18 WASHINGTON SQ W - BUILDING INSPECTION d
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:
�I SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
54W S.o,1e,, +MBA 019 `l U Hhwj oftwe He e
No.and Street s - City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used b-rh If New Construction check here❑or check all that apply in the two rows below
i
Existing Building❑ Repair❑ Alteration ❑ Addition❑ TDemolition % (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 19
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 0
Brief Description of Proposed Work:
Remove l� Dispose a� wctl�a PA hA4eD �7e1 �� Awa oa wA1\ eaveni �5 s
J
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) O
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❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional 1-1 ❑ I-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility 0 Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA Ill ❑ IIA13 IIBO IIIA13 IIIB ❑ 1 IV ❑ 1 VA ❑ 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: 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): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
(S! / w4eh ) 9 / -`?53-
keoli) ChA,,5
SECTION 9: PROPERTY OWNER AUTHORIZATION
1 INamej�and Address of Property Owner
R �+
O.w I't ux 4o`1e� I B Wks�i, -,.xt � 1� J 41e&i 120
Name(Print) No.and treet City/Town Zip
/�n'1Property Owner Contact Information: pQ/^� r yii��
1Stahl.Ak In1AwAgeL - - qQ� iNF %Awfk-(grJe, COM
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 budding 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
/U/Professional Responsible for Construction Control /�
Nois AIow, R�_43�- 4$p1 ��R151T SVH�i11•CO 151421
Name(Regisnt TelephoQn�e No. e-mail address es s Registration Num_ ber
DO MA $tEBk S tA^ M Aoz1Ro �T L Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor i
3ftV%C( AASTCL ®;,AA d RSSOL,
Company Name
Strpa e.i Cjor?uk CSL j 043$5-
Name of Person Responsible for Construction //`' License No. and Type if Applicable
2 '00e.15 sn{,0 W-4STI'o2o N,A- ols%(v
Street Address City/Town State Zip
2323 SCLtlzie2e pnmpol=( err.
Telephone No. business Telephone No. cell e-mail ad ress
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C(6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this applica bon? Yes W No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 9 SD 0'00 AlI
Building Permit Fee=Total Construction Cost (Insert here
2.Electrical $ appropriate municipal factor)_$ S2,SQ a S•40
3.Plumbing $ $9'S0
4.Mechanical (HVAC) $ Note:Minimum fee=$ (conta crpahty)
5.Mechanical Other $ Enclose check payable to CA, 0� MA
6.Total Cost $ 41500.�0 (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 isst(true and accurate tt e best my knowledge and understanding.
yty�lt. l .,tz Jlt-r --tom; . dig `6SL -2323 3 5 I2DIz
Please nprint and sign name r� Title Telephone No. Date
1 VIA1S W® WtST� ,4o 'MA 0 l
Street Address City/Town AA State Zip
Municipal Inspector to fill out this section upon application approval: '1"t�+raIOY l2
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) 11
�� WAShiNy�orl�c,� SAt4s^� 01910 ��W °R►dE � u �<I
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)
NI issachu tts�-Department oLPuLlic Satoh
Boat-d-of Buildim, Re,ulitiuns and Stand ud1z
" -
lr Construction Supervisor'License
{e ..License: CS 104385
.. YS
� s
S'. STEPHEN CLIZZIERE
2 DORIS RD - 4
`WESTFORD, MA 01686
t .
Expiration: 411 S/2014_. i
('o�imiiwione.N Tr#: 1;043135?"g. .�
cell �`l o- 4,SZ 2323
CITY OF SM ENt, MASSACHUSETTS
• BUILDING DEPARTMENT
120 WASHINGTON STREET,P FLooR
TEL(978)74S-9S95
FAX(978) 740-98"
ICI3i8FR(FY DRLSCOLL
MAYOR THOMAS ST.PMM
DIRECTOR OF PUBLIC PROPERTY/BUI DLNGCONLMBSStONFR
Workers' Compensation Insurance Affldavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �^ 1 Please Print Leeibly
Name(Business.'OrganizatioNlmiividual): 5eQyice MA•S1f2 '0 iT-A-Acp ry5sot: _
Address: l o D MAOe StRecr
City/State/Zip: SA'ONc�M M A D z 1 So Phone#:
Are you an employer?Check the appropriate box: T of
Type project(required):
1.J#1 am a employer with qS 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet: 7• ❑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
required.] officers have exercised their 10.0 Electrical repairs of additions
3.11 1 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.❑Roof repairs
insurance iequired.)? employees.[No workers' 13❑Other
comp.insurance required.]
•Any applicam that checks box s1 most also fill out the secrmo below slowing their wortters'compema ion policy informadon.
t 1 hmreownen who submit this intdavb indicating they are doing all wort and then hire outside='two=must submit a now affidavit indicating such.
:t:onuacton that check this box mat an tched an additional shed showing the name of on sub-cmuma"and their women'comp,policy information.
I am as employer that is providing workers'compensadon Insurance far my employees. Below is the paltry and Jab site
information
Insurance Company Name: TpgJ�eRS a Oz N ss t
Policy#or Self-ins.Lie.#: V 9-9`14 6 L 5 L1- I ca Expiration Date: 1 0 27 2012-
Job Sire Address: 19 Wns�iNy�nti Sluri0.e W City/State/Zip: Skle•, MA 0117D
+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 cartlead to the imposition of criminal penalties ofa
finc,up to S1,500.00 and/or one-year imprisonment,as wall 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 of the DIA for insurance coverage verification.
I do hereby cerlyy e► and enallies ofperJury that the Information provided above Is TeandcorrecL
t ire l a : 3 9e a i Z
P one#: r]$]-y $-b033
Oklal use only. Do not write in this area,to be completed by city or town oJJiciaL
City or Town: PermiliUcense#
Issuing Authority(circle one):
L loam,of llealth 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other, _
Contact Person: Phone#:
aCITY OF SM Elti1, UxsSACHUSETTS
BUILDING DEPART%IENT
120 WASHINGTON STREET,r FLOOR
TEL (978)745-9595
FAX(978) 740-9846
IQ\IBERL.EY DRISCOLL
MAYOR Tttoauc ST.PIF1eR8
DIRECTOR OF PUBLIC PROPERTY/BU DING CONLNQSSIONER
Demolition Permit Sign-Off
(Supplement to permit application)
I, hereby supply the following releases as part of the
application for a permit to demolish the structure located at
. and shown on the Assessor's Maps
of as being on Map # Block # Lot#
The sixth edition of the Massachusetts State Building Code, 780 CMR, states in part: "A
permit to demolish or remove a building or structure shall not be issued until a release is
obtained from the utilities, stating that their respective service connections and appurtenant
equipment, such as meters and regulators, have been removed or sealed and plugged in a safe
manner."
Utility to be Notified 4 Notice Received by Date Received
Gas
Telephone.
Electric
Public Utilities (Municipal)
Health Department
Fire Department
Other -
Other
Demolition debris hauler:
Location of licensed
demolition debris landfill:
Signature of Applicant Date:
Signature of Owner Date:
This sheet must be returned to the Inspections Department along with a completed
application for a permit, a site plan, and any other applicable information and fees.
Denioperm.doc
• f
CITY OF Sm Em. NLxSSACHUSETTS
• BUIIAING DEPARTMENT
120 WASHINGTON STREET,r FLOOR
° TEL (978)745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THows ST.P[ERRE
DIRECTOR OF PUBLIC PROPERTY/11UUMING CO%L\MIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In.accordance.with the sixth edition of the State Building Code, 780 C_MR 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 wiII be transported by:
DisNS ler tlTSSOcINkes
(name of hauler)
The debris will be disposed of in :
SeRvieeMAS}eIL &A41L.aeAees
(name of facility)
too &X Aple ssaeeT o Z I o 0
(address of facility)
signature of permit ap 1' ant
— 3 Jy 112
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