7 TURNER ST - BUILDING INSPECTION t
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The Commonwealth ofVLOM
Department of Publbl ic ety ERVICES
Massachusetts State Building Code(780 CMR).
Building Permit Application for any Building other th `176 or l'wAFV welling
(This Section For Official Use Only) y "
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
72;;&� d5pi9170
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used 0w' If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair Alteration ❑ 1 Addition❑ 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 as part of this permit application? Yes ❑ No ir-
Is an Independent Structural Engineering Peer Review required? Yes ❑ NoeR
Brief Description of Proposed Work:
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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) El
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 ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ I H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2g- R-3❑ R-4❑
S: Storage Sl❑ S2❑ I
I U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ HB ❑ IHA ❑ IIIB ❑ 1 IV ❑ I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR I11.0 for details on each item)
Water Supply: =outside
on Sewage Disposal: Trench Permit: Debris Removal:
Public i9 ne@ Indicate municipaL�- A trench will not be Licensed Disposal Site;R
Private❑ or on site system❑ required8or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable Er 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): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
i
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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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)
building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check hertJff`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
Company Name
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Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
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Telephone No. business Telephone No. (cell), e-mail address
SECTION 11:WORKERS'COMPENSATION 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? YeaZ,No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ c
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 $ (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 true and accurate to the best of m mow dge And understanding.
Please print and sign name Title Telephone No. Date
.<l 12 Ye 4 y .5.7 /Y.ct.../ e3Z4rry
Street Address City/Town State Zip r
Municipal Inspector to fill out this section upon application approval: 7fYan o, 7
Name Date
c
i CITY OF S.0 EINt NUNSSACHUSEM
BUILDING DEPARTMENT
• 120 WASHINGTON STREET,3"FLOOR
T L (978)745-9595
FAX(978)740-9846
ICIN BERLEY DRISCOLL
MAYOR THOMAS ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BUILDING COJLmISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information A� / Please Print Le 'blv
Name(BusitlessOrpniratioNlndividuaq:f///Giti9EG
Address: 1�57
City/State/Zip: L en/ g::Z�yg�z Phone#: d5l7-
Are you an employer?Check the appropriate box: Ty
pe of project(required):
1.0 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.[�4am a sole proprietor or partner- listed on the attached sheet t 7.19.IZe modeling
ship and have no employees These subcontractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9• Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its I0.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13❑Othu
comp.insurance required.1
•Any apparam dust checks box#1 must also fill out the section below stowing their worker'compensation policy mlmmmk,.
'1 krneuwnrs who submit this affidavit indicating they ate doing all work and then him outside comr im most submit a new,anldavit indicating such
:Contmtxon that cheek this box most attached an additional shoes showing the name of the s,b,,nuactm and their worker'comp.policy inWrmmim
I am an employer that Is providing workers'compensation insurance for my employees. Below Is the policy and Job Yte
information.
Insurance Company dame:
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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations urthe DIA for insurance coverage verification.
f des Irereby eerto under the pains and p�e Ides of perjury that the itrformadon provided above Is true and correct
t v ' 40, ezz�� Date:
Phone# 7217— 7S7/5i�/3
Official use only. Do not write In this area,to be completed by city or town official,
City or Town: PermitflJcense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Citytfown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF S.-1I.Eti1, TNLksS.-1CHUSETTS
BuI DING DEPARTMENT
• 130 WAsHINGTON STREET, 3t0 FLOOR
R830 TEL (978) 745-9595
FAX(978) 740-98"
KINIBERLEY DRISCOLL
MAYOR THmIm ST.PIERRR
DIRECTOR OF PUBLIC PROPERTY/BUILDING COJLMUSSIONER
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 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:
(name of hauler)
The debris will be disposed of in
�czn/S�eaE �'�Jters.,�l�'
(name of facility)
S!�lA�rPS�ar� �i�9Q
(address of facility)
sig iatur f permit applicant
date
dcbri dr.dm
1�t Massachusetts-Department of Public Safety.
�f Board of Building Regulations and Standards
Construction Supenisor - -
License CS4094290
MICi9AEL A NAPES s
11 CLAYTON s
LYNN MA 01!: i�
1 '%L�- • ' "`' `` Expiration
- Commissioner 0620/2016 -
Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet(991m3)of
enclosed space.
} Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
-I For DPS licensing information visit w .Mass.Gov/DPS .
lug Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 153013
Type: DBA
,
Expiration: 1023/2014 Tr# 232751
M.A. NAPLES CARPENTRY _
MICHAEL NAPLES
11 CLAYTON ST
LYNN, MA 01904
Update Address and return card.Mark reason for change.
DPS-0A1 0 5oma4/04-e101216 -- ❑ Address Renewal Employment ED Lost Card