2-10 TRADERS WAY - BUILDING INSPECTION (06) oa3o od � �
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The Commonwealth of Massachusetts
( t Department of Public Safety
/ 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: -Budding Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
MN ER
No.and Street /^ City Town Zip Code Name of Building(if applicable)
G p 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 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes X No ❑
Is an Independent Structural Engineering Peer Review required? - Yes ❑ No
Brief Des c .�tion of Proposed Work:
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'Pa.r 'al ll�:w Ply rn1�-g,� t�1ew a c a...Za�
SECTION 3:COMPLETE THIS SECCTION 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): - Proposed Use Group(s): A 3
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
q, No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3yy ?Ul?juS�
Total Area(sq.ft.)and Total Height(ft.) 2D,2�t.(ti
SECTION 5:USE GROUP(Check:as applicable)
A: Assembly A-1 ❑ A-2❑:Nightclub ❑ . ,A-3 A-4❑ A-5❑ L B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ ,F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ d-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4 ❑
S: Storage S-1 ❑ S-2❑. - U: Utility❑ Special Use❑and please describe below:
Special Use: -
SECFION6:CONSTRUCTION TYPE;(Check as applicable
)-
IA ❑ IB ❑ IIA ❑ IIB IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
` SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public Check if outside Flood Z6neA Indicate municipal A trench will not be p
Private❑ or indentify Zone: or on site system❑ requiredxor trench or specify:
permit is enclosed❑
Railroad right-of-wa : Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No Yes❑ No
SECTION.8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): A-31C�Type of Construction:� Occupant Load per Floor:7jq�p
Does the building contain an Sprinkler System?:'IES Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
JAC,Ef, fWwpGEMEld1.1NG IoI1),g0EK W , STE I00 JEtyKIt�Tot, j PA 04
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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AILAW V.Xm' L1Z-m-SSJ X11 �Gt uft -JS8— 0,AM tAQPX VVIf.T.CO1Y�
Title Telephone No. (business) Telephone No. (cell) e-mail ddress
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)..
buildingis less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control • 'F ,'; '•
DAWE-L MMUN 2/19-Sq7--nti S d 5OL19 7�
Name!Registrant) Telephone No. e-mail address - Re istration Number
512 `I2 5. MAW S'i. MOSLDW 1 1(7 ,� 838'i3 T 1
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor L _ -
�k(' ✓ E "/
comp Nye �03 ad -$13'7
PU
Name of Person Resp2�5ible for Cone tion - License No. and Type if Applicable
ZellF� 1/2f ate/ s
Street Address City/Tofy State Zip
3_341_ odd e�63_7%/ 2G6 5/
Telephone No. business Telephone No. cell e-mail address
SECTION11:WORKERS`.COMPENSA'110N INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
,:.SECTIONS 12:CONSTRUCTION:COSTS-AND PERMIT FEE -
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ A. Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $ -
4.Mechanical (HVAC) $ - Q K Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ 'C Enclose check payable to
6.Total Co (contact municipality)and write check number here
SECTION-.13:SIGNATURE OF BUILDING PE 3 IT APPLICANT
By entering my name below,I hereby attest under the pains and penaltie perjury that all of the information contained in this
application is true and ac "rat to the best o in ow I nd rstanding.
�a Z.
Pse�print a sign naves ,Title elepho e�V Date
(fro
Street Address City/Towff State �t
Municipal Inspector to fill out this section upon application approval: / [
Name Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block # and Lot# for locations for which a street address is not
available)
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
• 3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
DARIEL K_ A1lL\tJ _&U-_&55 da6160 in.cDm �'�Ca
Name(Registrant) Telephone No. e-mail address Registration Number
511,12 S. rrww ST. M cnw ) 83843 MC7
Street Address City/Town State Zip Discipline Expiration Date
Oil) 81�_4)0_2858 39 1T ' 39939
Name(Registrant) Telephone No. e-mail address Registration Number
(,3S wEstPo�T Plcwy StE3o0 G2APEV1IJE TX �(�ns� MUM -VELEL
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town/Town State Z Discipline Expiration Date
i
CITE OF S!3LEl�f, 'AILSSACHUSETrS
BUILDING DEPARTJIE2NT
120 WASHNGTON STREET, 3w FLOOR
Ame TEL. (978) 745-9595
FAX(978) 740-9846
ICIMBF_RLEY DRISCOLL
MAYOR THoNfAs ST.PIERRB.
DIRECTOR OF PUBLIC PROPERTY/BCII.DNG CONWISSIONER
CONSTRUCTION CONTROL DOCUMENT p
Project'Citle: QNE� FITNESS —�L�M Date: 8.�rJ•��
Project Location: �� OR �L �JAOPP�t�+ CFNC 2q Tlz DEF.S A1A&y
Scope f Project: �Im1 R�ZIWA02 DEMO �tFu� A�km— PKC�LlL
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In accordance wit SECTION 116.0-116.4.2 of the 6th edition of the Massachusetts State Building Code :
1, DAN1El tt�l)U laJ Mass.Registration Number 30A'
being a registere professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised
the preparation o all design plans, computations and specifications concerning:
( ] Entire Pr 'ect X Architectural [ J Structural [ ] Mechanical
( ] Fire Protection ( ] Electrical [ ] Other(specify)
for the above named project and that to the best of my knowledge, such plans,computations and specifications meet
the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all
applicable laws for the proposed project.
Furthermore,I understand and AGREE that I shall perform the necessary professional services and be present on
the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the
documents approved by the building permit and shall be responsible for the following as specified in section
116.2.2:
1. Review of shop drawings, samples and other submittals of the contractor as required by the construction
contract documents as submitted for the building permit, and approval for the conformance to the design
concept.
2. Review and approval of the quality control procedures for all code-required controlled materials.
3. Be present at intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine, in general, if the work is being performed in
a manner consistent with the construction documents.
I shall submit periodically, in a form acceptable to the P D A � ess report together with pertinent
comments. Upon completion of the work,I shall su t�Ibul I final report as to the
satisfactory completion and readiness of the project f ancy.
t o No.30497 ,n
Signature and Seat of registered professional: o BOSTON,
ASS.
O �
r'
CITY:OF'S'ux' I, NUsSACHUSETTS
BUILD INC.DEPaRI=NELNT
tC 120 W ASHINGTON STREET, 31D FLooR
TEL. (978) 745-9595
FAX(978) 740-9W
10XffiFRT FY DRISCOLL
iRAY0R T'HOnus ST.IrIERP.E
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CO',I IISSIONER
SECONDARY CONSTRUCTION CONTROL DOCUMENT
(for Professional Engineers/Architects responsible for only a portion of a controlled project)
Project Title: SET FITNESS^ 6ALEm Date: B AS•k\
Project Location:HpcW MpRd li✓ 5Q MA L SAQv h1 & CEAAI:2 29
ScopcofProject: NELZ MELTO,N\GAl_ , PA12:11AI NEIQ PLLM24"
In accordance with the sixth edition Massachusetts State Building Co4ie,780 CMR SECTION J 16,0:
Mass.Registration Number
being a registered professional Enginoer/Architect hereby CERTIFY that I have prepared or directly supervised
the preparation of all design plans,computations and specifications concerning:
[ ] Entire Project [ ] Architectural [ ] Structural Mechanical
] Fire Protection pq Electrical [ ] Other(specify)
for the above named projcct and that to the best of my knowledge,such plans, computations and specifications meet
the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all
applicable laws for the proposed project.
Furthermore, I understand and AGREE that 1 shall perform the necessary professional services to determine that
the above mentioned portions of the work proceed in accordance with the documents approved for the building
permit.
Upvu cumpieiioti of the work,%shall submit a final.re art as to the satisfactory completion of the above
mentioned portion of the work.
1>{or:a�4�cy ��titrior:rq�q
o D.J. D.J, c�a
ELECTF CAL o FIE HA
Signature and Sea] of registered profession " 4+ A/ C N7CAL ti
No.3 742 iao.393 9
A