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49 SUMMER ST - BUILDING INSPECTION (3) z5 - OS The Commonwealth of Massachusetts Department of Public Safety lr � ' Massachusetts State Building Code(780 CNIR) 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) _ 4Yy1�1.12C/1�� 7e5� No.and Street City/'rown 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 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 ❑ Is an Independent Structural Engineerin Peer Review required? Yes ❑ No 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): IProposed 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❑ I B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-IIX R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2 Cl U: Utility❑ Special Use and please describe below: Special Use: �' U SECTION 6:CONSTRUCTION TYPE(Check as app [cable) ' IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ IV ❑ 1 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 9 Indicate municipal A trench will not be Licensed Disposal Sit e requiredA or trench or specify: Private❑ or indentify Zone: - or on site system❑ permit is enclosed❑ Railroad right-of-way: hazards to Air Navigation: 1IA I.li t n i Not Applicable K Is Structure within airport approach area? is their review completed? or Consent to Build enclosed❑ Yes❑ or No jo Yes No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): — LType of Construction: Occupant Load per Floor: Does the building contain an Sprinkler Systen ��P h?: AP Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner � Name(Print) 'No.and Street City/Town' Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address if alp 'amble,the property owner hereby authorizes 5 7. /� �/ O'q- 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 Appendix2). If 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 Re ister d Professional Res orisible for Construction Control Name astrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor - Con a y Name eme of Person Responsible for Construction License No. and Type if Applicable "StfeeT Address Ci /Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:WCaRKIsIS'(-O%`u'FNSA I[ON INSURAaVCE AEFfUAVI'I 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? Y,0 No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT fEE. Item Estimated Costs:(Labor Total MMa�ate�rials) utal 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:Minimum fee=$ (contact mupic' 'y) 5. Mechanical Other $ Enclose check payable to / Pa y 6.Total Cost I $ 4,9 tzv I (contact municipality)and write check number here SECTIO • IGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I here attest nder the p.'ns and penalties of perjury that all of the information contained in this application is true and accurat to ne kn dge and understanding. Please print and sign name Title Telephone No. D� —�lLS St... Address City/Town State Zip / Municipal Inspector to fill out this section upon application approval: Name Date f CITY OF Si]LLl ) LY�aSSACHUSE- L S ©U=LNG DEP.ARi-\MNT 120 MASHCYGTON STREET, 3a°FLOOR TEL (978) 745-9595 KIJtBERLEY DRISCOLL F-'Lx(978) 740-9844 INLAY03 THo.% 1S ST.Ptun DIRECTOR OF PUBLIC PROPERTY/BCILDL\G CONNISSIONER Construction Debris (Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 OAR section 111.5 Debris, and the provisions of LN101, c 40, S 54; Building Permit A 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 NIGL c 111, S 150A. The debris will be transported by: (nan c ofhauler) 'fhe debris wi11 be disposed of in (name o/f facility) (address of facility) signature of permit applicant date Iehn,a(�,Lie ' CITY OF &U EMI, NLNSSACHL'S.ETTS 4 . a BUILDING DEPART,ff—Nf ! c, 120 WASHINGTON STREET, 3aa FLOOR � Df TEL (978) 745-9595 FAx(978) 7.10.9846 KmBERLEY DRISCOLL AMRTFlontAs ST.PIEARfi DIRECTOR OF PUBLIC PROPERTY/BUILDING C0\1MISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractorv/Eleetricians/Plumhers Applicant Information Please Print Legibly Name(Business/Orgyaniration/Individual): / Address:f1T 7 /��/�/7 C>y�/y -+7 p City/State/Z,ip: � 404 Shone lt: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ i am a employer with 4• ❑ 1 am a general contractor and! 6. New construction employees(full and/or part-time).' have hired the sub-contractors 2 I atu a sole proprietor or partner• listed on the attached sheet.: �• 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 worker'' comp. insurance 5. ❑ We are a corporation mid its lo.❑ Electrical repairs or additions required.) officers have exercised their _ 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers'sump. C. 152, 9l(a),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other cump. insurance required.] . -Any applM.1 tlur checks bus pl ntou also rill out the section below showing their worker'compensation policy inlbrmation. 'I buneuwncns who wbmit this affidavit indicating they arc doing all work and then hire outside contractors most suhmit a now affidavit indicating such 4:mwxtun that chuck this box must anachcd an addiliural shwl showing the nanc of the sub-eommaors and their workers'comp.policy information. l out an employer that is providing workers'compensation iusurancefor my employees. Below Is the policy and job site information. Insurance Company Name: Policy 4 or Sclf-ins. Lie. H: Expiration Date: lob Site Address: - CityiSlate/Zip: 'knach a copy of the workers'compensation policy declaration page(showing the policy number and expiratlon 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 imprisnnmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded tothe Office of Iovcstigmions ol'the D 'nsurance coverage vc 'ication. - 27 /d'lrrreby c• rti r ias a rJ p r !11 ojperfrLry that the inforsatlon provided above is true and correct. Date: Phone 'jJ 1j T Official use only. Do not write in this area,to be caaepleted by city or town ofeiaL City or Tmvn: Issuing Aulhurily(circle one): I. Board of health 2. Building Depurmllcnt 1 Cilyffown Clerk J. Flectrical hlspector 5. Plumbing Inspector 6.Other Contact Person: -_ Phone n: til ,sl)dD S ' I_' 3. t - ----------- - �.----- ---.-- - - - - - _ r ,-1T 7 -. 1 1 J_ �. - I 11 t I t TLt f J .- i - ,, i 1_-1 t 7_ i I__ I � _I__ 91vrs'glv�r7ts�ll�yS�fQ/r'6/.1.�f9n #JJM -�r tis - __ I �--�--I-L�_L-1-1_�j �.L- �wolltNnlr�aaiv►r�n¢ `lybf