118 WASHINGTON ST - BUILDING INSPECTION (12) mow .
1� •
The Commonwealth of Massach a is
Department of Public Safety
9 Massachusetts State Building Code(780 1R)
Building Permit Application for any Building other than a e- r o amily Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Officia
SECTION
,,1:LOCATION(Please indicate Block#and Lot
#�for lo�c nations for which a eet address is available)
'
No.and Street C (
City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA Statte/
eCode use ❑d If New Construction check here or check all that apply in the two rows below
Existing Building tat Repair❑ i Alteration ❑ Addition❑ JD,,uolition ❑ (Please fill out and submit Appendix t)
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 0Y .
Brief Descripption of Propu ed Work: t� n>'e- nIFLcJ LU19-/���i4/�/r
�Xl�iJS F /�,e/C,�� /lc/d L 9-GEl
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❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-21C H-3 ❑ H-4❑ H-5❑
-aia:.t+^Tk w3 '4>Anstitutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4 ❑
t,
--- —*--
S: Storage Sl ❑ S2❑ - — U: Utility❑ 1 Special Use❑and please describe below:
Special Use:
SECTION6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ HA ❑ 1I60 IIIA ❑ IIIB ❑ 1 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❑ Check if outside Flood Zone El Indicate trench will not be Licensed Disposal Site❑Indicate municipal❑ d
Private❑ or indentify Zone: or on site system❑ ❑or trench or specify:
permit required enclosed❑ -
Railroad right-of-way: Hazards to Air Navigation: \tA I,lislt n<(."),),,iws�,m hrvm"� r 1 ns�= :
Not Applicable O 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: Use Group(s): 'type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
s
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nine and Address o Property Owner
J` -e-j z Y� �s�x Sf & W4nl
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail a dress
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 budding 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
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
z-4:, C� ( �S 6 S6 e 2
Name of Person Responsible for Construction Iy icense No. and Type if Applicable
�Q( M DFiG�
Str ddress City/To vn State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKFRS CY)NiP[NSATION INSURANCE AFHOAVI'I 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.
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 $ Builduig Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
4.Mechamical (HVAC) $ Note:Minimum fee=$ (contact municipality)
n ' 5. Mechanical Other $ Enclose check payable to
6.Total Cost $ CL
(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 4nd accurate to the best Ai kn :e,,nd understanding. S
Please print and sign name Title "Tole ho eal 7 ZJ Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
y
CCI'Y OF S.U.E,%[, NWSACHUSE"ITS
BUILDING DEPARTMENT
r
1_0 WASHIINGTON STAEET, ) FLOUR
-rEL (978) N5-9595
F.+x(979) 110-9844
U>(3ERIEY DRISCOLL
Akyol Il-to.MS ST.PIMUS
DIRECTOR OF PUBLIC PROPERTY/BUR.DING CONNISSIONER
%Vorkcrs' Cumpensailon Insurance Al7Tdrvit: Guilders/Contrac it)rv/E lee trlcians/Plumber$
l s sllcant Information Icase Prin Le?ihl
.V IIInC llluninu.0 Urgtmralinn,Individual): —
Address: �y�s�
Ci(yiStatc/Zip: D(YI11.1411
Are you an employer!Check the appropriate boas
Type orproject(required):
I.❑ 1 am it dmploycr with 4, 0 1 an a general contractor and I
dill
(fiall and/or part-time).• have hind the sub•cantractors 6' ❑Now construction
2.0 1 am a sole proprietor or p riner. listed on the attached.rhee4 t J�
7•Z Remodeling
.hip and have no employees These sudcontraclon have b. 0 Demolition
working liar me in any capacity, workers'comp,Inaumaee.
(Na warken',comp. insurance 5. ❑ We are a corporation and its f' ❑ Building addition
required.) officers have exercised their 10-EXElectrical repairs or additions
)•0 I an a homeowner doing all work right of examplion per MGL 11.0 Plumbing reptdrs or additions
myself.ISO worker.'sump. c. 152, §1(4).and we have no 12.0 Roof repairs
insuranca«yuirad.l t vmpluyees. (No workers'
camp insurancamyuired.J 1I.0Other
;.41Y applh:un Jar ehwka but ill mum 31w 011 uul the veliue bubw.bowing their rakan'eompenudun pulley inn umui on.
I I,vneuwnns whu.uhnul this rmdevil indleaing they.m doing all,wrk and then him uunide costtaemra Mimi ar,hmlt a new alydaril indiaring such
l'emcwtun Thal chtsk this box Most.m.aehed un addillurud.h=1 thawing the"wee o/the ru s►ionrracuae and thalr workare'comp,policy Intemmdon.
/urn an empluyfr that h provldlnx rvorken'rumpeuror/un lnrnrunte/ar my empluyees Bduw/a du poNry and/ub sUt
Insurance Company Nmne: Vlc L
. t^�(
.. .
Policy a or Self-ins• Lid.it! L� C- C)o _�
Job Yi —/ 2S Expiration Dote: �/
w Adtlress: I I I,.�,C 1ln C `I 1'� City/Stutr:/Zip: /ter' r
Attach a copy of the workers'compensatloa pulley declaratlen paKs(showing the policy number and expiration data).
F.liiure to wcure cuveraga as required under Section 25A df,%fGL c. 152 can lead to the imposition of criminal penalties of a
tire up to 51,SCO.00 untUur one-year irr'pri.rnnmenk as well as civil penalties in the form of a STOP WORK ORDER and a lino
of up to 52i0.00 u duy against rite violator. Ile advisdd'hat a copy of this,141cincrit may be furward,:d to Ile 011id13 of
IovV„i gutiuns,tI'drc DIA idr insurance leverage veriliraliun.
1,10 hereby Vert' ndtr ie pain rr perjury/hut the injurnrurlun provided ab ve it 1rustaild correct
Andy. O'.nut"rite in this area, ru bt runtpleted by city ur town n/11Viuf
City nr I'tnvn:. _ __ I'crmiriLlcertse i
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I„uie;,\utlmrily (circle rand); � -�"
1. liuurd ul Ilcuhh !. ILlildln�Oepafhncul 1. ('ilyi fawn Cldrk I, lileetrla.11 N,peclnr i. Phrnhin4 Inrpee6'r 5. 011wr
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Ln❑1.1,1 Pifln n:
CITY OF S-VZNf, AUSACHUSETTS
dt;MDLYG OEP.ItlTMONT
1'0 177.1.-4NGTOM STRM, 1iO ROOJI
FAX(978) 740.934d
!U10ERLfiY DRISCOII.
MAYOR T CAUST.PMUA
011MCTCBAP?LBL)CPROPERTY/el' ovaCowassro Est
Construction Debris Disposal Alfidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CrMR section 111.1
Debris, and the provisions of MGL a 40, S 34;
Building Permit a is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licemed waste disposal facility as defined by NIGL c
111, S 150A.
The debris will be transported by:
(nameOfhgheuler)
The debris will be disposed of in
(name o�� �D
�I ( 1 �t �
r �(iddreuarl'�cipty)
W W 6
61 �
"fin.4Nre vf;,ermit rpplicint
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