Z .ti : pC Imt iselli losl'd-0
Railroad right-of-way.' Ilatards to Air Navigation:
Nyt:\pf+ticdlF ❑�.,.,. Is Slrlctore tc ithiWairlort.tl+p route.lr',i.'�, Is their rvvii'l. courpl�IrJ „'*`
4
or L ooll'Il( t0 BIIIIII V11 f(1\ed❑ \l'\❑ 4,No❑ + �I )\'"❑, i ll ❑
SFC I ION N:CON I EN 1 OF C'Flt I(FICA F L• 01:OCCUPANCY
111011111 of Cute: __. ._ Cse l:roup(.q - I\pi.A Camden Wm: llll updntI oad lief I tenor' -
11ee+Ihr building c ontato.ul Sprinkler Seslem'. Spec 1.11 Slipulaliolls: -
tAAA C-TV
—fin f'-ca C,&&1-7 rCA-7ahJ
l�fu Ca"P,c�T' Si-7�C�r�
4 1
SE(:'I'ION 9: PIi01'I II IY OWNI:11 AUTIIOI(IZA'I'ION
N'aua•,ntd Address of Propvrl} Ow tier --
v
Name(Print) No.and Street --- -----city/gown 1 Zip
Property Owner Contact Information:
n�-
I Ole -- — Felephone No.(business) ...Felephune No. (cell) e-mail address
If applicable, the properly owner hereby authurites
_.....—_ Name - - Street Address t. -- -City/Town --- State -- Zip
to act on the propertyowner's behalf, in all nt,utcrs rclativo to Work-authorizcd by tliLq building ,omit a ,plir.i tiun.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if building is less than 35,0011 cu.ft.of enclwwd space and/or not under Construction Control then check here O and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
Nano(Registrant) Telephone No. e-mail address Registration Number
Street Address. City/Town State Zip Discipline Expiration Date
10.2 General Contractor
—
Company Name
_.5&Z) 2A C®oK � 99Z33
Nance of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
_ Za. M 3Y1 cnhd/ ,p Piro etion . CIO rA-
Tole,hone No. business Telephone No. cell e-mail address
SECTION 11:ttt�i 1 t t ,._S.aA)l I Ns;N nt)\ I\ t.n'.wt.'I All_II"tt'I I M.C.L.c.152§ 25C 6
A Workers'Compensation Insurance Affidavit from the NIA Department of Industrial Accidents must be completed and
submitted with this;tpplication. Failure to�,nrvide this affidavit will result in the denial of the issuance of the building permit.
Is a xfmcil"AYfidavit submitted with This a lication? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(front Item 6) ��
I. Building S 0010 Building Permit Fee=Total Construction Cost x_(Insert here
'_. Electrical - S gQ 0 appropriate municipal factor)=S
3, Plumbing S Q Q
Note ::\linimunt fee=S on tct n1U1110 p 111ty
J. \Ict'hanical ( thor) S fJ )
S. ,\Icchanind Other) S - Enclose iluw'k payable to [1J
c
h.Total Cost S Q (contact nmuticip,d itv),uul write check number here _---__
SECTION 13:SIGN.\"fURE OF BUILDING PERMIT APPLICANT
By cot n• g my i ri below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
apl,lii lii on is trite an, acntrate to the best of mt' knowledge and understanding. r.
I'case print and sign name J title Iblcphone:No. Ila c
/ga-C,M&7 ST _ _ . tre�Cc,- f - --- 0/?/J-
Itrcet Address Citt'i town titate /ip
Municipal Inspector to fill out this sediun upon application approval: _-
N'ante Ipatc
L
�9assachusette - Department of public S.Board or Buihlin'{ Regulations and Shmdardfct�a
Construction Supervisor License
.License: CS 99233
Restricted to:. 00..
SANDRA COOK 7
14 BROOK ST;
MANCHESTER, lol,:194q
..
Expiration: 1/27/2012
('momi..aiuner
"-- ^..,,,..�.•,....... _. ,-._.. .Tra: 992331 _..,. .
CITY OF SM—EM, NL-1SSACHUSETTS
BUILDING DEPART',--NT
120 WASHINIGTON STREET, So'FLOOR
TEL (978) 745-9595
F.kX(973) 770-9844
KIIBERL.EY DRISC01_L
AI.YOR T Hams ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSLMISSIONER
Workers' Compensation insurance Affidavit: Duilders/Cont rate tors/Elect rief3ns/Plumbers
Applicant information ,/) Please Print Legibly
VatTIC l0usitxss,(JrWaniration,ihdividual): QD , (/,�f F- ('J9l.&MeQCT70(J
Address:
City/State/Zip: 9 Phonef{:_b/7
Are y an employer,Check t appropriate b F
roject(required):
I. I am a cmploycr with 4, am a general contractor and tv construction
employees(full and/or part-time).* have hind the subcontractors
. 2.0 I am a sole proprietor or partner- listed on the attached.ihccL Iodeling
ship and have no employees These subcontractors have olition
working for me in any capacity. workers'comp.insurance. ding addition
[No workers'comp. insurance 5. 0 We are a corporation and its
required.) . . officers have exercised their trical repairs or additions
3.❑ 1 am a homcuwncr doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'Gump. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. (No workers'
comp.insurance required.) 13.0 Other
'Any applieeat Our dtceks box rl most also fill out the ruction below showing(hair waken'compenmdun policy irm naralion.
'I4an vwft"who mbntit this yniMvil indicaling they ate doing all work and then hire outside contmcm,m ul submit a new amdaril indiotiny ruck(1mry;wn t that check thin box must atmchrd m additiurva sheet showing the nwne of the rabruntrsckrn and their workers'comp,policy infummtion.
lain an earplayer that is providing workers'conrpenradon insurance for my emplayeex Below Ls the polity end Job site
irrfar,nation.
Insurance Company Vame:
Policy 4 or Sclf--ins. Lie. 4: Expiration Date:
Job Site Address: Cily/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Flilura to secure coverage us required under Section 25A at'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 aline
of up to S'_S AO a day against the violator. lie advised that a copy of this statement may he forwarded to the OI'fca of
Invesligaliuns ul'thc DIA for insurance coverage verllication.
l do hereby cerrify ader the pains Id penaldes of perjury that du information provided above is rwe and correct.
Pig t r t / Data: /�/ rL
Phoned- ��� D 7O p
Official use only. Da aot wrile ht Flris area,to be courpleled by city or/awn oJJIviai
� I
City or l'nwnt Pcrmitfl.lccnse d
�ulhorit IssuinK. y (circle one):
I. Board of Health 2. Iluildimg Deparlmcot .1.C'itylrown Clerk 4, Electrical Inspector 5. Plumbing luapeetor
6.Odwr
_ Phonc;h
i
Information and Instructions
.\lassachuseus General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also statds'tiiat"every state oriocal Ilcensidg agency shag withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any
applicant who has not produced acceptable evidence of compliance withihe Insurance coverage required."
Additionally, MGL chapter I52;§25C(7)'statcs"Neither the coinmonweslth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Scif-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Omcials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
-The Commonwealth of Massachusetts
Department of Industrial Accidents.
Of11ee of tavestlgations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-NIASSAFE
:ie%i;ed 5-26-05
Fax All 617-727-7749
www.mass.gov/dia
CITY OF S,U-&Nf, ttiL1SS,kCf-IL'SETTS
9LLLDLNG DEP.IRTJtLVT
120 WASHNGTON STR =v Sy Ft00A
I'M (978) 745-9599
Kl3®ERI rqy DRLX()LL RVt(978) 140.9846
,ti(AYOIt Tkoscu ST.PtM"A
D"EcrOta OP PC SUC PRO PEp7y/at:Mn LNC.CON NIS$tON Eit
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
rn accordance with the sixth edition of the State Building Code,
Debris, and the provisions of MCL c 40, S 34; 180 CMR section 1 11.S
Building permit a is issued with the condition that the debris resulting from
111, S I JOA.
ibis work shall be disposed of in a properly licensed waste disposal facility as defined by MCL c
The debris will be transported by:
(more of hauIv )
The debris will be disposed of in
(nameoYfacdity){ •
=87 �!Y/r 021y�
(Jddrefi ar•rJ,a�+y)
Zvi _
+ ynJNreofpermitpplwmf