Loading...
11 SYMONDS ST - BUILDING INSPECTION Lf9S- w GK Lt The Commonwealth of Massachusetts W Board of Building Regulations and Standards CITY O Massachusetts State Building Code, 780 CMR SALRevised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied:Jej �7 P 1 Building Official(Print Name) Signs"m to SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers a �-r—fZt94&1d1s S L la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq 11) Frontage(tt) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Requred Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.S Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes[] Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owners of Recor r/i y a4 5 J� Name(Print) City,State;ZIP // Sc IAm m L- S- 69402P:10 z No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ 1 Existing Building-RIOwner-Occupied ❑ 1 Repairs(s) GSpecify: : ition ❑ Demolition ❑ Accessory Bldg.❑ Number.of Units Other ❑Brief Description of ProposedWork : — iQ. Lo" SECTION 4-ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only L Building /Sr 000,0 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical ❑Standard City/Town Application Fee �t O 00. $ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing 2 )WO.00 $ 2. Other Fees: $ 4.Mechani 1 List: 5.Mechanic 1 Mre $ Su ression Total All Fees:$ i Check No. Check Amount: Cash Amount: 6.Total Project Cost: ❑Paid in Full ❑Outstanding Balance Due: ot'1 3(55 1 c� � t?-r�l.C:Z-`I"C�1A�Ue'_ IN COtJs1ZActCK• MK w SECTION 5: CONSTRUCTION SERVICES 5..1 Construction Supervisor License(CSL) ,1,Od—f q 6 0 2Q 6 (C YAA,d /S` � (�tm L(7 License Number Expiration Date Name of CSL Holder d L List CSL Type(see below) ' �No.-a7nd Street / ARC WBuming Description I —,2 Lr/L ,/ 114, ©�� L/ Buildin s u to 35,000 cu.R /�-1114, �'(I� 2 Famil Dwellin Ctty/fown,State,ZIP -Sidin,,//��,,,, SF ming Appliances ?N� , -60, i7L1 CeWUOLOOAit Al, (.'Om I Insulation Telephone Email address D Demolition 5.2 Registered Home I rovement Contractor(HIC) ` CFr 2 Lt t0 L n (inGptt !7 Q/r'L/ CC Registration E irati Da e HIC Com Name or HIC Re ' trant N P N/ dStreeiAQZG fUT r�1—u06Dka�cSWECDAq crr/O U "Email address Cilyfrown,State,ZIP Te] hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance o5the building permit. Signed Affidavit Attached? Yes .......... No...........Cl SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLI$$FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION 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. C.29,1.J A (is+d'll�1/ Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.sov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is plamned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" I Z\ Office a'imer airs ]CTOR HOME IMPROVEMENT CONTRARegistration. �410484 Expiration '10/20/2014 C OLDREMODEUNN ,�RICHARD CERU51 KIMBALLAVEREVERE, MA 021Und Massachusetts -Department of Public Safety Board of Building Regulations and Standards'. Construction Supen is/ir License: CS-028460 ```.FITS fill. RICHARD A CER�O - r 51 KDNBALL AVE REVERE MA 02$51 I gas Expiration t Commissioner" 08/26/2075 r.. 0 1• P License or registration valid for individuf use only before the expiration date. If found return to: - . .. Office of Consumer Affairs and Business Regulation _ IO Park Plaza-Suite 5170 . Boston,MA 02116 i Not valid without signature i s Unrestricted -Buildings of any use group which contain less than 35,000 cubic feet (991M )of enclosed space. Failure to possess a current edHon of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS M1 QTY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET,3" FLOOR rnnx TEL. (978) 745-9595 KIMBERLEYDRISCOLL FAX(978) 740-9846 " MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER 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 111.5 Debris, and the provisions of MGL c40, 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 deposit facility as "defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature/of applicant Date CITY OF S:ULEM, NL-usi.cHUSETTS 4 BUILDING DEPART\I&\T 120 WASHLYGTON STREET, 3aa FLOOR TFL (978) 745-9595 F.tie(978) 740-9846 fCl\IBERL.EY DR)SCOLL TtLonlAs ST.FiEaR13 ��.AAYOR DIRECTOR OF PUBLIC PROPERTY/BL:ILDf\G CO\LMISSIONER Workers' Cornpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A \ licant lnformatinn ^ Ptcase Print Le ibi Name(nusinusOrganira'i„m'Individual): �F��� L[l (r © Y Address: 1tJMKa u T vI— City/5[atclZip: �/L "hone Are you on employer?Check the appropriate box: Type of project(required): I.❑ I am a employer with 4• ❑ I am a general contractor and I 6. ❑New construction d us(full and/or pan-time).• have hired the sub-contractors 2. I am a sole proprietor or partner. listed on the attached shcct. t �• El Remodeling ,hip and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition 1No workers'comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MOIL i LEI Plumbing repuirs or udditiore; myself.(No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) t employees. (No workers, 13.0 O(her comp. insurance required.) -Any upplicwit thus chucks box iI mast also fill out ate section below shawing their workrri eumpensitiun policy inlnrmatlon. 't b,meuwmnro tcho submit this atfldnvii indicating Ihcy am doing all work and then hire outride cuntmcton must aihmit a new aMdavil indicating such. :Cmnnuio.shut cheek This bux must art ichd an additional sheet ahuwing she natne of the nbromrmturx and their waken'comp,pulley information. I out an euployer that it praviding Ivorkers'compensatlon insuruneefor my employees Beloty is die policy and job rice irijrnuution. Insurance Company Name:Policy 4 it or Self-ins. Liu. 0::^"�� Expiration Date: Job Site Address:�[ J'�l Y—1 D/M• 7 T City/State/Zip: `61LL1 , a Attach a copy of the worker'compensation polity declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25.\al',%IGL c. 152 can lead to the imposition of criminal penalties of a lino up to S1,500 00 und/or one-year imprisonment,as well us civil penalties in the form of STOP WORK ORDER and a line of up to S2A00 d day against she violator. Ile advised that a copy of this statement may be funvarded to the Oflice of I IIYe511gallUnx ul ills DIA far InSUfall[e UlvemgC Vefdll'a11Un. - I to ere y c ify i v i is a persallle, perjury that the btforatadan provided it Uwe i. true and correct Official use anly. Du not rvrile in this area, to be completed by city ur lown official --- ---- —_ IIII City or I'u\vn: Permi0.lccn1c q lsvuiag,lulhurily (circle one): 1. Board of Health 2. Buildlm„ Ilepanment .l.Ciiylruwn Clark J. Electrical Inepeclur 5. Plnmbing Inspeclor 6. Other l Contact I ennn:.._ ._— _ __ Phone 3: i -� 4- NF NUM6ER OF '4 5TEFIE TO GRADE Ftl T PORCH +-�- EXIST LMNG RM EV15T BEORM (� 6 BLOCK EXIST DOOR R io -'-x>J-FIL ECIST STAIRWELL � n � II 111I I I EROPOS 0 (�) EVST KITCHEN EATH EAST EN1R'f Ul � .� Erlsr aECRn 0 0 O u E Do to w U1 EVsr B4THRM ED 4�,�;; A UNIT 1 A 1 SCALE I/4'=T-0' 1 i EXIsr PORCH. EXIST LMNG iU1 EU'ST BFORM ' U m EXIST STNRWEt1 (A 3G6'-3 ECIST 6EDRM EXIST ENTRY EAST BATH EOST MCHEN 0 s E EtlST BATHRM o UNIT 2 A 2 SCALE ll6'_T-p CH 6-2 -- -- -- ----------I -- ------ CH 5-2 EKSr CHMNEY DOST BMFW COST HALL BGSTUVNGFU "0000---------------------- --------------------- ._--____-________ CH IV-8 Emar SE DMA 11-2 CH 5-2 EY MT MDRA BOST FALL UVNGFW DW SEM E)OSTSTARVVELL E-39T ENTRf BUSTICTUIN CIR V-2 --- - --- -------- n z C.F-2 -------------- CR 4'-B --------------------- LNrT 3 3 SCAIE14"=10" A] March 3, 2015 To: Mike Lutrzykowski 120 Washington St 3rd Floor Salem, MA 01970 From: Charrissa Vitas of Vitas Realty Trust PO Box 25 Hathorne MA 01937 Subject: 11 Symonds Street Salem, MA. -Release of General Contractor, Richard Ceruolo Hi Mike, Please release Richard Ceruolo,the General Contractor at 11 Symonds Street, Salem MA from all future liability in connection with the construction of 11 Symonds Street, Salem MA. Richard is no longer responsible for work completed at the property. Richard asked me to send this letter as he is on-board and has no objections to a change in contractor. Thanks so much, Charrissa Vitas 617-838-0042 °r^ . Commonwealth of Massachusetts 1 L Citv of Salem a\ F 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 Return card to Building Division for Certificate of Occupancy - Permit No. B-14-1476 FEE PAID: $495.00 PERMI 0 B %j LIDEJ DATE ISSUED: 9/11/2014 This certifies that VITAS REALTY TRUST VITAS CHARRISSA CTR has permission to erect, alter, or demolish a building 11.,SYMONDS STREET Map/Lot: 270032-0 asfollows: Renovation FRAME ,V BATHROOM,r.W/ CLOSETS,'REMOVE/RE PLACE DECK BOARDS2ND FL. INSTALL ENTRY DOOR (4X4 Amended on 3/5/15. John HARVEY �r ° Contractor Name: � pp,,; �F DBA: JOHN HARVEY, LLC tf+ ra is �3t 1i c Contractor License No: CS-093706 t � � b „� f •, � � i n Hsi r , n i �` s d 9/11/2014 41" Budding Officialor Date .L is 8 N 5 This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official may grant one or more extensions not to exceed six months each upon written request.' All work authorized by this permit shall conform to the approved application and the approved construction documenf�ts for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. I .� a F€ I i J �a �... ti A ` '- - The Certificate of Occupancy will not be issued until all applicable signatures by the Budding and Fire Officials are provided on this permit. gg H t i �# i i ik F iiN `i Sw ("cxT �-� H IC#: Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A). Restrictions: ` Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. °= Commonwealth of Massachusetts { s Citv of Salem 120 Washington St,3rd Floor Salem,MA 01970(978)7459595 x5641 x n° Return card to Building Division for Certificate of Occupancy Permit No. B-14-1476 IN U fill FEE PAID: $495.00 Fm—ft"` """"""" RM1T TO BE";I R a I L I=0 406 DATE ISSUED: 9/11/2014 This certifies that VITAS REALTY TRUST VITAS CHARRISSA CTR has permission to erect, alter, or demolish a building 11 SYMONDS STREET Map/Lot: 270032-0 '1; asfollows: Renovation FRAME lgBATHROOM;W/ CLOSETS,`'REMOVE/RE PLACE DECK BOARDS 2ND FL. INSTALL ENTRY DOOR (4X4 L'AND(NG)`1 " n . raw ;, hf � Contractor Name: RICHARD A CERUOL%�:' ft�• t"QrinFl� 3 " DBA: CERUOLO REMODELING Im ' fflt� l F Contractor License No: CS-028460 t men; .-. : 9/11/2014 s Bullding Official N Date v n71" . r ik:n. This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official may grant one or more extensions not to exceed six months each upon written request "r`r 3 � .N -� it t �. a x n ;kV All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. -P a } r "n,-.g l i1j The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. i 4 T H IC#: 110484 Peyrspons contracting with unregistered contractors do not have access to the guaranty fund"(asset forth in MGL c.142A). Restrictions: Ar Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 l` www.mass.gov/dia _ Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information T / / Please Print Legibly Name (Business/Organization/Individual): Address 20A &1ZPL-e City/State/Zip: J;1&a•"1 0 Phone#: ��2.D 'e Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. I�am a sole proprietor or partnership and have no employees working for me in $. R�J nrodcling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself[No workers'camp.insurance required.]t 10 OB l Ing addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I I. lectrlcal repairs or additions proprietors with no employees. 12. Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. - I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: - Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cover Ike verification. I do herNe, ify the pains and penant. s ofperjury that the information provided above is true and correct. Signalur Date: 3 Phone#: — 6 Official use only. Do not write,in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more - of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also'states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permitAicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia .1 QTY OF SALEK MASSAaR SE M tip .i BUILDING DEPARTMENT ` 120 WASHINGTONSTREET,31DFLoOR TEL(978)745-9595 KINMERLEYDRISCOLL FAX(978)740-9846 MAYOR TkIOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTYIBLUDING COMMISSIONER 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 111.5 Debris, and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) 4atu4�ef applicant Date SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner /w n !�er // C1\0x�Fv1 U1k, yk� akj Al66m Zc, I f1Otie_ YYI{� 2)��2� Name(Print) No and Street City/Town Zip Property Owner Contact Information: V Title Telephone No.(business) Telephone No. (cell) a-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the propeg owner's behalf, in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) 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 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Wit, n ,Uwf�r, «c Company Name n/t Name of Person Responsible for Construction License No. and Type if Applicable 30R G-2oye- &726a� gli-/er1 MI9 & d Street Address City/Town I State Zip 1) - L/V- 6 16 J C##rjV-e- t✓ Y06i00. C©r-` Tele hone No. business Telephone No. cell e-mail address SECTION 11:1V0RKERS'C0bt PENSAIION'INSURANCE:AHADAVt 1' M.G.L.c.152.§25C6 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 a lication? Yes❑ No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) 'total Construction Cost((ram Item 6)_$ 1. Building $ Building Permit Fee-Total Construction Cost x_(Insert here 2. Elatrical $ appropriate municipal factor)=S 3. Plumbing $ 4. kleclumical (HVAC) $ Note:Minitn un fee=$ (contact municipality) 5. Mechanical Other $ Enclose dweck t [ble to P•y 6.Total Cost $ (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name bet v, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accu rte to •best of my knowledge and understanding. alNt�1 ow,.fa c)-9 -430.6446 3/5i P eease,, � print and sign name Title Telephhonne.�No. Date a Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts Department of Public Safety 2 4yp Alassachusetts State Building Code(780 CNIR) ������✓✓✓ Building Permit Application for any Building other than a One-or'rwo-Family Dwelling (This Section For Official Use Onl ) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block N and Lot R for locations for which a street address is not available) ll sYmow T si SA/eft . 019V No.and Street City/Town 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 d I Repair❑ 1 Alteration e I 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 os part of this permit application? Yes No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ vM' Brief Description of Proposed Work: ' 1 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 encloses)(See 780 CNIR 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 as applicable) A: Assembly A-1❑ A-2❑ Nightclub Cl A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1❑ 1-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2 Cl U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) IA ❑ Ill ❑ IIA ❑ I16 ❑ IIIA ❑ II111 ❑ 1 IV ❑ 1 VA Cl VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CNIR 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 required❑or trench or specify: .rystcm❑ permit is enclosed❑ Railroad right-of-way: Ilazards to Air Navigation: C nu m'q ,I 'w'-, P.,.,� Not Applicable❑ Is Structurewithin airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 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 Hooe Does the buildiny,contain an Sprinkler System?: --Special Stipulations: __._