0029 WASHINGTON SQUARE NORTH- BERTRAM HOUSE T - l tot 8Lygg51 $31 S5 .
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 a street address is not available)
29 414s aeq, on yLkkre 0/970 RecjrAm +louse
No.and Street City/Town Zip Code Name of Building(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 P4 I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy O 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 0"
Is an Independent Structural Engmeerm Peer Review required? Yes ❑ No llY
Brief Description of Proposed Work N IorS-P r) H✓AC S S-fe..+t
Q;r 1'IGAd s .��kH nf.,.r -wa fI - mjt.. l-led UN
n, `d !p' I bn+'S 4-1- drea5 we Conti en Sr rS,
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) ❑
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: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: _
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill O IIA O IIB ❑ IIIA IIIB ❑ IV ❑ I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl}: Flood Zone Information: Sewage Disposal: 1. Trench Permit: Debris Removal:
Public p I Check if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site
Er
Private❑ !. or indentify Zone: or on site system❑ required 2ror trench :
permit is enclosed❑ or specifyQ,
Railroad right-of- Hazards Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable WJ' �!i is Structure within airport approach area? Is their review completed? _
or Consent to Build enclosed❑ Yes❑ or No Er 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:
C;Aif� Ep F0C-- Plu 4� ll, Z
r
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Betkr4. House_ 29 Wilshin 4bnS+. Salewt , M4 0/97d
Name(Print) No.and Street City/Town Zip
Property Owner Contact c-
ntact Information: �/`.
R,u ,c-& Crr<F1 W Aal. �_ _ 99 -7g - f 'ChGre�r�rf�(norcb fuls.�o
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby,authorizes
7in L'os hn �Gna:„ C:M�) r16 Sc u.�ra rf k. Sc% rr/a yi9ryo
Name Street Address City/Town State Zip
to act on the pro er ,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 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
102 General Coo/ntractor
.2/ pp
Company Name
Name of Pe on Responsible for Construction License No. and Type if Applicable
4L Sti/4�s705. ,74Ad, .S4/erst N9 D/97o
Street- City/Town State Zip
7BI -Sq).- 3i3.- 979 234 - 9d75 rbo:ae0. Co. ,
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? Yes No 13
SECTION 12:CONSTRUCTION COSTS AND PERMIT FiEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ 52r o oU Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ 4$ o o 0 appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ ,f0 Oo O Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to.
6.Total Cost $ , 4570, 000 (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.
Please print and sign name Title- - Telephone No. Date
Street Address City/Town _ tate Zip
Municipal Inspector to fill out this section upon application approval: /tz
Name bate
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
I Architectural
2 Foundation
3 Structural
4 Fire Suppression -
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electricals
8 Plumbin 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/Investi abon
16 Enerev Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other S eci
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 pennit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State Zip
CITY OF SALE .1, iN'LkSSACHUSETTS
• BuumlI IG DEPARTM&N-ir
130 WASHINGTON STREET,31D FLOOR
or TEL (978) 745-9595
FAX(978) 740-98"
Kl�tBFRt RY DRISCOLL
MAYOR Tkonus ST.PIERRH
DIRECTOR OF PL'B11C PROPERTY/BUHMING COMMSSIONER
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::
C1Y?sarNl c-6viS�Yvc,�i✓ y�!/Lc Aid"
(name of haul
The debris will be disposed of in
(name of facili /.) py�/yA
(address of
signature of permit applicant
date
kbrisaftdce
Massachusetts -Department of Public Safety
- Board of Building Regulations and Standards
Construction Supcn isor
License CS-054043
TIMOTHY P'COSTIN
18 BERKSHERE ST e
SWAWSCOTT MA "00 907` ..,.
s .
Expiratio
Commissioner 03/19/201
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