Loading...
87 WASHINGTON ST - BUILDING INSPECTION (9) The Commonwealth of Massachusetts o Department of Public Safety G9V E Massachusetts Stale Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Famil (This Section For Official Use Only) Building Permit Number: Datc Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not avar a le) ;3'7 wgs14i%-iGTUN 57- 5,91e ^ 01'�110 vr'v5 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 bclmv Existing Building❑ Repair❑ Alteration I`f 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 supplied as part of this permit application? Yes ET No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: 6LIJLI A 5M9c.[_ SUS/f/ 6"3!e, 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): 13 Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&r 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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ Fh High Hazard H-1 ❑ H-2❑ H3 ❑ H-4❑ H-5❑ L' Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 Cl R4❑ 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 Cl IIA ❑ IIB ❑ IIIA ❑ IIIBMr IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public LLl Check if outside Flood Zone❑ Indicate municipal 61' A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: il14TL permit is enclosed❑ Railroad right-of-way: Hazards to Au Navigation: \IA I li,ur n � on,n _ 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 Edilimn Of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: pA?,j VC)0 A\j0 Sod - �sLt `� � o3 �6y r r SECTION 9: PROPERTY OWNER AUTHORIZATION + Name and Address of Property Owner &y L D 66fZ'(-. - .7 ,ZfYiWW 1)Z f T Yb eA9/Z,-U-[ ✓I-A' y l l cV Nance(Print) No.and Street City/Town Zip Property Owner Contact Information: 57L=t/L' GOyD P, GeLG4�8-gFIZ 0 'eW Title Telephone No.(business) Telephone No. (cell) a-mall address If applicable,the property owner hereby authorizes D91V16L N0( MAVjD 5 oy3�UV.rki� 3w r6y „qd, 01 -7) 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 tinder Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction.Control r/C NA9 b 60 SIN n717l`6I' 0)` -1 _www.(,tTif rP)/u Name(Registrant) Telephone No. e-mail address Registration Number 3-1 -1"UaNGl2 Sr 5/-) LF. ^ �IF.lU Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name DgNIe-L IJ u 2&'4h-0 Name of Person Responsible for Construction e License No. and Type if Applicable Street Address City/Town State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:1VORKERS'CONIPF.NSA l'ION INSURANCE AFFIDAVI"I M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the NIA 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 ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE - Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ - 1. Budding /Z 7 N Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ O (Y Q appropriate municipal factor)_$ 3. Plumbing $ r$- / 20 J 4. Mechanical (HVAC) $ -Note:Nlinimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ 6 Z..'� (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 State Zip Municipal Inspector to fill out this section upon application approval: Name Date �'7vr CITY OF sm.Em A-USACHUSETTS 1 BUILDLNG DEP:IRT\tE,`iT 130 WASHLNGTON STREET J w FLOOR TEL (978) 745-9595 F.tx(978) 740-984,5 IUJiHF_I2IEY DtiISCOLL NL4YO;l I710SLAS ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BUILDCYG COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Cade, 730 CNIR section l l 1.5 Debris, wid the provisions of bIGL c 40, S 54; Building Permit k 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 Nf c l 11, S 150A. The debris will be transported by: y (name ufhauler) The debris will be disposed of in (name of facility) --G G 6 IL(S 7b A,.n, n1,9 (address of facility) siyno Nre of permit applicant datc ` 7 CITY OF S,=,Nl, N1,NSSACHLSETTS BUILDING DEPARTMF_NT 120 WASHLNGTON STREET, Sae FLOOR TEI_ (978) 745-9595 F.kx(978) 740-9846 KL,,BFRI EY DRISCOLL THOMAs ST.PIERRB ,N AYOK DIRECTOR OF PUBLIC PROPERTY/BC[LDLVG CO\L\tISSIONEA Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers Applicant Information I� Please Print Legibly Name(13usincss:Organization,'Individunl): r/�'N/EC.- �t7✓Mil p�.� Address: 'S OGet I J 2 City/State/Zip: 6&1'e_r7(-`1 MA- Phone it: 5-o}5 Are you an employer?Check the appropriate box: Type of project(required): 4, ❑ 1 am a general contractor and 1 \ l.❑ I am a employer with g' 6. ❑New construction �,ylnployees(full and/or part-time).' have hired the sub-contractors ,�, 2.[2't am a sole proprietor or partner- listed on the attached sheet,t 7• [21 emodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp: insurance. 9. ❑ Building addition [No workcn' comp. insurance 5. ❑ We are a corporation and its F� � required.] officers have exercised their IO.t .fecrrical repairs or additions },❑ I am a homeowner doing all work right of exemption per MGL I I.Vlumbing repuirs or additions myself.(No workers'sump. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.) t employees. [No workers' 13.0 Other sump.insurance required.] -Any applicunt Run dtecks box Nf must also fill out the uclion below showing their worketi compensation policy innarmatiom 'I lomeowm"who submit this affidavit indicating they are doing ull work and then hire outside comrac,on must submit a new affidavit indicating such. $?mrmoors shut ch vk this box mtut mtachcd an additiowl xhsxt showing the mmnc of the sub-contncton and(heir warkere'comp.pulicy information. I am an employer that is providing workers'compensation insurunce for my employees. Below Is the policy and Job slid infonuarion. Insurance Company Name: _.._..-- Policy A or Self-iris. Lie, q: Expiration Date: VJob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ot'NIOL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 cerrify a/a/dyry/the pallsd penulde-n perjury that die information provided above is true and c'urrrec'L Sianoourc' / I / Dare 2., Pho X<[ 3 0-7 6 `f OJJiciul use unly. Da not write in this area,to be completed by city or Iowa ufjlcluL Citynr"town: _._._. . .__. PcrmiUl.)ccnsek --_—.__. Issuing Authority(circle one): 1. Board of lie,alth 2. Building Department 1.Citytrowu Clerk J. Electrical Inspector 5. plumbing Inspector 6.Other Canlacl Person:_ _ _.. _ Phone it: C � x : ry 4 CITY OF SALE,, INL-�SSACHUSETTS Ali BL'ILD LNG,DEP�RTNYMNT 120 WASHINGTON STREET,31O FLOOR TEL (978)745-9595 F.}s(978) 74 9844 KIMBERLEY DRISCOLL THONUS ST.PIFJtRB MAYOR DIRECTOR Of PUBLIC PROPERTY/BUILDING CONWISSION ER Workers' Compensation Insurance Aft3daviti Builders/Contractors/Electricians/Plombers applicant Information Pt case Print Legibly+ Name(nusitxss;O'rganizatioriIndividual): Atlantir.Weathe6ao4ion,I L(; Address: .. 61 R Jef as(in Avenue ; em MA 01970 City/Statc/Zlp.1, Phoneli: 97� 7 yL/- 8l Are y amn employer?Check the appropriate box: Type of project(required): YI 1 a it cm to cr with - 4• ❑ 1 am a general contractor and,I P y 6. Q,New construction employees(full and/or part-time).• have hired the s*Lbritraetors 2. I am a sole proprietor or p`urucr listed on the attached sheet _ �• ❑Remodeling ship an 1 d,hav' no employees ,' These subeontiuetors have s. ❑ Demolition v kin forme 1 'm ,ca acity.. workers'comp.insurance: 9 B Y P ❑ building addition • No workers comp insurance] 5. ❑ We are a corporation,and its �-required) �� �. officers have exercised'their.' 10.❑Electrical repairs or additions } f am a homcowncr'doing alf work right of exempt iun per MGL , 11.Q Plumbing repairs or additions ysf.,[No•workus' onp. c. 152,¢I(4),a 12.❑ Rof rem n pairs insurance require t=- employees.[Na workers',. 13.Q Oilier, comp.insurance mquinid.J• 'AnY applicant slur ehw:ks bo:.Nl mlue[alxd fill out thu action below showing then worken'.cpmpem ition policy mfurmation. t I h>tttuowis n who submit this affdavit indicating they are doing alfwork and then hire outaide cantmcias most submit a new affidavit indioting,xuch. ' 'Controci64 that chuck ibis box mustattacluxim atfditiotut sheet showing IN name of tho sub-contractors and thelr"woristi comp.policy information. . tam an employer that is pfovtdlug workers'compensiMonbtsurance for my einp!oyeex Below,is the policy and Jab site tnforihildan. ., insurance Company Name: Policy 4 or Self-ins.Lic,N 122 2 7 n Expirution Date: - •�'�t `' Job Site AddressiJd //1 Fvl (1c City/state/Zip:`- ! �9//c / lttat.h,a co py'of the workers'cotupensailon policy declarallon page(showing the policy number and expiration date). Failure to sc urg'coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fihc up to S 1,500.00 and/or oae-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a fine of up to S2i.0.00'u Juyagainst the violator. Be advised that copy of this statement may be forwarded to the Office of Invuugatiutig'ofrite DIA for iiisuralicdcoverage ventlll eation. - !do hereby ti ertlfy under Me pahttss/aad penaltles of perjdq that the hifonuuflar providedi ubu true and correct `'`/� / Rhone : q� 7 iL 7 Y F O flu!use only. Do not wiile in ddy area,ta'be completed by city or town of/leiad City or Tow,n: Permit/[:Icenle 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 tt: CITY OF S, LEltiI, ;tiL1SS 1C L-I LSETI'S aL'1LOLYGDEPAA"17-N MNT \ ,,�h. I?0 C9.\SHLVGTON STREET, S °FLOOR T L (978) 745-9595 KIS[MUZY DRISCOLL FAX(978) 7•I4-984S NC 03. T�IOSG�3ST.PIEAttg DMECrort OF pt:OLIC pR0FEATy/8C1L0LNG CONNISSIONEA Construction Debris Disposal Affidavit (required for all demolition and renuvation work) In accordance with the sixth edition of the State Building Code, 730 ChfR section l 11.5 Dcbris, 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 property licensed waste disposal S I50A, facility as defined by bfGL c The debris will be transported by: /�0 /0t?. (name ul'huulcr) The debris will be disposed of in : (nnmc ur— t'a�ilijY) �— (,"dress ur•t'arflit7) signatutC )fPcrn1it applicant (Lice T'b fo®srts&s all basic requhemmtsofhestatdslT=Dlmprove mtCmtractorLaw(MGLchapter142A),but does not inrindestandard languagamprotecthomeowuers. Seek legal advice if necessary.Any Person planniug home improvements should first obtain a copyof"A Massachusetts Consumer Guide 1q Home improvement"before agreeing to anywodc or you naido w.You may obtain afree copy by calling the ' Office of ConsumerAffha and BesinessRegulation's Consumer IntermationHotline at 617-973-878 7 11 1-8 8 8-2 83- 3757 oron omwebsife. BComeowner Information Coatractorla€ormation t�dAldjd. Compavy Names or aport OffiContmetor/Salaperso�Jlhwer nil State ZipCode BusinAdd eetad Salem MA 01970 yrveove Evcnfngphone City/rown State - Zip Coda IvlailingAddass(IIdifferevtfroma6ove) Bvsivess Phonc Federd Emp7oyaIDor S.$.N mher L.nsryvirtnµlmos[8omv 8m-rmpmrmmtevvhulvcRS^.Nmn� Eepvva'mao. impnsemm f�cvin,iv�6m'v vrvGtl m�ishaavvvvmEa The Contractor agrees to do thefollowingworb ter the Homeowner. (Dacrih,e//��iv detaiitbaworkio completed,specifyi�t'h/atype,band, dgade of materials to 6eused,vseadditiosui sbeefs i£necas .) �1ow � ee(�ie �a5-e _ efa(IS 2-(5 r7 G -C 3 Required Permits-The followringbuildingpermits arerequtred Proposed Startand Completion Srhednle-'17tefollowingschedulewill mdwillbe securedbythe contractor as thefiomeowne2s agent: be adhered to unless circumstances beyond the oonnactofs control arise (Owners who secure their own permits will be excluded from the Guaranty Fund provisions o€ Date when contractor will begin contracted work MGL chapter T42A.) Date when contracted work will be substantially completed Total Contract Price and Payment Schedule The Con tractor agrees toperferm the work,famish thematerial and labor specified aboveforthe totalsum of: �D00.Or� Payments will bemado accordingto the fallowing schedule: $ upon signing contract(notto exceed 113ofthe total carroactprice g the cost of special orderitems,whichever is greater) $ Y / orupon completiono by allQ-1-' or upon completion of uponcompletion of the contract. (Lawferbids demandingfullpaymmtuntil contractis completed both P parTy's satisfaction) Tbefsllvwiag matuialrKripmeatme,be special $ tobepaidfor ordered 6efom the contracted work begins in order tomedds,rompleticeschedulc(e%) $ f4 he paid for NOTES:(-)Including all finance charges(tt)Law requires that cry depositor down-paymectreq.i,.d by the contacter before work begins may not exceed thegeataof(a)onrib"vd ofthetotal coniractpd'ce m(6)the actual wstofany special equipment orcustom madematerist wtichmust be spaial ordered 3v advanceto meet the completion schedu]e. Ex ras Warra ty-I ante being vrovid dh b Er t v EIM.Elyes f Ilt fn c`musth H hed to thetract) Subcontractors The contractor agrees to be soblyresponsrblefor completion of the workdescribedregacdless of the actions of any third party/subconhacon"'lized bythewntractor. The contractor farther agrees to be solelyresponsible for all payments to all subcontractors for materialsmdlaborunderthiaa cement ContmetAcceptance-liponsigtingtwsdoc=mtbec mabiudingcontmctundcrlaw. tildes otherwisenetedwithia this document the eontractshallnatimplythatmylimorotherseeudtyinteresthasbemplacedonthermidence.Reviewthefellowing cautions and notices =efullybefine signingthis contract. a Don't bepressumd into sigaingthecontract.Take time to read and fully understandit.Aslcquestionsifsomethingisunclesr.o Makesure ecoutrachKhas avolid Home rmDrOvemmEConfractarRe2istradon. Tiielawrequires most homeimprovement contractors and subcontmetomto be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration bywritiagto theDirector at IO PukPlaza,Room517O,Boston,MA 02116 or by calling 617-973-8787 or 888-283-3757. o Does the contracterhaveinsomnce?Ask the Contractor£orhis insurance companyintemation so thetyou can eonfum coverage,or askm sea a copy ofa'proefofinsurance,document. • Know yomrights and responsibilities.Read the Importanthrformatioa on the reverse side ofthis form and get a copy of the Consumer Guide to the Home improvement Contractor Law. You may cancel this agreement ifithas been signed at aplace other than the contractor's normal place of business,pmvided you not ifytha curatmeorinwiitingat hisrhermain office orbranch office by ordinary mail posted,by telegram sent or by delivery,not later thaare en; of third business day following fie signing ofthis agreement, Sea the attached notice ofcancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THER) ARE ANY BLANK SPACES111 Trvo ideatiw(eopiaoF3e wotractmu[be wmplcvd aedsigyed,naewpysbouldgetuaehovuorvna� sbouldiwleptby&,.suinrr. �eovmer's ignatura e"A-ti Contractor's iiignature Date 4 14( � - d1,r//�( Date The Home Improvement Contractor Law provideshommeowners with the right to initiate an arbitration action(as an aptemative to court action)if they have a dispute with a contractor. The same right is not automatically afforded to a contractor,however. The contractor wouldhave to resolve any dispute he/she has with a homeowner in court unless • bothparties agree to the optional clause provided below. This ck sewouldgive the contractorthe same right to arbitration as is afforded to the homeowner by the Homeimprovement Contractor Law. The contractor and the homeowner hereby mutually agree In advance that in the event the contractor has a dispute conceiving this contract the contractor may sums tthe dispute to a private arbitration firm which has been approved by the Secretary of the Execufive Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such azbitration`as pt6vided 7n Mnsiabliusetts General Laws,chapter 142A. rt•,i 3t t�Gr s�-1 Homeowner's Signature Contractor's Signature ;I TICS:The signatures ofthe parties above apply onlyto the agreement of the parties to aitemafive dispute resolution initiatedbythe contractor. Thehomeownermayinitisfe alternative disputeresolutionevenwhme this section is not separately signed by the parties. Homeowner's eights A homeowmefs rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e.MGL chapter 93A)may not be waived m any way,even by agreement. However homeowners may be excluded from certain rights if the contractor they choose is not properlyregisfered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fundpr,w sions of the Home Improvement Contractor Law. The contractor is responsible for completing the work as described,in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights orif the contractor guarantees or provides an express warranty forworlmtanship ormaterials. In addition to guarantees or warranties provided by the contractor,all goads sold in Massachusetts carry an implied warranty ofinerchantability and fitness for a particular purpose. An enumeration of other matters on which the homeowner and contractor lawfully agree maybe added to the terms of the contract as long as they do notreshict a homeowner's basic consumer lights. If you have questions about your consumer/homeovmer rights,contact the Consumerhaformation Hotline(listed below). Execution of Contract The contractmust be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted, i or not applicable. One original signed copy of the contract with attaents is to be given to the owner and the other kept by the contractor. Anymodifrcation to the ori chm ginal contract must m in wrting and agreed to by bothparties.Contracted workmay notbogia until both parties have r the contract and the three day rescission period has expired. eceivedafully executed copy of wrin Accelerated Payments A contractormay not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure. However,in instances where a contractor deems him/herself to be financially insecure,the contractor may require that the balance of funds not yet due be placed deems in joint escrow account signatures as of pantie to continuing the contracted work. Withdrawal of funds from said account would require the signatiues of both parties. Additional 1ni'ormation If ypuhave general questions arrived additional information about the Home Improvement Contractor Law or other consumer rights,or ifyou wish to obtain a free copy of "A Massachusetts Consumer Guide to Home Improvemeut" contact: Consumer Information Hotline Office of ConsumerAffiiis and Business Regulation 10 ParlcPlaza,Room 5170,Boston,MA 02116 617-973-8787,888-283-3757 or visit the OCABR website at http://www mass gQv/ocabr/ If you want to verify the registration of a contractor or if you have questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact: Director of Home Improvement Contractor Registration Office of Consumer Affairs and Business Regulation 10ParkPlaza,Room 5170 Boston,MA02116 617-973-8787,888-283-3757 or visit the H[C website at ham://www mass,,Ov/ocabr/ Go online to view the status of a Home Improvement Contractor's Registration: hCR7//db.state.ma.iis/`homciT,DrovenienUlleenseelist.asp For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Section Office of the AttomeyGeneral 617-727-9400 AND/OR Better Business Bureau 508-652-4800,508-755-2548 or413-734-3114 W.tm2.1-11i22/2010 i