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60 WASHINGTON ST - BUILDING INSPECTION (8)
i _ . The Commonwealth of Massachusetts 'T ! Department of Public Safety 1� i'�' \lassaChusrlts SLrtc Iiu ihGng Cudc(7811 C'\III) Building Permit Application for any Building other than a One-or'1'wo-Family Dwelling (This Section For Official Use Only) Building Permit Number: _ _ _ Dale Applied: Building Otficial: i1 —SECTION 1: LOCA YION (Please indicate Block#and Lot#for locations for which a street address is not available) .:f ---60— 45L/i�6 DAl_.-tT__---�- �•M"--_--1J12� __ 73EN /1NA -TF lrl_`1--------- Nu.and Street City /Mown Zip Cade Name of Building(if applicable) SECTION 2: PROPOSED WORK Edition of MA State Code used If New Construction Check here❑or chock all that apply in the two rotes helow -- FxislinI; Building❑ Repair❑ I Alteration ❑ Addition❑ Demolition ❑ (Please till out and submit Appendix 1) Chan);•of Use ❑ Change of Occupancy ❑ Other Specify:-J-4AVFA[$1Ar /V Arc building plans and/or conslruCliun d,k'u nu•nts being supplied as part of this permit application? Yes C No ❑ --- Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work:.—AF✓/Ln DUT /✓FW -Q&"� 5rA&-ZL1 SECTION 3:COMPLETE THIS SUCTION 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 CNIR 34) ❑ Existing Use Group(s): __. Proposed Use Group(s): _ SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(inClude basement levels)dr Area Per Floor(sq. ft.) 'Z 700 z 700 Total Area(sq, ft)and Total Height(ft.) 7 5- SECTION 5: USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-1 ❑ A-i ❑ A-3❑ 1 Bo Business E: Educational ❑ F: Facto F-I ❑ F2❑ I If: Ili h Hazard H-1 ❑ H-2❑ 11-3 ❑ 11-4❑ 11-3❑ I: Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R 2❑ R-3❑ R-a❑ S: Storage SI ❑ S2❑ U: Utility❑ Special Use❑and please describe below: Special Use SECTION 6:CONSTRUCTION"IYPF. (Check as applicable) IA IB ❑ IIA ❑ [W (3 MA ❑ Hill ❑ I IV ❑ F VA ❑ VII ❑ SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) Water So Flood Zone Information: Sewage Disposal: French Permit Dehris Removal: PnbhC ll Chv'k if oulmde Floo,l !_one 2r, Indicate municipal Ge A trench is 1 , be I.icvnsad Disposed Site n'yuin•d , Irvin or.pecdv:.. Privaly❑ or indentily Lone or on site sysA•m ❑ permit is vnc lewd ❑ .- Railroad right-,,-wa Ilizards to Air :Navigation: - , . .1._1 . Not :\pplical O Is titru,tore w Whin a i rport a ppr,,,,h.uea? Is their rrvwv, rnmplclyd? eer C,mx•ut la IN dd cm I...... tan❑ ear ..\'o( ),rv❑ No ❑ SPC1lUN ti:('UNl"Ii N"f OF CFR"I'IFICA71 UP UCC'U I':\NCY ILlitiun ut lode: .... _ L so Gnmp(m): . . . k i,v of Conmrmti,m: l)C,upaut la'r l h'e'r - I)ovs t by bui ld in);cevuam on'41mmklar SN tom': tip-t 1.1 <t1pu leu ions: ell --Y- T7 g 90� J SECTION 9: I'ROPFR'IY OWNER AUI'IIORIZAIION N.wm.inrl Al- ress of Proper Ow tier -- _C�E•N�✓F_.Q�.��vrif�lQ—_�° Wr n yr�_gT_ -S91Fc�-- ram`¢.—---------- °i 970 ._ Mime(Print) No.and Street City/Tow, Zip Properly Ow tier Contact Information: L78- 3/7- I itlu Fclephone No. (business) Telephone No. (cell) c-mail address It applicable, the properly owner hereby aLI(horizes -1-14. EAU 6,nt LAt rr4L6-.,_./[V�—_,ram 50"y y /J✓�'-•_--- -�� ._— /�'t/rl —.QL�� Name Street Address City/Town State Zip to act on the property owner's behalf, in all.matters relative to work authorized III-this building permifa p phcltion. t SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) 1f buildin p is Icss than.33,Wtl cu.ft.of enclosed space and/or not under Construction Control then check here® nd.ski Section IU.I 10.1 Re istered Professional Responsible for Construction Control Nante(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor A(A-ME/ lma&9&ZriAeA /A/'/ Company Name 7e"f&j z A42!1'r/ -5 16la Name of Person Responsible for Construction License No. and Type if Applicable /dI SI/yTON m,4- �l/970 Street Address City/Town State Zip Tole phone No. business Telephone No. cell e-mail address SECTION II:tut l,KI IN'•UNA.Nt.'I All 1 -A I M.G.L.c.152. 25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be contpletud and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. - (s a signed Affidavit submitted with this a lication? Yes O No O SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item- Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=S_ I. Building S O B - Building Permit Fee=Total Construction Cost x_(insert here 2, Electrical S appropriate municipal factor) -5 1. Plumbing 5 J. Mechanical (HVAC) 5 Note: \linimum fee=S (contact municipality) 3. ..\Icchanicit Other S Enclose check p,wable to n.Total G?st '+ (contact nwniripalih•) and write check number here SECTION 13:SIGNAI'URE OF BUILDING PERMIT APPLICANT Itv entering ntv name below, I herebv ][lest under the pains and penalties Of perjury that.dl of the infurmgliun contained in this application is true and accurate to the hest of ntv knowledge and understanding. T7i�s�r__r i,>tE� - --/_ _ ---�- - P365.1- ,--- -_ .3659- �/6�i I louse print III,] ign name I itle . - 1•Iephot o No. hate ';IrvvI Address Cih'i Potrn Slat Zi Municipal Inspector to fill out this section upon application approval: _- i\',t to Hue ti CITY ()F S,v-&Nf, Akss.ICH[,'SETTS BL DLNG OEP.IRT\tLNr 120 WASHLYGTON STRE". J'e FtOOIt TIM (978) 743-959S 1CIJ®ERLBY ORMOLL Ftx(978) 740.9846 MAYOR nicmw ST.PMUS DIRECTOR OF iK 8LlC PROPEATY/31:MDLNG COJLVtSsIOV ER Construction Debris Disposal Affidavit (required for&U demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section I I I.S Debris, and the provisions of MOL c 40, S S4; Building Permit a is issued with the condition that the debris resulting from this work shall be disposed of in a pro 11 If, S I JOA. perly licensed waste disposal facility as defined by NIGL c The debris will be transported by: Rrl� i/n C/l1fr.�i r (name of hauler) ,- The debris wi 11 be disposed of in ll/ORrN /nE L' r�ni�_ (name of racdlty) (iddrm or rdaliiy) + ynamre o(permrt�pphuaf 'life T'R©Pa5ro $11110 OUT - 3 10'01RO y / .66V t -JE2a-f 7 WORK f F4TI otv �r-90 WtIMIN6r9 $T. TAkt' ovr v✓INA6W SAtrM MA 0/570 V✓o R� 5 T�TJo�P �aunarE� 8 0X IST/46 GootelT couar�r� fic' 3T1v6 cootER 3 9 11 COON h NZ T $N�tVtNfr � � 3 � o 36 y � 3 VVI fd AC3UV WIN DO q ' b y n10 E ST. PR0?0551'49 6vxv our 3�'�; ro f° / BEN .?L .T ry5 wog 5r�*nevv '60 W^V1,vSrgP1v sr, 71f oircow WIIVAD'0w 5lerAl AV 0f970 36 A/wolo our 9 WiAlto 0 fin/ C 7A i. LYNDt I r. I 5vR'FACE � ; � � y8 16H covN e ray ; CITY OF 5:1LEN•t, %WS,kCF1 SETTS t Gu ILDING DEP.{RT\lE.\T , ` 1 120 \Y/ASHLVGTON $TiIEET, 3�FLOOR ` 'ILL (978) 743-9595 Fla(97S) 7.10-9846 ?CI.%tISERLFY DRISCOLL �L�Yoq Tllo�tAs Sr.Pt) RRf3 DIRECTOR OF PLSLIC PROPERTY/BUILDING COWMSSIONER Workers' Compensation Insurance Aff7davit: Guilders/Contractorv/E(ectricians/Plumbers Amilicant Information Please Print Levibly .V:Imc (IInx111hLOfpnlllllofL IadIVl(1Wll): 1 & C o61_77 77,01/ //ye, Address: /17 r"A/ /x tot t__ City/State/Zip: !� 4lGavl M6, 19/9-70 Phone* 7`6 - 7t1s- 36� 9 9 Are you an employer?Check the appropriate box: 4 � 11rr1 a 'hype or project(required): 1.0 I am a employer with general contractor and 1 5. ❑New construction employees(full and/or part-time)." have hired the subcontractors 2.0 I am a sole proprietor or partner. listed on the attached sheet % 7. (O"Remadeling .hip and have no employees These sub-contractors have ll. 0 Demolition working for me in any Capacity. +orkers'camp.insurance. y, Building addition (No workers'.comp. insurance 5. Lr We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions ).0 1 am a homeowner doing all work right of exemption per MGL I L0 Plumbing repuirs or additions myself. (\o workers'comp. c. 152, 11(4),and we have no 12.❑ Roof repairs insurance required.) t employees. (No workers' 13.❑ Other comp, insurance required.) ;-,pi-,pity appik uno den chucks box rt must also fill uul the wcliuo Waw-hawing their waken'compenudon polity information. ty h.neown who whmil this uBMvie indicating they ate doing all work and then him outside contm =moat auhmit a new allldavil indicting awl, $1�mrxwn that check this box mwn atuch xl on addilianal.hunt.huwing the town,or the rubaontnetun and Iholr workmi wimp.policy infonnanon. fain on eatplayer that is providing IvorAers'rumpearadun insarancefar my etnpluyeex Below is the policy and Job site infer/nation. Insurance Company Namr. ---'-- Policy Our Self-inn. Lie. d: Expiration Date' Job Site Address: Cityistatcaip: Attach a copy of the workers' compensation pulley declaratlen page(showing the policy number and expiration date). F.tiluru to secure coverage as required under.Section 23A of MGL e. 152 can lead to the imposition of criminal penalties of a line up to 51,500.00 and/or one-year imprisnnmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a line Jf lip to 52)0.00 1 Jay against the violator. RC advised that a COPY❑f thtx stalctnent Inay be furwarded to the 011lca JI Invrsligmiuns of dl{ MA for insurance coverage vcrilicaliun. l do hereby certify wider doe poins and penahies o/perjury that the infurnrutlon provided above iv true cord correct Lk � Phrnte j' I / fl Ol/iciu!n.lr only. Do rtor write in dris area, to be cunrplef✓d by city or town n/jirjaj I Cif lr Puwa: Y' — . . __. Prrmir/Llecnxe,� Is-utnq Aulllorily (circle tine): I. Loard of Ileallh 2. Iludillnp llepucnnent 1.Cityamvii Clerk 4. Eleetri{11 htrpectnr 5. Plo(ohi l;Inxpeetor l 6.Other I Contact I'crmn:,_-- _ _ Phone d: l Information and Instructi®n3 >lassachuscus General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an eurployee is defined as"...every person in the service of anodier under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corpuratiom or other legal entity,or any two or more of the foregoing engaged in ajoint 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." %IGL 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) nume(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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should he 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 Ofilcials 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 till in the permiUlicense 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 permit to bum leaves ctc.)said person is NOT required to complete this affidavit. The Off ice of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of ladustrial Accidents Office of favestigations 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 aaviscd 5-26-05 www.mass.govldia