Loading...
5 RED JACKET LN - BUILDING INSPECTION (3) 4110. od � (j � - 9 The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One or Two-F (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) .P✓' JnU LN y k 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 V I Repair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 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 Per Review r itured?,' / / / �, Yes ❑ No f}' Brief Description of Proposed Work: RG,O/n�%hi �Fw �tr/rah /.a.hihcllt LOv✓Yle7o'os 1 4Jnar.- A/o S rdc rm ia/or S�nx a ov 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 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ 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 fx CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ UB ❑ IIIA ❑ 1II130 IV ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information e Sewage Disposal: Trench Permit. . Debris Removal: Public V 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 Historic Commission Review Process: 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 Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION - Name and Address of Property Owner MAAfro PALMe12 Pfi1T *4aer LANE SAL9740 WlA- 01 -16 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: n 6 41-_ q18-7-_`6 7 1:7— react a wlar<,o,yuxm•f.co Title Telephone No.(business) Telephone No. (cell) e-mail addrJss if applicable,the property owner hereby authorizes /17L / �� �✓iH 7 ya/�/e� � o,oV2_ Name Street Address Ci /Town State Zip to act on the property owner's behalf,in all matters relative to work authorized b this building permit application. SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2) - -. 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 - _ Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.22Geneeral Contractor / Company Name Si6To cS� Name /of Person Responsible for Construction /license No. and Type if Applicable / Street Address City/Town State zip Zip -Vd,3. 93"63 971 - 13- 63 mcG�dwihc�m i y(/t/ G/df�s:��o�+? Telephone No.(business) Telephone No. cell a-mail address - SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 t' ance of the building permit. Is a signed Affidavit submitted with this application? Yes Pf No 0 SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ rZ 5 0 D Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ p p p, p o appropriate municipal factor)=$_ 3.Plumbing $ o 0 0 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ 6 6 d (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. 06 �i�d t.is 9t-`/d3- Fy63 -) - 3 Please print and siy name Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name "' Date 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) 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) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this.The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where plicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Discipline Expiration Date Street Address City/Town State Zip i CITY OF SM Mvl, INLksSACHUSEM • BI.:II.DING DEPARTJ(ENT 120 WASHINGTONS STREET, Yn FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KmBERLEY DRISCOLL MAYOR THoma ST.PmRRz DIRECTOR OF PUBLIC PROPERTY/BUUMINiG CONMUSSIONiER Construction Debris Disposal Affidavit (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# 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 111, S 150A. The debris will be transported by: �r�ishlll�s/-P+s i/iS��iS.,/ i/JeH76 (name o auler) The debris will be disposed of in i vVJW'r,sl of /�os41 (name of facility) (address of facility) signature of permit applicant date dcbni fT.dm The Commonwealth of Massachusetts w Department of Public Safety Massachusetts State Building Code(780 CMR) dQS' Building Permit Application to Construct,Repair,Renovate or Demolish any Building other than a One-or Two-Family Dwelling Code and Other Requirements for Building Permits The Department of Public Safety has issued these building permit application forms so that municipalities across the state can move toward use of a single permit form and consistent pemrit application process. The MA State Building Code specifies the requirements of building permits and the applicant is advised to review and be familiar with these requirements in order to avoid some of the common permit application problems.Likewise the applicant should be aware that some municipalities require that the owner confirm, even prior to acceptance of the building permit application, that no outstanding property taxes, water fees, etc.exist Filing Instructions 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be reviewed if construction documents, specifications, fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a check for the Building Permit fee. The fee may be calculated using the information to be supplied in section 12 of the Building Permit Application. The check is to be made payable to the local city or town where the work will be done. e�ry„rvra„ro&Bus �P/f�,.�oc/rs�l(a License or registration valid for individul use Office of Consumer Affairs Bosifiess Regulation only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to _ I Office of Consumer Affairs and Business Regulition j agistration: 105029 Type: WN xplraUon 7/16I2014 Individual 10 Park Plan-Suite 5170 i Boston;MA 02116 MICHAEL F.GOODWIN A-, I i .Michael Goodwin Jr 7 HOLT RD. i EPPING,NH 03042 = - - Undersecretary . ' Not valid without signature Massachusetts -Department of Public Safety ,. 1 Board of Building Regulations and Standards 1 Construction Supervisor License: CS-081670 'wf4B `-,I 1\ ,,,.. &HCHAEL F GOOpWIN 'I,. -. 7 HOLT RD - V Epping NH 0304E 1 1 Expiration 08/08l2015 Commissioner 51;?' ®'L Your complimentary 13" 3" 753' 12" 24" ' Iu� use period has ended. „ - Complete Thank you for using M1 2-71 " _, POFComplete. WAII 1 [e..x Y. .r W(fr�li yitira .a;ttr .. NiV�•«¢. _ ul 1 r 8a k. II 12" ece on LH of ge 1239 ER39L ea N N t 32124 24.DISHW O SWSi83 SLSCR rn W 93132 -�- n Double Sin rash Pull-o O Tilt-Down ray p y Super Draw with se rom o m Tail Utility /ShelVee m 4 Drew r ese p � W (J Kemper C Instry Pull Doom Spice Ra w= Color" rstylo ;a Maple Woo W Natural Rosh Soft Close Doom and Drawer m Super Susan 'th Chm M pJ W Cb i y :p Comp Mr m N r BE 3WDJMP A a '�- W a 17 1G ' a 2.4{ 1 5" m yi„ o N ..�,.._ 12" !.. S A 1GS1.. Y: 2 " W 0 D7 All dimensions-size designations 20 2O j This is an original design and must Designed: 7/16/2013 given are subject to verification on TECHNOLOGIES not be released or copied unless Printed: 7/16/2013 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. Palmer Townsend 4 Kitchen All Drawing#: 1 CITY OF S�U.&N4 IMASSACHUSEM BUILDING DEPAR'fJIENT • 120 WASHINGTON STREET, Sae FLOOR a TEL (978)745-9595 FAX(978) 740-9846 KI\fBERLEY DRISCOLL THO MAYOR MAS ST.PD3RR8 DIRECTOR OF PUBLIC PROPERTY/BUILDING CO'.MUSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �� / Please Print Leejbly Name(BusinaswOrganni/izazion/individualll):_. / //-; �c C�✓l.� Address: 7 h��� lAq d City/State/Zip: s= it /r/ 36� Phone#:_778'ea-3 Yy63 Are,you an employer?Check the appropriate box: Type of project(required): L d1 am a employer with,_ 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-tithe).' have hired the stub- contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition (No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t employees. [No workers' comp. insurance required.] 13.0 Other Any applicant that checks box 01 meet also fill out the section below showing their workers'compmmion policy infomtmiom *Ifortxrowners who submit this affidavit indicating they are doing all were and then hire outside watmctars most submit a new affidavit indicating such. :Contrmxon that check this boa most anached an additional sheet showing the came of Poe wb•coneacton and their worker'comp.policy information. l am an employer that b providing workers'compensation Insurance for say employees. Below br thelialey andJab site information. /J L ur . Insance Company Name: - Z4, Policy#or Self-ins.Lis.M. ✓Wc- 6 016 1 750/ Expiration Date: �y�j� ' Job Site Address: S Rod ��`tc7r Z-h: City/State/Zip: .S�,4, Oy Attack 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 S1,500.00 and/or one-year imprisonment,as well an 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. 1 do herby t'erllfy under the pains and penaldes of perjury that the information provided above is true and correct SiLnatttreo^ Date- Phone#: Official use only. Do not write In this area,to be completed by city or town ofciaL City or Town: Permk/Llceme# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cityffowh Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: