33 SUMMIT AVE - BUILDING INSPECTION (2) j
j37, r�-o a fit
\ The Commonwealth-of Massachusetts
Department of Public Safety
a� Massachusetts State Building Code(780 CMR)
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 tot It for locations for which a street address is not available)
No.and Street City/Town Zip Code Nvne of Building(if applicable)
rr
SECTION2: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❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ftB Specify: e�r.c jj r7'A,r•-J + Q is°)-
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review re uired? ` / n Yes ❑ No ❑
Brief Description of Proposed Work: jAtd?14/1 S �1,.,A SfR).v 0- 10'E r� 1'U
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): —Pro posed 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.)
SECTION5:USE GROUP(Check as applicable).
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-f❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Factory F-1❑ F2❑ 1 H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 El1-2❑ I-3❑ Id❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-1❑
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 ❑ VA13 VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR111.0 for details on each item)%
Debris Removal:i Trench Permit:Water Supply: Flood Zone Information: Sewage Disposal: Trench
Disposal Site❑
Public❑ Check if outside Flood Zone Cl Indicate municipal❑ A trench will not be P
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.tlslorr-0miniissi,n lievu v Process:
ess:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ .or No❑ Yes❑ No Cl
- 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:
SECTION 9: PROPERTY OWNER AUTHORIZATION r `
Name and Address f r perty Owner (1
1eP�ic . ,dL V��.r,1 �L SigIt.-1
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
6 n-�- -k Z
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
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 2)
[f buildin /is less than 35,006 cu.ft.of enclosed space and/or not under Constriction Control then check here 17 and skip Section 101
10.1 Registered Professional Responsible for Construction Control -
Name(Registrant) Telephone No. c-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor r -
/^11P
Company Na e
Name of Person Responsible for Construction License No. and Type if Applicable
Cr
Street Address City/Town 56te Zip
Telephone No. business Telephone No. cell e-mail dress
SECTION 11:\k01'KFR13'CUn4PF.N5A ri(�N INSURANCE AFFIDAN"IF (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 ❑
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 $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ Z�v (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 tru and acc rate to the best of my knowledge and understanding.
cam �Of
Please print and sign name Title Telephone 1 o. Date
Street Address City/Town �J Sta i r T
Municipal-Inspector to fill out this.section upon application approval: V —SX 3
Name Date
CITY OF S.�I.E�t, AkSSACHUSETTS
,.
GULLI)VG DEPAIt1TJLENT
! ) ' NsHLYGToN STREET 3"O FLOOR
•.,�\b.��:. TEL "978 745-9595
h
,n l )
" F.+s(973) 7-10-9344
f<I�[BEY DRLISCO[l
,`,L�Yolt I'EtoNL+s ST.PtERxs
DIRECTOR OF PUBLIC PIIOPERTY/9UMDL`7G CO%LMISSIO:iER
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 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it 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
t 11, S 1 SOA.
The debris will be transported by,
(name of haul—er)
The debris will be disposed of in
(name of facility)
--(address of facility)
signanue of permit applicant
date
I
's
CITY OF SM.E.M. itiL1SSACHL;SETTS
8L'ILDING DEPARTMENT
' �1; •' 120 WASHINGTON STREET, 3iO FLOOQ
\CC; TFL. (978) 745-9595
F.+x(973) 140-9846
;j.N(BFRf RY DR)SCOLL - THo.%vsST.FIH.QR9
Mr1Y01 DIRECTOR OFPL'OLIC PROPERTY/8t:M.OtNG CONINIISSIONER
Workers' Compensation insurance Affidavit: Builders!Contractors/Electr(c(ans/P(umberf
\pnlleant infirrmatlnn PICame Print Legibly
Va111t:(0usili,syOcipairatiurvindividual):�y�- f� C-4e>NJ ✓'rL1�L�V/�1/`
Address:
City/State/Zip: DA/✓6&.( phonaN: 97
Are you as employer?Check the appropriate boat 'rype of project(required):
lam a employer with 1 _ 4• [] I am a general contractor and l
employees(full and/or part-time),* have hired the sub-contractors6. Now eunsuuction
2.0 lama sole proprietor or purtm:r- listed on the attached.rheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors have V. Demolition
working fur me in any capacity. workers'comp.Insuronca. 9. 0 Building addition
(No workers'comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
7.❑ 1 am a hoineowner doing all work right of exempfluo per MGL 11.0 Plumbing repairs or additions
myself.(No workers'cutup. c. 152,410),and we have no 12.0 Roof repairs
insurance required.1 r employees.Wort workers'
cutup.Insurance rcqulrvd.l ll.❑Olhes
•Any appikae dua vilml sex h /1 meat alto 1111 out 1ho"guar below ahaw(nr?half workers'mmpotiont a policy inlhmmtlmt
r 1 hwouwnors who suhnot this amebwit indleaing thay am doing all work and Thee hire moside conuarion must submit a new afndavil indiodnI tuck
C,mlm tan that check this boa Men j"Whod m uldidunal ahwt showing the nano,of the mtaa'dnit'rCWrs and ihalt warkara'sump pulley infornudoe.
l sum Isis euep/ayfr that prov(t(ing lvarker 'rompenradoe hrsurunee�or my smpfuyerx Bduw is rhr pulley alyd Jub site
in�onmalom 1/b Insurance Company.Name:
Policy 4 or Scif•his. Lic. d:Z�?l/u,/C. 3T Zxo y' Expiration Data:
Job Site Address: 2 Sl/rll y ) (/� City/State/Zip: ��� ')0
Attach a copy of the ivorkers'compensatloo policy declarallan page(showing thepolley numbor and expiration data).
Failur0 to secure coverage as required under Section 2JA of VIGL e. 152 can lead to the imposition ofcriminal penalties ofs
Kra up to 51,500.00 und/ur and-year imprisonment,ai wall as civil penaidus its the form of a STOP WORK ORDER and a lino
of up to 5250.00 a day against the violator. lie advised that a copy of[his slatomunt may bet t'urwardcd to the Oil Ica of
iavestigalimts or aid OIA 'r ovemgo vcrilTealium
l do,b.reby Cori/y rr tat Bah and p uldes algaluty r/rut rAe Gt/urnrur/an provided ubuw is true wtal correct
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U/Jieiul use—1A Oo out write in t/dr urrw ro be cumplemal by city ur town af/h•/uL
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Ci or'Puwn:
ty _ PCrml0.1cemc.9
Imutnq Aulhuriiy (circle one).-
1. Iluard of IleAll !. Iluildlnq Mparnnmrl 1.Cilylruwn Clerk 1. E:lectrlcal inyiector i. I'lumbiny Inrpuctor
6. Olhcr
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