20 SUMMER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
d4 Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwellin
(This Section For,Official,Use.Only)., {'
Building Permit Number.' _Date Applied "•' : . Building OEfia -
SECTION 1:LOCATION(Please indicate Block fY and tint(k for locations fa'r`'wlvch'a street address is not a '
90sE','42r Sf- Q G6q
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK , V
Edition of MA State Code used If New Construction check here❑ or the all that apply in the two rows below
Existing Building❑ 1 Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition (Please fill out and submit Appendix 1)
Change( I Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No /
Is an Independent Structural Engineering Peer Review required; / �,p,2 / Yes ❑ No 9--�
Brief Description of Proposed Work:r 7 S G/'.�l�{— ' Rim "T t
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 asapplicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H. Hi 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-10 R-2❑ R-3❑ 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 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 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❑
Private❑ or indentify Zone: or on site system❑ required ❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA Historic Commission Review Pnress:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes ❑ or No❑ 1 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:
r ,
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner � f
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Gwhe r)g't` S_7G-`r�3 -_- �byors� (�T/
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes G
iop�,yiF,Lw43 yaf s ?G SwK-twLq(' S )C'
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
If build is less than 35'06 cu:ft.of enclosed s ace�and or riot unatet Construcfion.Cbntro[thert Bieck bere.CPand'skf Section t0.1
10A Re istered Professional'Res onsible for Construction Control
of�.v'%d 61612S 96-1 --5'2G -93<3_ h6X�s�
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor. a-
19?426 A �,�,s
Company Na e
04-ur � � 12S o t Ti?
Name of Person Responsible for Co truction License No. and Type if Applicable
3 Ca_r A tiQ rC1,( SF tm A-P--b(0-Aegcj irv�
Street Address City/Town State Zip
'761-S26 -g3SS bb,Wr.SQ
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORkER5 COMPENSATION INSURANCE AFFIDAVIT 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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No 0
SECTION42:.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 $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact mun'tperCify)
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 true and accurate to the best of my knowledge and understanding.
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PleaseprinMt and PinC- n,e S� �_ 1 'e�Tel m Telephone Date
Street Address C �Vll City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name. Date
'`° CITY OF SiU.F—M, 1ANSSACHUSETTS
a 13t:=ING DEPAIMW—IT
� ) y< 120 WASHLIIGTON STREET, 3i a FLOOR
TFL (978) 745-9595
F.tix(978) 140-9844
)V.NfgFRt FY DRISCOLL
�r1,AYOR. T1t06tAS ST.FIE.QFtB
DIRECTOR OF PUBLIC PROPERTY/sunnmto COSLiliSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractor.9/Electrlcians/Plumbers
Applicant information p�7�U/n Please Print Legibly
Nat net flusilless PA-N""A- kd
Address: 3 I4f���co^_t k-e ro;S.( S'f— �-
_
City/State/Zip: hPgy 1hA-. �l7-0 PhoneM: ?&L5-26-2J
Are you an cm toyer?Check the appropriate boat rype orprn eat(required):
1.0 1 a employer with 4. 0 I am a general contractor and I 6, owe nstnxtion
ployees(full and/or part-time).• have hired the sub-contractor
2. 1 am a sole proprietor or partner• listed on the attached sheet t 7. em ng
ship and have no employees These subcontractor have it. add- - 0n
working fur mo in any capacity. workers'comp. insurance. 9, wilding addition
(No workers comp, insurance 5. 0 We are a corporation and its 10.❑Flew teal repairs or additions
required.) officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MOIL I I 1941umbing repairs or udditlonst
myself.(No workers'comp. c. 152,41(4),and we have no 12.❑ Roof repairs
insurance required.) t employees.[No workers'
Gump.insurance required.) 1J.0 Other
•Any uppllcum dwt ehcsks box s Musa l mu also fill uua thv seetioo below showing?halt waskes'.companradon policy inrurmatlot.
'I4mvuwncts who submit this affidavit indicaing they an doing all work and than him autridscomracron must submit a maw allldavit indiaing,itch
�C„mramom that Owk this box most uaul ad an addttiunal shoot showing the numa or this subaotnracton and their workers'comp.policy inrc madoo.
l con on eutploye►that Is providing worker'comprnsfadan hisuranee far my emplayerx Below is the pollcy and Jab she
informalialt.
Insurance.Company Name:
Policy d or Seif-ins. Lic.tl: Expiration Data:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failura to sucurts coverage as required under Suction 2JA of,,tGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a lino
of up to S2J0.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Off-we of
Investigwiuns of the D1A for insurance coverage vcrificuliun.
/da hereby cr y under thr polns a td Ienultles of perjury 1/191 the hrfor}natlote provided above is true mtd correct.
Zc::;-(3
phoncl
t UJJicial use oury. Do not wrilr in thls urea,ro be completed by city at town n/jlelrrd
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city or'rown: _ Permtt/T.Icenre# i
Issulall Aulliority(circle one): — _—
I. ❑curd of I(cull It 2. fluilding Departntent 1.Cilylrown Clurk J. Ctectrlcal Inspector 5. Plumbing lnspeeror
Contact 1'orsont. .. ..... _.. Phone lI• ..
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/err
' - CITY OF SiULE,%f NL L-1SSACHUSETr'S
Y
BUILONGDEPARTMEINT
120 VV-")i IGTON STREET, 3' FLOOR
TFL (978) 745-9595
IUNWERT Y DRISCOLL F.*x(978) 740-9846
+�L1YOR T lO,% is ST.FIEMa
Dt.2ECTOIt OF PUBLIC PROPERTY/BCII)LIIG CONNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 1 l 1.5
Debris, and the provisions of NMI. c 40, S 54;
Building Permit tt 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:
rs�0-- ✓ti er-5f
(name of hauler)
The debris will be disposed of in
�
(name of facility)
c!_ o ��Pti.E'r- (S
(address of facility)---
t
signature of permit applicant
date
dvbun. f'.6 k.
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