96 SWAMPSCOTT RD - BUILDING INSPECTION (27) The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One or Two Family Dwelling
T
his Section For OfficiatUse Cal
Building rn Permit Nuliei:�
SECTION 1;LOCATION(Please indicate Block 4and.Lot.#'for locations for Which a7strcet,addre'ss is,not availabl'),
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK =97
Edition of MA State Code used— If New Construction check here 0 or check all that apply in the two rows below
Existing Building 0 Repair 0 1 Alteration 0 1 Addition 0 1 Demolition)A((Please fill out and submit Appendix 1)
Change of Use 0 Change of Occupancy 0 1 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0 No J&
Is an Independent Structural Engineering Peer Review required? Yes 0 No W
Brief Description of Proposed Work: _htn 3 A� �Sj , F-t k V
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING.RENOVATION,ADDITION;OR
'CHANGE IN USE OR'OCCUPXN&.'!I
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 13
Existing Use Group(s): Proposed Use Group(s):
L,'SECTION 4:BUILDING'HEIGHTAND.AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
Y
SECTION 5;USE GROUP(Check�as applicable)p�.'_
A: Assembly A-1 0 A-20 NightclubO A-30 A40 A-50 I B: Business 0 E: Educational 11
F; Factory F-1 0 F2 0 1 1L Jigh Hazard H-1 0 H-2 0 H-3 13 H-4 1:1 H-5 0
1: Institutional 1-10 1-2[3 1-3 0 1-4 El M.. Mercantile 0 R: Residential R-113 R-2 0 R-3 11 R-4 0
S: Storage S-1 0 S-20 U: Utility 0 Special Use 13 and please describe below:
Special Use:
SECTION 6:CONSTRUCTION,TYPE,(Check as applicable)'=
TA C3 IB 0 IIA 13 IIB 0 IIIA 0 IIIB 0 IV 13 1 VA 0 VB 0
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for&tails'on each item)
Water SUPPI Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Il Check if outside Flood Zone 0 Indicate municipal 0 A trench will not be Licensed Disposal Site 0
Private 0 or indentify Zone: or on site system 13 required 13 or trench or specify:
permit is enclosed 13
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process 7
Not Applicable 11 Is Structure within airport approach area. Is their review completed?
or Consent to Build enclosed 0 Yes 0 or No 0 Yes 0 No 0
.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:
C'e
SECTION 9r PROPERTY 04VNER'AUTFIORIZA'I'ION'`
Name and Address of Property Owner
jl+ iu�h,wc5 co&Vtcs qG s�Au�xa-t{- zu. SDI ran.
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
AAze A7�/ l_- 70- 8623
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes w fi r, c ?-S. &kc,54e t AL14 0y43 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.
{� �SECTIDN 10 CONSTRUCTION CONTROL(Please,fill out Appendrx 2)°
[f buddtii"vs less than 35,6(b cu.ft of erido"sed s'ace and%or not urider Construction,Control•then check he a l9 and"skf Section 7011
IO:1'Re` 'stered'Pr6fessi6nal'Res onsibl'e for'Constructimi Contl'OI:
- Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
102 GeneralContractor�
Company Name
�iancS �4" /�4d-7
Name of Person Responsible or Construction License No. and Type if Applicable
Street Address City/Town State Zip
qV _677- 5/Sf9 1w sari riGJ. co.n
Telephone No. business Telephone No. cell - e-mail address
eSECTION:II:=WORKERS'.COLIEENSP.IION INSUftANCL-:APPIDAVI`r (M:G.L.c.152_ 25C 6 =_x . a-
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:CONSTRUCTI61.4 COSTS"AND PERMIT FEE
Y:-
Estimated Costs:(Labor - -
Item and Materials) Total Construction Cost(from Item(5)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)
3.Plumbing $
4.Mechanical (I-NAC) $ Note:Minimum fee=$ (contact municipa , )
5. Mechanical Other $ Enclose check payable to
6.Total Cost em n I $ z 1, S S�'�� (contact municipality)and write check number here
:` SECTION 13:SIGNATURE OF BUItiDING.PERMIT APPLICANT -^ r By m name below,I hereby attest under the pains and penalties of perjury that all of the information
y g y y p p p r7 ry rmation contained in this
application is true and accur to to(theme best o m knowledge and understanding. 14
VfI PtgGs �j�j k-.c`�'y \_� ,✓t-S✓rtD c a s- 1(%aa, -`1?$`9? 36` e
Please print and sign name Title Telephone No. Date
�3 Vet(s�i//njC _. /ic NEl p3o3e
Street Address City/Town State Zip
Municipal Inspector to fill out thissection upon application approval
- Name , ' [Date. -
CITY OF SALE.. INLAisSACHUSETTS
BuIMIING DEPART NLENT
120 WASHNGTON STREET, 3AD FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI�iBERLEY DRISCOLL
NMAYOR Tmws ST.FtERRE
DIRECTOR OF PUBLIC PROPERTY/BCm .DmG COSLMIISSIONER
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 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # 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:
(n4rt-tes e"4LejiL-
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
nature of pe i applicant
it � 13 flz
date
Icbn salt:dux:
CITY OF S.1LE1I, A--1ss.kcHUSETTS
BUILOLNG DEPARTMENT
3 - t i+• _ 120 WASHINIGTON STREET, 311D FLOOR
TEL. (978)745-9595
F.tX(978) 740-9844
KIN(BERLBY DRISCOLL
MAYORTHOistASST.FIHRRB
DIRECTOR OF PUBLIC PROPERTY/BUIIDLNIG CONMUSSIONEP
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Va111C(nusitx5s-Urganizaticrvindividual); MO 45A_)SiR-�" c n/ Cl�.
Address: `I zi ceJG1 ( 5 tJ1 ((✓I`j` -Z Q
City/State/Zip: G 14 Phone M: q7u 6ffI- S/�/B
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with 4.o I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors -
2.0 1 am a sole proprietor or partner- listed on the attached sheet.t 7. 0 Remodeling
ship and have no employees These sub-contractors have V. gw Demolition
working for me in any capacity. workers'comp. insurance. 9, 0 Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its
required.)
of ricers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152, §10),and we have no 12.0 Roof repairs
insurance required.)r amployces.[A'o workers' 13.0 Other
comp,insurance required.)
•Any appikam dot chaeks box 91 most also nil out the suction bclowshowing thaw workers'compensation policy infutmation.
r I hxnouwnera who submit this affidavit indicating they am doing call work and then hire outsidecontractort most submit a new amdavil indicating such.
:Cuntmctors that chssk this box mustattachud an additional short shoeing the name of the scb+.rear ctGm and their workers'comp.policy information.
I um as employer that/s pravidfng workers'compelrsadoa lusurance far my employees. Below Is the policy and Job site
information.
Insurance Company Name:_ PO)[A6k-
Policy d or Sclf-in& Lic. 6: - Expiration Date:
Job Site Address: City/State/zip.-
Attach a copy of the workers'compensatlon policy declaration page(showing the policy number and expiration date).
Failure to s:curu coverage as required under Section25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 fine
of up to S'_30.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ul'the DIA for insurance coverage verification.
I do hereby re rut the pu/ uad peso/ties of perjury that that heforatation provided above is true and correct
d " 1
Phonc#: �1 7
O/Jirial use auly. Oa got write in r/t&area,to be completed by city at town n/pr/at
City or'ruwn: ._...... Permit/1.1cense
Issuing Aulliority(circle one):
I. Board of Ile•allh 2. nuifding Department 3.Citytrown Clerk J. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: