4 SUMMIT AVE - BUILDING INSPECTION The Commonwealth of (Massachusetts
1 l I Department of Public Safety
ra ,.• :\hus lchusolts SLII, Buildin+;Code(i SIIC\Ilt)
Building Permit Application for any Building other than a One-or'I'wo-Family Dwelling
(I Ilis SCChtlll For Official Use Only)
Building Permit Nwnber: D,Ife:Applied: Buihliog Official:
S ECIION l:LOCATION(Please indicate Illuck M and Lot p fur locations for which a street address is not available)
A-e arf 7' j or'
No. and Street City i ruwn Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of•\1:1 Slue Code used If Note Con.Strt1C lion check here❑or check all that apple' in the two rult:s below -_
hsisting Building❑ 11opoir Altcrtliun Addition ❑ Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ I Change of Occupancy ❑ Oth r ❑-Specify:-_---- ___
Are building phms and/ur ronstnlclion documents being supplied as part of this permit application? Yes ❑ No-In --_---
Is an Independent Structural Engineerii},%�Peer Review rcyuiry'd? Yes ❑ No Yr"
/�e�eBrief Description of Proposed Work: � e 2.f, Aaq� is
SECTION 3:CONIPLHE TILLS SEC-FION IF EXISTING BUILDING UNDERGOING RENOVA"r10N, ADDITION,OR
CHANGE IN USE OR OCCUPANCY '
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 G\IR 14) ❑
Ex isling Use Gruu p(s): . —_-- _ Proposed Use Gruup(s):---__
SECTION 4: BUILDING MIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement leevls)&Area Per Fluor(sq. ft.)
TuLal Arca(sy, ft.)and Toted Heigm(ft.)
SECTION is USE GROUP(Check as a licable)
\: Assembly A-I ❑ A.2❑ Nighldub ❑ A-1 ❑ A-T ❑ A-i❑ 3: Business ❑ E: Educational ❑
F: fv4n F-I ❑ F2❑ II: High Hazard H-1 ❑ H-2❑ HI-1 ❑ li-4❑ 11-i❑
I: Institutional 1-1 ❑ I-2❑ 1-3❑ 1.4❑ AI: Mercantile❑ R: Residential R-10 R-2❑ R-1❑ RA❑
S: Storage 5-1 ❑ 5.2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONS rRUCrION TYPE(Check as a licable)
I:\ ❑ IB ❑ II,\ ❑ IIB ❑ I11,\ ❑ IIIB ❑ IVO VACS VB ❑
SI.C'FION 7:SITE INFO 10,IAT ION(refer to 780 C.Nall I ILO for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: french 1'ennih Debris Removal:
PuhliC Cl Check it outside Flood Zone❑ Indione mtmicipal ❑ A Ire 11 kill not be Lk vused Di.puS,J Site❑
Pricale❑ or indenlih Lone: or sill site St slum Cl , required ❑or tronch or Specify:
_..._. __— pandit is rni locrd❑
Railroad right-of-way: Hazards to Air...\aw igatioo: ,. . .
\', I:1plhrahle❑ IS�trurlure a ilhin .urpnrl ipprook h area.' Is Illeir rev it 1 nnlpleled! .
nr Cnmrnt hollud,l an,InsrJ ❑ lrs❑ ar.\'u❑ 1IS❑ ..\',i ❑
SFCI ION 8:CON LNI'OFCFR 111 K A I F OF OC('UVANC'Y
fd11-1-1 ode Cv•C;mup(SI. I\pore l„llanl,mnrt: 0, up•InI I.-,id ln•r I'I ivr —
"—
bnildn ��,� am,m�plu) , Ikli-r 1il h'ttl�" �piti l,d�11p11 .I lit lhl
I4m. lhr � �nl� . ._
�}%ice j' � .r_ "' -�^'�`--a-6 ✓� -c �6L- s- -- -
7
SR II0N9: ilitolli!l(IYOWNI:ltAUlll()I(IZ,'LltON
Noiticank I Ad,I rvs4ut Propcitv Owner
Name. . (Print). , _ No.and Street City/gown Zip
Property Owner Contak I information: 7e-,, VAv Der&a cfe ke'l
f.2� _106
fide Telephone Nil. (business) relephone No. (cell) a-mail address
lf,ipplicable, the property owner hereliv Hidiori/vs
Nome Street AlILINSS City/Town State Zip
Ill At on JIIV property owner's behalf, in all matters relative to work authorized by this building permit ai,,Lflication
SECTION 10:CONSTRUCTION CONTROL(please fill out Appendix 2)
If buildin is less than}S,IHIII cu.ft.of elici,jeki space anti/or not under Coiistnictit)tiC(,lltf,iI then check here 0 and skit Section 11)1)
I().I Registered Professional Responsible for Construction Control
Mime(Re,islraot) Telephone No. e-mailaddress Registration Number
r
Street Address City/rown State Zip Discipline Expiration Date
10.2 General Contractor
T�lll- dr) C7 (D/5 14 /7 ft e Cd-4)
Company Name
71-t" ffkrJC7 Ae?-4
Name of Person Responsible for Construction License No. and Type if Applicable
tl--f /-?a r•4er r. 0174 eff
Street Address City/Town State Zip
Tole shone No.(business) Telephone No.(cell) C-mailaddress
SECTION 11:M 11 l N!, Ek MI ""A I lk 1%.N.,11"AM I A1.1ji o',\'l l, N.G.L.c.152.4 25C(6))
A Workers'Corliper'sation Insurillicij,Affidavit from the NIA Department of Industrial Accidents must be completed Jnd
sotirnitteet with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is signed Affidavit submitted with this application? Yes 13 No 13
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor Joel Materials) Total construction Cost(from Item 6) -5---_
I. Building 5 Building Permit Fee'Total Construction Cost x—(Insert here
2. Electrical 5 Appropriate municipal factor)'$-
1. 11111111bilie, 5 Note: Mmill"I'll fee='5--(contactIll"lliciPlitO
4. M"hallic'll (11VAC) Is
01111m) 1:0 Fnclose check payable it,
f" foI'll Cost 5 //1 (contact municipality)and write check imililler hart
sticridN 11 SIGNA WRE OF BUILDING PERMIT L - NT
I liercliv attest under the pains penalties of perjury inforl atioll'ont'lowd Ill this
It%-entering Ilk "arlie bvio-, . that 't ti
Ipph"Ition is truearld act orate to the best of ilil. knom ledge and understanding.
4z L/- 6y67
--- -- -----
Plcasv Imot mid lgll uamt I role 1, t-phorte Nil Doe'
�trtcl lef
.Municipal Inspector to fill out this "tion upon application approval:
N.atiAt, I tv
1 ,
cl-rY OF S:u E-mil AkSSACHUSEITS
1 BUILDING DEP.kR MENT
it 120 WASNLNGTON STREET, 3ta FLOOR
TEL 978 745-9595
F.k-'c(978) 7 09844
j.\(BEALEY DRISCOU I�{OSL�SST.PiFstRB
NLAYo.'t
DIRECTOR OF Pl:OL(C PROPERTY/BCRD(NG CONLVISSIUNER
Workers' Compensation Insurance Affidavit: Builder/Contructurv/Electrlclansl Plumbers
lnolleant information Please_Print Legibly
Noire(iloslne+SOr�laN.IIIUhINI1V11111.11):
Address:
CilyiSratc/Zip: Phone N:
Are you an employer?Cheek the appropriate boo Type of project(required):
1.❑ 1 am a employer with 4. Cl I am a general contractor and 1 6. ❑Now consuuction
employees(filll and/or part-time).* have hired the sub-cwniractan
2. 1 aln a sale proprietor or partner- listed on the attached shec1.t 7, [] Remodeling
.hip and have no employees Thee subcontractors have V. ❑Demolition
working for me in any capacity. workers'camp.insurance. 9. C3 Building addition
[No workers'.comp, insurance 5. ❑ We are a corporation and its
requirod.( officers have aaercised their 10.❑Electrical repairs or additions
3.0 I an a homeowner doing all work right utdxmnplion per MGL I I.Q Plumbing repairs or additions
myself.(No workers'Gump. c. 152,11(4),and we have no 12.0 Roof repairs
insurancerequired.(t employees[No workers' aC]Olher
Gump.insurance rcquimd.(
wy appll,q dial d imisi bat el mutt Aw fill uul the U%lim below lowing Ihair Taken'eompanudun Puduy mOumuUon.
'I Lnnouwnna who.unlit this A111I indlwins they am doing ail,wrk and then hit*weids eantncton mwet shmk a maw 1171davil indicuing,udt.
4%,nimion,that Owk this bus meet ntachud in adlldunaf.haal+huwing the nuns o(the mlhSenuleturs and their worket*'mmp.policy in/umudoq.
l urn an employer that It pruvfdhtirr workers'cumpensaNun hisurunee/ar my employees Below lithe policy and joh vile
inlurlrrurlon.
In,urannCdntpunyNmne: �RVe%y -T�'7-.-._
irulicy 4 or Sclr-itu. Lic. d: Expiration Date:
tub Sita Addrvss: y .S�....1 1411, Ci(yiSlattizip;
teach a espy of the workers' compensation policy declaration page(showing the policy number and expiration data).
F.tlJura to wi;ury cuverap as required under.Svction 25A of MGL c. 152 can lead to the imposition of criminal penalties of s
tiro op to i 1,500.00 undlur one-year imprivnnment,as well as civil penalties in the corm of a STOP WORK ORDER and a line
of op to S_M.110 a Jay against the violator. Ile advised that a copy of thiv.+tatement may be(urwurdcd to ilia Oiiico of
to vc,ti gal ions oft lie DIA f:)r insurance coverage vcri ticaliun.
l du hereby certify ender ilia paint cud penuldev of petiury that the lnfaratudon pro Aided above;,true end correct.
i i..•. I I ^ Dnfar ` 23 l C
I'F,y J
Official tme ouly. Da,rot wore in this area, td he cmuplewd by city or town rl//1rmG
(:Ry fir I"oval:_ I'ermiul.lccme 4_,__
I'ming.\ulhurily (circla mac):
I. hoard of Ileallh L Dcp.trluteat .1, f'i(p fowl Clerk 4. lihetrlc.tf Iil+pecfur i, pLtnlhin4 Intpecror
(. ILhcr
Phone h
CITY OF 5., -am, Aus.,CHuSETTS
dLLLOLVG DEP.iA-nL .VT
f'0 '4•."14LNGTON STXW. }'Ftcc%
Kj. LMERL&Y OVXOLL P.Vt(97� 1447846
MAYOR f)tomu ST.PMUS
DIIttGTOr 4PPl eLIC PRGPrATY/BCQALYG CO.Nausst0.VElt
Construction Debris Disposal Atfidavit
(required for all demolition and renovation work)
In accordance with the sixth edition Oahe State Building Cade, 780 C.MR section I 11.J
Oebds, and the provisions of MCL o 400 S 14;
Building Permit V is issued with the condition that the debris resulting from
Ihis work shall be disposed of n property licemed waste disposal facility as defined by NIGL o
I 11. S 1 JOA.
Th/e/de/b'ris will be trans/portcd by: (
(n une-if'hauler)
at debris will be disposed of in :
(name of racily)
1 ddrerr ar AahIY!
u�n�nlreufrermitipph.�nl