99 WASHINGTON ST - BUILDING INSPECTION (6) � 25 °- C�c 1 -2-
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The Commonwealth of Massachusetts
Department of Public Safety
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Massachusetts State Building Code(780 CMR)
rBuilding Permit Application for any Building other than a One-or Two-Family Dwelling
t (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 address is not available)
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No.and Street City/Town Zip Code Name of Building(if applicable)
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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 Or� Repair❑ 1 Alteration 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 ❑ No 51`�
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 0-�
Brief Description of Proposed Work: '�u011>` �tfs'n11)Lr S'Pb29r;2L0 s-119/AfbDt+J
A,aD RFf F U511% &2_ "r- syo u AS Ar<eovetS By
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 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi It Hazard H-1 ❑ H-2❑ .H-3 ❑ H-4❑ H-5❑
li Institutional Fl❑ I-2❑ 1-3❑ Ft❑ M: Mercantile R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION'IYPE(Check as applicable)
IA ❑ IB ❑ ❑A ❑ IIB ❑ IIIA ❑ ❑IB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details 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❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: EV-Le- ;-L-
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: i\I li t�r� G,nn„�_a9n itc ��
Not Applicable❑ Is Struc[u re 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: Use Group(s): Type of Construction: Occupant Load per Floor:
Dues the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title 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 property owners behalf, in all matters relative to work authorized by this budding permit application.
SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix2)-
If budding 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
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Name f Person Responsible f r Construction License No. and Type if Applicable
Street ity/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COAVENSA"I'[ON INSURANCT AFFIDAVIT M.G.C.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.
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. Building S 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 $ Enclose check able to
6.Totil Cost $ �+�., P y
2,�.�t,�� (contact municipality)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 accur. to he best of my knowledge and understanding.
[lease pr' t and sig�y§7r _ tl� ,� Tclep Date
Street Address VI�[,vv 1tQ�� City/Town,_ \ fN-3/ttatte Zip
Municipal Inspector to fill out this section upon application approval: /
Name Date
The Commonwealth of Massachusetts
Deparonent oflndustrialAccidents
l Congress Street,Suite I00
Boston,MA 02114 2017
UW www.mastgov/dia
Workers'Compensation Insurance Affidavit:Builders/ContraMors/Etectricians/Plumbers.
TO BE FILED WITH TILE PERMrrnNG AUTHORITY.
A licant7nformation Please Print Iepilsly
Name(Business/Orgamzation&dividano.-t�G.l j2 ' . ZZA L(—_
Address: 625 C,0I. 6u&s. " Z�r—
City/State/Zip:_ C�M,,w o/9 0 Phone. / I ��9 9 Z'
Are you so employer?Check the appropriate box:
l.�a employer with employees(fdl and/or . Type of project(required):
-time)' 7. ❑New construction
2.❑I am a sole proprietor m parmerahip and have no employees working forme in
any capec"y.[No workers'comp.imtuance required.) g• odeling
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance requhM.]t 9. ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I wig 10❑Building addition
emme Chet all contractors either have workers'compensation iWo mree or are sole I].❑Electrical repairs or additions
prepnetore with no elployees.
12. Plumbing repairs or additions
5.❑1 am a garnet cermactm end I have hired the subcomrectora listed on the attached sheet.
Uses sub•contrectnr have employees end have worker'comp.immance-t 13.❑Roof repairs
6.0 We are a corpompon and its officers have exucised their right of exemption per MGL c 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insuratte required.]
'Any awlicant that checks box#1 must also fill our the secticn below showing the*workers'compensation policy information.
1 Homeowners who subimt this affidavit indicating they are doing all work end these hire outside contractors must submit a new affidavit indicating such.
4-- nuactors that check this box must stitched an additional shoes showing the come ofthe mb•contrsuors and state whether or not those cotities have
employees. lfthe sub-contractors have employees,they must provide their worker•comp.policynumber. . .
lam an employer,thW is providing workers'compensation insurance for riry employees. Below is the policy and job site
information.
Insurance Company Name:_ �� / N •D �
Policy#or Self-ins.Lic.M Expiration Date:
Job Site Address: �h/Sinop.
Attach a copy of the w cl rs'compensation olicy declaration page(showing the policy number and expiration date).
Failure to secure erage as required under GL C. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year mprisonment,as well as penalties in the form of a STOP WORK ORDER and a fuse of up to$250.00 a
day against the 'olator.A copy of this ement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verifies ' n.
I do hereby certify u and iiiii!r7Fpenahles ofperjury that the information provided above a and correct
Signature, 11 ate- /[
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/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#•
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 curry workers' compensation insurance. if an LLC or UP 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 permittlicense 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 pemrits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or pemut not related to any business or commercial venture
(i.e.a dog license or permit to bum 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
I Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-NMSSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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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 150A.
The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
(name of facility)
S
(address of facility)
Signatu f applicant
L
Date