87 WASHINGTON ST - BUILDING INSPECTION (3) ver
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 addres not available)
No.and treet City/ own Zip Code Name of Building(if applicable)
g 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 ❑ 1 Addition❑ 1 Demolition ❑ (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 ❑
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) ❑
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 Cl A-2 Nf Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ IH: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional I-1❑ I-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 ap licable)
IA ❑ IB ❑ IIA 13 1111 ❑ IIIA O IIIB e IV ❑ 1 VA ❑ VB 0
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
L Trench Permit: Debris Removal:
Water SupJp y: Flood Zone Information: / Sewage Disposal: Licensed Disposal Site
Public l9 Check if outside Flood Zone 5 Indicate municipal A trench w' not be p
Private❑ or indentify Zone: - or on site system❑ required�trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Comrnission 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:G�Use Group(s): Type of Construction:lT s Occupant Load per Floor:4�?P,_ �
Does the building contain an Sprinkler System?: 4 Special Stipulations:
- SECTION 9: PROPERTY OWNER AUTHORIZATION -
Namec7r/and Address f Property Own-err /� Q
` Arlelrfr�5 ! �Zb i�.-./l.'�T• 1 JLUi,Ir [,�
Name(Print No.and Street
/� �] City/To zip
Property Owner Contact Information: ✓ � CrjV kei,j
elr 79- 4WCs Sagr� ia�flelaf�BlaA�le�n RE
Title( Telephone No.(business) Telephone No. (cell) V e1lhaiYaddr— �ess' .Ca[vx
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 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
V7It rr ' Zg /4-
Name(Re 'stra ) two lepf ne No. e-mail ad re s egi tratlon Number
Street Ad ess City/Town State Zip Discipline Expiration Date
10.2 General Contrac or
M D�'twb�
Company Nam
r
of Person Res onsible for Construction License No. and Type if Applicable
Street Address City/T wn State Zip
S 03G
4--
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.
Isasizned Affidavit submitted with this application? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$ Q Oo Q
1.Building �T
$ O 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) $
Enclose check payable to (�jl7RY of � 21ti
6.Total Cost $ t!0 QO Q (contact municipality)and write cumber 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 State Zip
Municipal Inspector to fill out this section upon application approval:
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)
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 Z�/ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No Cd 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
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing 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/Investigation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
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 permit
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 Ci /Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town/Town State Zi Discipline Expiration Date
CITY OF S.UEm, INLksSACHUSETTS
BLumLNGDEPART\ NT
• 130 WASHNGTON STREET, 3w FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
Kl\tBERLEY DRISCOLL
MAYOR T HoNiAs ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BU SING COWMISSIONER
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:
(name of hauler)
The debris will be disposed of in
(name of facility)
r<T- 133 G 6V4c�u�N
(address of facility)
signatur permit applicant
3 sss
date
debdsafr.do
CITY OF S.U.F.M. NtksSACHUSETTS
• BUILDLNG DEPARTNIENT
120 WASHINGTON STREET,3'a FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOIHA3 ST.PrEM
DIRECTOR OF PUBLIC PROPERTY/BUI DLNG COM MSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Attplicant Information n Please Print Leeibly
Name(Busim-ssiOrganiratioNlndividual): ��)✓l� N J�r✓1�tin
Address: S o rS col'u t. t2 D
City/State/Zip: 6&V4:y1 C' 1 44 Phone #: 5_0Y 6 4 3 03 6;"4
Are you an employer?Check the appropriate box:
Type or project(required):
1. 1 am a employer with 4. ❑ I 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 palmcr- listed on the attached sheet.: 7• U Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. El Building addition
[No workers'comp:-insurance 5. 0 We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions
myself.(No workers'comp. c.152,§1(4),and we have no 12•0 Roof repairs
insurance required.)t employees.[No workers' 13.Q Other
comp. insurance required.]
"Any applicant that cll%*s box d I most also Till out the section below stowing their worker'compensation policy infumtattoa
t I lomeowness who submit this affidavit indicating they ate doing all work and then him outside contractor most submit a new affidavit indicating such
-Comnxnon that check this box most attached an axlditional sheet showing the name of the sub•eontracto i and their woikem'comp.policy information.
1 am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and fob site
information.
Insurance Company dame:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: Ciry/State/Zip:
Attach a copy of the workers'compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S.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. 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 certify under the A and p h of perftiry that the information provided above Is true and correct
Signalure: y Date: -3 — S— �T
Phone#:
Ofrcial use only. Do not write in this area,to be completed by city or town affwial
City or Town: Permit/License#
Issuing Authority(circle one):
L Board of}lealth ,2.Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#: