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29 WASHINGTON ST - BUILDING INSPECTION (2) d5.0 � 1n The Commonwealth of Massachusetts 7 n� Department of Public Safety Massachuscits State Building Code(780 CMR) 1 Building Permit Application for any Building other than a One-or Two-Family Dwelling .(This Section For Official Use Only) r Building Permit Number. Date Applied: Building Official: _^ SECTION 1:LOCATION(Please indicate Block 0 and Lot N for locations for which a street address is not available) q QN�WA MPY ©VJ"?t9 �,.�o�w (3+ 'l.Aw, �� v No.and Street t City/Town Zip Code Name of Building(if applicable) SECTION 2 PROPOSED WORK Edition of MA State Code used_ If New Construction check here O or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 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 supplies!as part of this permit application? Yes ❑ No IT Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: 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): SECTION4: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 Cl A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-513 1 B: Business ❑ 1 E: Educational d13 F: Facto F-I❑ F2❑ fi: Hi h Hazard H-1❑. H-2❑ H-3 ❑ H-4❑ H-5❑ L• Institutional W Q 1-2❑ 1-3❑ 1.4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ Rri❑ S: Storage S-I ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6,CONSTRUCTION TYPE(Check as a licable) - IA ❑ Ill ❑ IL1 ❑ 11110 IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORAiATION(refer to 780 CbIR 111.0 oreetails 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❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system 13 permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: lL\IIiGgri.C.mimissi.na K_,i.o,,. Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Cade: Use Group(s): Type of Cominiction: Occupant Load per Floe Does the building contain an Sprinkler System?: Special Stipulations: _ (o SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner - C Name(Print) No.and Street - City/Town Zip KProperty Owner Contact Information: Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes r 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 cheek here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. c mail address Registration Number Street Address - City/Town State Zip Discipline Expiration Date 10.2 General Contractor aA1*.-M 5�. ; the - two Company Name got ,t�� ds -(s,& Name o Person Responsible for Construction License No. and Type if Applicable g p M A n l ']6 Street Address City/Town State Zip -7�9- 73ea �8-c�_1�.3F� �AewtS6,�e;�s��',lli�lapl-�Co M Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION IN5URANCE AFtIUAVfI' M.G.L.c.252.§25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with thisapplication. 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 O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Rem Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Budding $ Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical $ - appropriate municipal factor)=$ 3. Plumbing $ d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Encluse check payable to 6.Total Cost $ $ (contnt municipals )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, 1 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. (des �54 -5tR- -7 3 P 'e print sign na{jr,!,�.{s-t om 44 !Lb- 920 Date Street r ress lN'�j p city/Town State Zip Municipal Inspector to fill out this section upon application approval: e4, � G /6 Name Dale 3' SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 01t 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 pro.ertyowner's behalf,in all matters relative to work authorized.by this building permit application. SECTION 10.CONSTRUCTION CONTROL(Please III!out Appendix 2) if building is less than 35,0W cu.ft of enclosed space and/or not under ConshuctioncDatrol then dheck here D 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 �%V�04-t 51� :��Mle - l inxx3 Company Na Name orPerson Responsible for Construction License No. and Type if Applicable 5(� (JD'CA 'b&A S'r` C*-wJyr_\-" M-t00 r) tq�b Street Andress City/Town State Zip . Telephone No. business � Telephone No. cell e-mail address SECTION 11:W0kKEhS'GQt l "NSAhO WSUR.%NC1 A1=f1 r\Vrt' M.G.L c.In§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 o No O SECTION 22:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor :Item and Materials) Total Construction Cost(from Item 6)a$ 1.Building S Building Permit Fee.Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ c 4.Mechanical (HVAC) $ - Note:Minimum fee $ (contact municipality) ` 5.Mechanical Other $ - Enclose check payable to ( \ 6.Total Cost Is $ (contact munici li )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT i i By entering my name below,l hereby attest under the pains and penalties of perjury that all of the information contained in this I application is true and accurate 10 the best of my knowledge and understanding. _ - t ��t- l-.. K00 71W P 'e print and Sl M Telephone-No.70 Date 4 Strcet drJ.ress _ `�•, v �Ith- ,v City/Town Ste Zip r Y C� (p lXJ 6 /b / Municipal Inspector to fill out this section upon application approval• � � i'rc r Name & Date The Commonwealth ofMassaehusetts Department oflndusiWaiAceidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www moss gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FD,ED WITH TEE PERMrrnNG AUTHORITY. Applicant Information Please Print LeAbly Name (Business/organizetion4o"i dual): wry -5 e o Address:_ !60 /) �Ieil4r �� City/State/Zip: J9 n 4-�5 Phone LWem an employer?Check the appropriate box: m a Type of project(required): employer with a vloyees(full and/or part-time).• 7. ❑New construction m a aok tarquica,or permership sod have an employees working forme in 8. ❑Remodeling capacity-[No workers'comp.insurance required.] a homeowner doing all work myself.[No workers•comp,insurance required.]t 9. ❑Demolition a homeowner and will he my property I will 10❑Building addition hiring contractors to conduct as work on ure that all Wntraeors either have workers'compensation insurance w are sole I LED Electrical repairs or additions rietors with no employees. 12.❑Phmtbing repairs or additions 111019 general contractor and I have hued the subcomim ors listed on the attached sheet se mbco aema have employees and have workers'comp.ussureams 13.❑Roofrepairs are a wrporation and its ffices have exercisM theirrigMotexemption per MGL a 14.❑Other§10l and we have no employees.[No workers'comp.s.,,...snce reqund.] 'My applicam that checks box#1 must also fdl out the Section below showing their workers'compensaton policy information. f Homeowners who submit this affidavit indicating they are doing all work and than him orm de contractors mast submit a new affidavit indicating such. =Contractors that check this box must attached m additional sheet showing the name of the sub•emhactors and stare whether or not those entities have employees. Ifthe sub=connactarehsveemployKu,they mot provide their workers•comp.policy number. Islas an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. insurance Company Name: Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: Cih,/State/7ip_ Attach 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 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties oflierlury that the taformadon provided above is true and correct Silmature, X Date Phone M Official use only. Do not write in this area,to be completed by city or town official City or Town: Permtt/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person- Phone M Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the Issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmationof insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the,permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. _ City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or pemnit to bun leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suits 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 07 Y OF SALE14 MASSAQABE M BuLD=DBPAxnertr 120 WASIMMM SMW,32D ROCA UL(97)745-9593. PAX(978)740-9846 B71�ERLEYDRIS�I.L MAYOR 7iMMASSUUM DntECrMCFPUBUCRtOMt7Y/BUMDMaMWMCM Construction Debris Disposa/Afdavit (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 coo,S 54; Building Permit 8 is 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,S 156A. The debris will be transported by: (name of hauler) _ The debris will be Asposed of in: (name of facility) (address of facility) Signature of applicant Date