64 WARD ST - BUILDING INSPECTION 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
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which eet ddress is W available)
6 WWI) SX, 5416m � vsi 1 O/9 X WW
No.and Street City/Town Zip Code NarAe ofBU g(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 j& I Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change,of Use. ❑ _Change of Occupancy ❑ .Other Ia-Specify'10�' RuR3.Ee Q, RepAz2.
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No I
Is an Independent Structural Engineering Peer Review required? Yes ❑ Nog
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) 0
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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 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-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ HBO 191A0 HIBO 1 W0 VA0 VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 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 system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation:
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): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
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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 here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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Name(Regoiwstranft)l s� eleprNo. e-mail address Re ' ation Number
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Street Address City/Town State Zip Thscipline Expiration Date
10.2 General Contractor fn�
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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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Tele hone No.(business) Telephone No. cell e-mail address
SECTION 11: .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"A No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 3 0 6 D 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 $
fo Enclose check payable to
6.Total Cost $ 3, 0 00 (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.
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Please print and sign name Title Telephone No. Gate
yG ? �GWEIL O/oleo)
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
A` CITY OF SiuEm. NL-1SSACHUSETTS
' BUU-DING DEPART\TENT
120 WASAIINGTON STREET, 3ra FLOOR
TEL (978) 745-9595
Eux(978) 7.0-9M
KntBE t F.Y DRISCOLL
VYAYOIt T1�fontAs Sr.P[t'✓exs
DIRECCOR OF PUBLIC PROPERTY/BI:ILDING CO\L\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anirficant Information Please Print Legibly
Nanic (ButincssOrganizatiom lndi`viSdu'aIl)/:��d 'l�1 �V\ \ �f \ ��
Address:TQ . 6/7A
City/State/Zip: V-\'q Phone 9:
Arc you un employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time)." have hired the subcontractors
2.X 1 ant a sole proprietor or p rtner- listed on the attached sheet.t ?• ❑ Remodeling
ship and have no employees These sub-contractors 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
.]
officers have exercised their 10,❑ Electrical repairs or additions
required
3.❑ I am a homeowner doing all work right of exemption per MGL t I.❑ Plumbing repairs or additions
myself. [No workers'cutup. C. 152, §1(4),and we have no 12.(ZRoof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp.insurance required.]
-Any applic:utt get checks box 01 most also fill out the section below showing their workers'compensmion policy iolt,rmation.
'I hurvowncrs who submit this atndnvit indicating they arc doing all work and then hire outside contractors most submit a new aaldavil indicating such.
$lomimciora thus check this box must atlahed an adeilimwl Awl showing(he none of rho subwontraclon and their workers'comp,policy information,
i ant un employer brat is praviding ivorkers'eampensatlon inrurancefor my employees. Below is the policy and fob site
inforination.
Insurance Company Name: --_..--
Policy 4 or Scif-its. Lic.H: Expiration Date:
Job Site Address: City/State/Zip:
,lttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failuru to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 tine
of up to S250.00 a day against The violamr. Be advised that a copy of this.statement may be furwardcd to the Office of
Invesligmians ul'the DIA for insurance coverage veriticalion.
i do hereby c'errify under thowahss turd penuldee'of perjury that the hi/arinaflun provided/above is true and correct.
Phone H / 7 b el
Official use visly. Do nor write in this area,to be completed by city or town off ciuL
Cityor'Ibwn: —.._._. .
Issuing Authority(circle une):
1. Board of health 2. Building Department 3.Citylrowu Clerk J. Electrical Inspector 5. Plumbing Ltspector
6. Other
Cosdact Person:_ . __ ,. _ Phone H: