12 UNION ST - BUILDING INSPECTION (2) Y
RECEIVED
UrA
The Commonweal thih��a�Slsachusetts
f� 4t Department of Public Safety 1 A & -23
W IPj Massachuselts State BuildinyISNe,ND UjR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(rhis Section For Official Use Only)
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)
/a yviot� S 4-
No.and Street City/Town Zip Code Name of Budding(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❑ Repair Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use - ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes Ef No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
n it 1 R Q V,eA K. I I h t
JA16 Gthk do G'$
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 CbIR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECFION4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor,(eq.ft.)
ApoTotal Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE CROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Huard H-1❑. H-2❑ H-3 ❑ H-4❑ H-5❑
L• Institutional I-I❑ I-217 1-3❑ I-�❑ M: hlerwntile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S-1❑ - S-2❑ U. Utility❑ Special Use❑and lease describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Checkas a licable) -
IA ❑ IB ❑ HA ❑ IIB ❑ ILIA ❑ 1118 ❑ IV ❑ 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 i(outside Flood Zone❑ Indicate municipal❑ ��trench will not be
required❑or trench Or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: IA IIi_Mrir G..mnklyo ROO.,'.1'r......:
Not Applicable O Is Structure within airport approach area? Is their review completed?
or Consent to Build enclose)❑ Yes❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code Use Croup(,): Type of Construction: _ Occupant Load per Flour:
Does the building,contain an Sprinkle System?: Special Stipulations: __
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner -.}�
F r�rnC'C Sco -F ; � a Uni Uil Sfi" dC Sa ��� /�i R f� 197b
Name(Print) No.and Street - City/Town Zip
Property Owner Contact Information:
big- 3 . s 7ba _
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)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and ski 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
q 6e lip Zoo�7,n
Company Name
Zobe-r+ hC, l) efie C? q � �� �¢
Nat of Person Responsiblefor Construction License No. and Type if Applicable
0 4 v8 )5ioA 1 os� Ad u,/G+/ la's d /t/);} 01-77e
Street Address City//Town State Zip
sad .309 ar 3 9b
Tele hone No. business Telephone No. cell e-mafl address
SECTION 11:4VORFEF4 COnu'F.NSAnON INSURANCI.AFFIUAvrr M.G.L.c.15 25C 6
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accide is must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of theAsuance of the building permit.
Is a signed Affidavit submitted with this application? Yes9 No E3
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
I. Building $ qP0- Building Permit Fee-Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
d. Mechanical (HVAC) 5 Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ Ot) (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 my knowledge and understanding.
2obet+ [r, DeAk D0ry-er SIB 3013 743 7-L3
Please fyrignt hJ sign h 1'� we�i IC�l A n�Telephone� _2 7 u Date
Street Address (� Cityi/Town ,VS/tate Zip S7
Municipal Inspector to fill out this section upon application approval:
Name Date
The Commonwealth of Massachusetts
Department oflndustriaiAccidents
I Congress Street,Suite 100
Boston,MA 02 11 4-2 01 7
www.mass.gov7dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMUTING AUT TT_HORy.
A IicantInformation -T Please Print Le 'bl
Name(Business/or ani7a[tifon4tul idual): -e,11.Q Ob{
Address: � fiin
City/State/Zip: th I Qh 617 7 hone#: SbIS S <
Are you an employer?Check the appropriate box:
Type of project(required):
1.�I am a employer with_�employces(full and/or paR-time).[
7. ❑New construction
2.�I era z sole propriemr or partnership and have no employees working forme in
any ceacit.[No workers'comp.insurance required] 8• ❑Remodeling
3.Q I a homeowner doing all work myself.[No workers'comp.'a mane re
md71 � 9. ❑Demolition
4.❑I ern z homeowner and will be hiring contractors m conduct all work on my pmperty. I will 10 Q Building addition
ensure shot ell contactors either have workers•compensation insurance or are sole l 1.�Electrical repairs or additions
pmnrietor with no employees.
5.❑I am z genesl contractor and I have hired the sub-contacors listed on the attached sheeC 12.Q Plumbing repairs or additions
7-nese suhcont actors have employees and have workers'comp,insurance.[ 13.❑Koo£repairs
6.0 We are a corporation and its officers have exercised thew right of exemption per b4GL c 14.Q Other
152,§1(4),and we have no employees.[No workers'comp,insurance required]
*Amy applicant that checks box SI must also fill out the section below showing their workers'compensation policy informadoa
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-mntracmrs and state whethm or not those entities have
employees. If the sub-cantactors have employees,they must provide their workers'comp.policy number.
I am an employer tilat isprovidingworkers'compensadon tnsurancefor'my employees. Below is thepolicy andjob site
information �f {
Insurance Company Name: / �- ' 01q-+_0(" y� �9.-t. w(��1/o-A G.Q
Policy#or Self-ins.Lic.# 5 3`0 Q 7 J�`�l/ "'�` l ry Expiration Date: 3 a a ((D
Job Site Address: It) 1A 2 City/State/Zip: S2,-I2 vr` AN
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 r
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00.a
day against the violator.A copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance ¢
coverage verScalion.
I do hereby ce " the pains' penalties of erjury that the information provided above U true and correct _
Sianatizie D L�G� c �y �i � - Dare �` I Z -� S
Phone#:
[F�IB%ojardof
only. Do not write in this area to be completed by city or town o�f�cwLn: Permit/Licensehority(circle one):
Health 2.Building Department 3.G9ty/Tuwn Clerk 4.Elech ical Inspector 5.Plumbing Inspector
son: Phone#.
1
Permit Services 401 246 2868 p.6
' SA
Massachusetts - Department of Public. Safety
Board of Building regulations and Standards
I--"9+'jie z.9ic t `?'_:-95 i:c V =.:'t'?i- OF "'m
License: CS4098666
tih.T 1 .4
ROBERT A LABE ,E
304 SON POST
Wayland MA 01178
Expiration
Commissioner 05/09/2017
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e a . y.
` %.i Y'�w;iiepl�'crr/!;'�i ��'"'./�r. ,. rri:i+t✓�!ia
�)1'ticx ir9'C:dn�surseer;At't;�'srs c� fl uAl .ss 6$eguhltiGI,
- f`sOME IMPROVEMENT CONTRACTOR
;Registration: 154084 TYPe i
Expiration: 2/5/2017 Private Corporatior
L.ABELLE ROOFING, INC:
ROBERT LABELLE
304 L;O)TON POST RR
VVAYLAMD, MA 01778 _
Q lndersecretary
s '#
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F i^fia°1s
Permit Services 401 246 2868 P.1
0 NER U H IZA I N
Job # (Q a
TO BE COMPLETED WHEN OWNER'S AGED T OR
CONTRACTOR APPLIES FORA BUI
LDING P R MIT
E, Francesco Froio as oi vner of the
subject property 12 Union St, #2, Sale , MA
hereby authorize LaBelle Roofing to act on I y behalf in all
matters relative to work relatingthis to b utl ling permit
application, and all permitted work
7/6/2015
Signature of Customer Date
Permit Services 401 246 2868 p.2
Victor Garber<VgarI;era@comcast.net>
To: Diane Metzger<ciano@lebelleroofing.com> Mon,Jul 6,2015 at g:55AM
Cc:Shayna garber<shayna.garber@gmail.com>
Hi Diane,
I think it would be best if we have Francesco roio, the owner of Unit 12-2 at
Union Square Condominiums, sign the attach ad permit request form. The
Union Square Condominium Association willpaying
the skylight being replaced is part of the roof, ic i the the
�use
responsibility. The skylight is also part of Fran co"s unit and work will be
Performed inside his unit.
Victor
Permit Services 4012462868 p.1
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QTYOF SALEA MASSAaA SEMI
BUILDING DEPAM ENT
120 WA9W4GT0NS7MET,311DFWOR
7kL(978)745-9595
KIWERLEYDRISOOLL FAX(978)740.9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OP PuBmcPROPBRTYIBu a Dm axaassiomR
Construction Debris Disposa/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 g Iis 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, 5150A.
The debris will be transported by: 0 0 2 TtU�y 7r dcZ
(name of hauler)
The debris will be disposed of in: v✓ d2
(name of facility)
fie." Mh
(address of facility)
Signature of applicant
Date