10 SUMMER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Department of Public Safety
�V Massachusetts State Building Code(780 OAR)
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) -
ID SunemY -e6e t -5deM
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 2rT Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
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 Er'
Ism Independent Structural Engineering Peer Review required? I/ Yes ❑ No [3�'
Brief Description of Pr o Work: �jiL //O f k t n £C K• rY ( 'H a �/�
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&T 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.) SL 00
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: Fact F-1 ❑ F2❑ 1 H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ ❑ ❑H-4 -5
1: Institutional 1-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R. Residential R-10 R-2❑ R-3 Uf R-4❑
S: Storage S-1❑ 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ HA Cl IIB ❑ HIA ❑ HIBA:I' I IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water SuppI Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public, Check if outside Flood Zone❑ Indicate numicipaLEr A trench will not be licensed D'' °sal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: o"
Permit is enclosed❑
Railroad rightof-way: Hazards to Air Navigation MA Historic C,...,.,,:a:on Review Process:
Not Applicable Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No Er-- Yes❑ No lam
SECTIONS: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:
SECTION9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Prirhf No.and Sbqet City/Town Zip
Property Owner Contact Information:
brad m1r .� 617 ?y6- I3gZ Et? - 8r0_ /3yz 63(�ear�S69( ��yr`°M
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
// /U vlo.�� Zjr 1Vrn 'It, (4
Name Street Address ity/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 33,000 cu.ft of enclosed space and or not under Construction Control then check here 0 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 b lT
&//t4-, u I CS' —eyygs� � f lyl,r
Name of Person Rasponsible for Construction License No. /and Type if Apphca�1
#r— A�r �^ -T r— - °v«I f'a'L !fir dl.f?U
Street Address City/Town State Zip
I` �,O- 77,11 =_ �jplHtsttcJ(Sf��C(�va/1coC . CL
Telephone No.(business) Tel hone No.(cell) e-mail address
SECTION 11:WORICER COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.S 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 ire of the building permit.
Is a signed Affidavit submitted with this application? Yes; No C3
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor U
Item and Materials) Total Construction Cost(from Item 6)=$ yDO 0 • U
1.Building $ ODO • D V Budding Permit Fee=Total Construction Cost x_(Insert here
Z•Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact munici_oali(y)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ #000. 00 (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.
MIA*, r2 M✓tz r-cr-- 7 //—/^/
Please print and sign name Title Telephone No. Date
S Address City/Town State Zip
O✓[sy r✓l
Municipal Inspector to fill out this section upon application approval: �'-'�"•' ter^-. J/ S
Name Date
i CITY OF S.0 ENI, NaSSACHL'SETTS
BuHMLNG DEPAR—nW.NT
• a• 120 WASHINGTON STREET,r FLOOR
TEL (978)745-9595
FAX(978)740-9846
K1%,{BEItLEY DRISCOLL
MAYOR Ti-mw ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO%06USSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
dame(Busimm�&Organiration/individual): yv 1 j I, .-- >'Yb R -•Rrl�
Address: YJ +� t a� S r
City/Statc/Zip:a,ve-2rt-IL At 2ls3a Phone #: 174i 846 - Z730
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
era (full and/or part-time).* have hired the sub-contractors
2.Plant a sole proprietor or partner- listed on the attached sheet. 7• - emodeling
ship and have no employees These sub-contractors have V. ❑Demolition
workingfor me in an capacity. workers'comp.insurance.
y9. ❑Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11-El Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 131:1 Other
comp.insurance required.)
'Any applirud that cheeks boa el must also fill out the section below showing their workent compensation polity infurmation.
'I lomem ors who submit this affidavit indicting they are doing all work and then hire mmide contactors most submit a new affidavit indicating wdl.
:Conlnctots that check this box must anwhod an additional sheel showing the name of as sua•caorecbn and their workers'comp.policy infamiada,
I am an employer that is providing workers'compemadon insurance for my employees. Below is the policy and Job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/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 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 as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. [It advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance cov .verification.
l do hereby cer ify under the nd penaties of periury that the information provided above is true and correct.
t ire Date:
Phone#: '??,f P4- 27 �r f -
OJfcial use onQt Do not write in this area,to be completed by city or town official
City or'fown: PermittLicense# _
Issuing Authority(circle one):
1.Board of Iferlth 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF SM ENM) i --1SSACHUSETI'S
BI;ILDNG DEPAR-MENT
130 WASHNGTON STREET, 3' FLOOR
TEL (978) 745-9595
F.kX(978) 740-9846
KimBERI.EY DRISCOLL
l LAY01 THo.%Lis ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BCIIDLNG CO%NISSIONER
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 9 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:
(name of hauler)
'fhe debris will be disposed of iin�
(name or facility) I ' y
(address or raclllty)
signature of permit applicant —
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