24 SAINT PETER STREET - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
W
Department of Public Safety
Alassachusells State Building Code(7S0 CNIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
('Phis 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 Q Zip Code Name 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 fff Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix I)
r\(� Change of Use ❑ Change of Occupancy ❑ Other pccify: !y
11 V• .1 Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Er/
Is an Independent Structural Engineering Peer Review required? Yes ❑ No t3'
Brief Description of Proposed Work:
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): I 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❑ - FL• High Hazard H-1❑. H-2❑ H-3 ❑ H-d❑ H-5❑
1: Institutional I-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 Cl R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ III ❑ lIA ❑ IIB ❑ 1 IIL\ ❑ IIIB ❑ IV ❑ 1 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:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify,Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: I,-�
Not Applicable ClIs Structure within airport approach area? Is their review completed? a
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY o
Edition of Code: Use Group(s): Type of Cunslruclion:_ Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
[Nune
e and Address of Property Owner
(Print) No.and Street City/Town Zip
rty Owner Contact Information:
Telephone No.(business) Telephone No. (cell) a-mail address
licable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owners behalf, in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildin 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
10.2 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:F1'ORFFR.S"COAIPE,V I 10I INSUIL\'.VCE:v'f1Ui\vll'
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 O No 13
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
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 $
d.Mechanical (HVAC) $ Note:Mininmmfee-$ (contact municipality)
5. t echanical Other $ Enclose check payable to
6.Total Cost - $ S�N (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering any 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 any knowledge anal understanding.
=A--,G
e _oTitle_ Telephone No. Date
c V/-ForJvn'L,,- AAt Sine o2-4- \�1��(,
Municipal Inspector to fill out this section upon application-approval: e-M,vv Pt ~
Name Date
Eiome._'lei lNSPECTHOINAL :3ERV•CJE.S' EJ�HP'��RTIVIE��r
FIRE ESCAPE AND FIRE BALCONY AFFIDAVIT
Date: Filing Fee: 'Smwdad�erstructure
AWPW(P
To: Commissioner,Inspectional Services Department
I that I have inspected the (please circle the following): ire esc:aDe (E, rior Bridge)
(�Fiieoosfc
=Egi:s (Couriecting balconies) rways) located @ c noose one) Side rout or
_(Wooden St ol) C 1 0 s
Rear of: Building Located at:c7A—Sw V.
Property Owner. -!�g: (� .ls--n-f.•l-k' Phone
Owner' do-ess: -\? �t 15 ske�
City State Zip
To the best of my knowledge, information and belief, this egress component is in conformity with
provisions of the Massachusetts State Building Code,Chapter 1001.3.2
Certification is required every 5 years by a Massachusetts Registered Professional Engineer,
Licensed Fire Escape lustaller, or other qualified and acceptable to the Building Official.? i
Registered Professional Engineer Registration Number
�Kvz- Q
Licensed Fire Escape Installer Licenge-d Number and Type
tiler k ed by BUilding Official)
AMP
Commonwealth of lvassachuserts
Suffolk County
Then personally appeared the above named:
And made oath that the above Statement by hirn/hur is true;
Before me: Date:
My Commission expires on: -Notary _
10 10 PnA SSAC HUSI-71'..'.AVEN U E GO ,Tt): M,A Cj.2 I i6 1
The Commonwealth of Massachusetts
Department of IndustfialAccidents
1 Congress Street,Suite 100
Boston,AM 02114-2017
www.massgov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lesibl
Name(Business/Organim iorWIndividual):
tr _(
Address:
City/State/Zip: 21 Phone#:'Q
Are you ao mployer?Check appropriate boa: Type of project(required):
1. am a employer with employees(full and/or part-tune).• 7. New construction
2.Q I am a,sole proprietor or partnership and have no employees working for me in 8. EJ Remodeling
any capacity.[No workers'comp.insurance required]
9. El Demolition
3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t di
10 0 Building addition.
4.❑I am a homeowner and will be hying contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.1—]Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.Q Roof repairs,
These sub-contractors have employees and have workers'comp.insurance.t
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box nl must also fill out the section 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 a new affidavit indicating such
tContractors 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-contactors have employees,they most provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. ���F
Insurance Company Name t
Policy#or Self-ins.Lic.#: C — Expiration Date: —r X t�5
�Job Site Address: �� J��4 T GSty/State/Zip .([ \'
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify un r the ain d penalties ofperjury that the information provided above is true and correct.
Si ature: Date:
Phone#: I�' ✓
Official use n 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 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts 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 a joint 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 states that"every state or local licensing agency shall 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 with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states'Neither the commonwealth 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-contractor(s)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
be 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. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
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 fill 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 dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Page If of pages
John Carter 1
Fire Escape Services
70 G St.
South Boston, MA 02127
617-990-7387
PROPOSAL SUBMITTEQ.i9:, - �� /�, JOaWAME JOBN
ADDRESS r-., JOB LOCATIO� (pVh/C7-.'
DATE< ��t_r\ � DATE OF PLANS
PHONE# Jv11 FAXq JARCHrtECT
YIYe hereby submit specifications and estimates for:A—UJIL !F-nSCJkPlL
---
NV
_w �
VV^� o furnish material tabor—c�e accordant ith th bove specifications for the sum of:
Dollars
with payments to be made as follows:
Any alteration or deviation from above specifications involving extra costs Respectfully
will be executed only upon written order,and will become an extra charge submitted
over and above the estimate. All agreements contingent upon strikes,
accidents,or delays beyond our control. Note this proposal may be withdrawn by us if not accepted within days.
01aeptance of ogat
The above prices,specifications and conditions are satisfactory and are
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above. signs e
Date of Acceptance Signature
A-NC3019/T-3050 09-11
r:rt;L
�PTI t�dt'401 bl'di0it
7 AN
1. All work shall be completed in a professional manner and in compliance with all building codes
and other applicable laws.
2. To the extent required by law, all work shall be performed by individuals duly licensed and
authorized by law to perform said work.
3. Contractor may at its discretion engage subcontractors to perform work hereunder, provided
Contractor shall fully pay said subcontractor and in all instances remain responsible for the
proper completion of this Contract.
4. Contractor shall furnish Owner appropriate releases or waivers of lien for all work performed or
j materials provided at the time the next periodic payment shall be due.
'5. All Change Orders and/or Additional Work Authorizations shall be in writing and signed by both
Owner and Contractor.
6. Contractor warrants it is adequately insured for injury to'its employees'and others incurring loss
or injury as a result of the acts of Contractor or its employees and subcontractors.
7. Contractor shall, at its own expense, obtain all permits necessary for the work to be performed.
8. Contractor agrees to remove all debris and leave the premises in broom-clean condition.
9. In the event Owner shall fail to pay any periodic or installment payment due hereunder, Contractor
may cease work without breach pending payment or resolution of any dispute. Failure to make
payment within days from the due date of payment shall be deemed a material breach
of this contract.
10. All disputes hereunder shall be resolved by binding arbitration in accordance with the rules of the
American Arbitration Association. '
11. Contractor shall not be liable for any delay due to circumstances beyond its control including
strikes, casualty-or general unavailability of materials.
12. Contractor warrants all work for a period of days following completion.
Note: This form is not a substitute for the advice of an attorney.Legal advice of any nature should be sought from competent,.
independent,legal counsel in the relevant jurisdiction.Absolutely no warranties are made regarding the suitability of this form
for any particular purpose.
�rD�1D�aY Page#�'�.,of pages
�1
1'
x
f i
PROP SAL SDBMITiEphQ _ � /�, ME A JOB#
ADDRESS � �` \v1C'T ej—� JOB LOCATIOpL�(C--r
`G✓ `�1\ tC DATE \vxyV� DATE OF PLANS
t M
PHONE If FAX# ARCHrrECT
tlYe hereby submit specifications and estimates for:
-
---
.�.e.pFepose o furnish material —cam le i accordance, ith th above specifications for the sum of:
- .
Dollars
with payments to be made as follows:
Any alteration or deviation from above specifications involving extra costs Respectfully
will be executed only upon written order,and will become an extra charge submitted
over and above the estimate. All agreements contingent upon strikes, '
accidents,or delays beyond our control. _ Note this proposal may be withdrawn by us if not accepted within days.
0(cceptance of o�aC
The above prices,specifications and conditions are satisfactory and are
hereby accepted. You are authorized to do the work as specified. Signat re
Payments will be made as outlined above.
Date of Acceptance Signature
A-NC3919/T-3650 09-41
Page# of pages
PROPOSAL SUBMITTIE & J- E JOB#
eL�S CU e 9C�
ADDRESS 1 � � ^ _� JOB LOCATIOI�,
DATE C'J
'` DATE OF PLANS
PHONE# FAX# ARCHITECT -
We hereby submit specifications and estimates for:
. Y�-propose herchy_to furnish material a"diabbf-
-com let accordance dh th above specifications for the sum of:
Dollars
with payments to be made as follows:
Any alteration or deviation from above specifications involving extra costs Respecttully
will be executed only upon written order,and will become an extra charge submitted
over and above the estimate. All agreements contingent upon strikes,
accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days.
2ueptance of _(((yyylll oast
The above prices,specifications and conditions are satisfactory and are _)`
hereby accepted. You are authorized to do the work as specified. nat Sig
Payments will be made as outlined above. •
Date of Acceptance Signature
A-NC0019/T-M50 0311 -