87 WASHINGTON ST - BUILDING INSPECTION (5) -file Commonwealth of INiass uset
Department of I'ubliC S,1 y
(��'t//j"J S ,! \Lr++drhu+c 115 tiLdr III, li lg Cr v1780(AIR)
B uilding Permit AVpIication for any 13uiIdIngothe than a One-a Ilvt . roily Uwellit g
(I his Section For Official Use On
Iuilding I'cnnit Number
. DJIe:\pplied: 9_-`1-.LL._ iImmiog Of"
SECDON 1: LOCAL ION(Please indicate Block 4 and Lot N for locations for ich a street address is ut available)
w9S_Hi(V 7o.iv-_ _S.Z_.- _59V 4 F& _vt__.t)�9
No. ,rod Street Cil1 ,r Down /if,Codo -__- Name of Buildio);(if applicable) _ _
SECTION 2:PROPOSED WORK
Edition of..'M St.1ty Code used 7—OO.q rt5C It:New Conslrur Lion rhvrk here❑or check,dl that epphY in file two rows bvlow -_
E\isti 11 liuildin); Reimir CI :\Iteration ❑ :\dJilion ❑ Uvnl,dition i 'Ivd.x fill oukmd ubmi,Appvndis l)
Chan);1,of Use ❑ Ch,utge of Occupanry ❑ Other ❑ specify:
Arebuildingplans,uul/urron.atrurtionJ,kuntentsbcingsupplicd,lspartoflhispenuitapplication? Yes (' No ❑---- --
Is'an Independent Structural Engineering Peer Review required? W.4 ❑ No M----
Brief Description of Prup,xscd l\'urk:_- r_Y�R0✓P NUo✓ t_Of}f) -3��1L(a_�h ✓T in✓l �_,/.-}7�s-
_.�7.7_�z/ /� SO�'✓!E _�.LQ_r^'A-c-c..J o�' i��9 37riL cat-
SECTION 3:COMPLE'l-E Tilts SECTION IF EXISTING BUILDING UNUISRGOING RENOV,\TION, ,\Doi I-ION,OR
CHANGE IN USE OR OCCUPANCY
Cheek here if an Existing Building Investigation and Evaluation is enclosed (See 7,40 CMR 34) ❑
E\isling Use Group(s): -- =Z._ _ Proposed Use Gruup(s):__
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
PAsSel11biy.\-I0
ors/Stories(include basentent levels)h Area Per Fluor(sq.It.)
(sq. It.),md rota) Height(it)
SECTION 3:USE CROUP(Check as a livable)
A.2- ,Nightclub ❑ A-3 ❑ A4 ❑ A-3❑ B: Business ❑ li: Educational ❑
FJ ❑ 14 Cl— if: Ili h Hazard 11.1 ❑ it-L❑ 11-\ ❑ 11-4❑ I1-3❑
1: Institutional 1-1 ❑ I-2❑ 1-3❑ 1-I❑ M: Mercantile❑ R: Residential R-I❑ It-?❑ It,i❑ It-� ❑ .
S: .S forage S-I ❑ S•2❑ U: Utility❑ Special Use Cl and please dcseribe below:
Spcci,d Use
SECTION 6:CONS if I'YI'F. (('heck as a licable)
IA ❑ IB ❑ IL\ ❑ IIU ❑ IIh\ ❑ IIIB IV ❑ V:\ ❑ \'I, ❑
_— Sf(IION 7: SITE INFOR•MA IION(refer to 790 C.MR I I L0 for dvtails on each item)
Water Supply: Ruud Lone Information: 1 Sewage Disposal: french Permit: Debris lieuuwal:
Public Check it outside Flood /_one C7 InJir,ue municipal CT A trench rrlll not be Licvmed I)ishwal �itr❑
Prn.rtc❑ nr iudv ulily/I _ „r on ail•s,,tvin ❑ wijuin•d ❑nr Irvnch or.prrdt-
pennn is rnelosrJ❑
Railroad right-ut-way: I 11.1/ards lu .\ir..\ac igatiom !
\'fq., ull ddr H,, Is 1Ini,lure isith in.urporf d) prod,h.irro' I Is thee ire r,c��nuld,lnl' I
ir l'ikn.rnt h, BItudJ,Ili hnrJ c7 � les❑ ar.\'o L� i lr+❑ \'oQ _11I
SECTION 9: ON II[NT()F CF It I MICA 11:
I ,Iirnm ,�l C'-dc l.r l;nnlpl+) I,it„I l'• n.lru,Inn l0,ul ,inl l ,iJ I„v' ll,•, r _— --.
lri s Ihr I uJ,lin+l„•nl.un. 111I,mil I, r
I
Sl:( I ION 4: I y Oty.N1:1t :\U I IIORILA I ION r.\ddws4 ul Proliviti, Owner__.
towncitvtownName (Print) No. and Street
I'lope,tY O%s nor Cont.1k t lillormatioll:
I ide 1,-it-phone No. roit-j,hone No (cell) V-retailaddre4s
It applicable, the 1,rojivirt).owner 1wirt-k- milhori/es
Street Address city/I'myll State Zip
Name -kI by this builklint',perinit application
t on the pro perty owner's in.itteri relative it,work authorized
SECTION it):CONSTRUCTION Ruc-rION CONTROL(Please fill out Appendix 2)If buildin•is less than lidAivsk-cioll
%5,00ticu,Itenc s p,Ice,jIltj/,r not under Collstr1l"jolIC...Control then check here C3-1
Ill.I Registered Professional Responsible for Lon-4tructitin Control
Name(Registrant) 'Telephone No. e-mail address Registration Number
slivet Address City/town State Zip Discipline r\piration Date
10.2 General Contractor
tt—
Company Name 00
Oil,.,/ C-1- A( v 12/-Xf�
Name of Per'()" Responsible for Construction License No. and rype if Applicable
City/Town State Zip
Street Address0 6'3(&41; L- C-a 1-h
rdepholle No.(bun lvc.is) rviellhorie No. (M U.Illa il add ressI)
SECTION JUN II: WW.;� —11 k'NII'I v"MO\ IV,I ;.\M r AI I It'-,I I [M.G.L.c. 152.§ 25C(6
A Workers'Coillp ))
ells,ltioll 111.4ur,111ce,liffidavit from the MA Department of IJ'iustrijIACCkIeI1tq must be completed and
submitted with this application.application. Failure to provide this affidavit will result in the denial of the Issuance of the building Permit.
(sasiaried Affidavit submitted With this"I'Plic"t'll"? Yes 0 No E3
SECTION 12:CONSTRUCTION IIUCTION COSTS AND PERMIT FEE
Item and
Costs; (Labor Mid Materials) total Construction Cost(from [tell,(1)
I. Building S Building Permit Fee'Total Construction Cost x (Insert here
2, rleetrical Ippropriate municipal fader) '5
�I I'lollibilit" Note: Milli'llull fee "5_--- lilt cil"I It%
4—Nlll It 5ill"Ill�(Qv�\�) 5 P�;
i. %IL11I,I0iC,II (Other) 5 1:11dose check payableit,
S (,,)ljj,jct IllLJjiciI,,jlItN)and i%rite divA number here
SECTION 13:Sl(;N,\IUI(EOFBUILDING nitmi-trAPPLICANT
twlmv, I liorvily IltL'St older the pains and penalties of perjury HIM 111 11 the illforIll-iti011'01ILlIM'd in 111i,
application is true and awir,RQ to Hle 1,,,st of it\ kiw%%Ivdgc 1011
I Itle 1,1vi,hom-No
Aid "gil
Fo%,11
%hillicipal 11i'vector to fill out this setliml upon application 11'Prov.11:
7v P
N.mit,
CITY OF S:tiE1I, , L-kS&kCHUSETTS
BUILDING DEPART\LF—NT
4 120 WASHINGTON STREET, 3TD FLOOR
j TEL (978) 745-9595
F.kX(978) 740-9846
KI.,(BFRf FY DRISCOL-L
MAYOR THO%w ST.PIE.aRa-
DIRECTOR OF PUBLIC PROPERTY/BUMMING COSLUISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
• Almlicant information Please Print Le ibis
Name(BusimssrOrganizatioro Individual): Pl' -lam 0 '
Address: r 005tr LItiJ �(�•
pltit�
City/State/Zip: &61/G✓LC r'1 /VIA Phone ll: Sad
Are you an employer'''Check the appropriate box:
Cype of project(required):
1.0 1 am a employer with 4, 0 I am a genera)contractor and 1 b. ❑Now construction
employees(full and/or part-time).' have hired the sub-contractors
2.X1 I am a sole proprietor or partner- listed on the attached sheet,t 7. Remodeling
ship and have no employees These subcontractors have V. ❑ Demolition
working for me in any capacity. workers'camp, insurance. 9• building addition
(No workers'comp.insurance 5. We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself [No workers'comp. C. 152, 41(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 13.❑ Other
comp.insurance required.)
-Any applicant out chucks box el mutt also fill uut the uctim plow showing their worked compcnutiun policy inturmatio".
'I hvneuwnen who submit this sdidnvir indicating They ate doing all work and then him outsidacontracton must nthrrllt a new amdavit indicating such
=Contmetun that chuck this box must attached an additiurud sheet showing the name of the subaontnctorr,and their workers'comp.policy infomution.
fain an employer that is providing)porkers'compensation insurance fer my employees Below is site pollcy cord fob.vits
injorrnaliom
Insurance Company Name:
Policy 4 or Self-ins.Lic. it: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy orthe workers' compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of,*vIGL 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
often to S'_50.00 a duy against the violator. Be advised that a copy of this statement may lace forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby c•erriviy untie ulna are enaldes ojper' 'Jrut are iufonnallon pro videod above is true and correct.
Si ndill If; Data
Offl•iul use wily. Do nor write he this urea,to be completed by city or town gjlvlat
City ar"1•uwnc Permldl.lccnseq___-----__----.--.
Issuing Authority(circle one):
1. Board of health 2. Building Dcpartntent .I.Citylfown Clerk 4-'Electrical Inspector 5. Plot
6.Other ing Inspector I
_._._
Contact Person: _.__ ._._ Phone N:
4i
1
"r k CITY OF SM.E.I, TAxSSACHUSETTS
BLADNG DEPARTMENT
130 WASHIIYGTON STREET, 3' FLOOR
T FL (978) 745-9595
F.tx(978) 740-9846
KINM Rt FY DRISCOLL
MAYOR Tlgo.%w ST.PIERRH
DIRECTOR OF PLBLIC PROPERTY/BCILDQYG COS11MIISSIONER
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:
r/i�rz
(name of hauler)
The debris will be disposed of in
(name of facility)
of thcility)
signature of permit applicant
dale
kbnsalt.dx