118 WASHINGTON ST - BUILDING INSPECTION (7) The Commonwealth of Massachusetts
�Q 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 Fo Offictel Use,Onl'
Building Pe rut Umber•' .D�teApplied ^ ° IiwldmgOffictal
SECTIO 1:LOCATION (Please indicate Block#and Lot#for locations for whic V a street address is riotavailable)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK
Edition of NIA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 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 Pe%Review required? ' Yes ❑ No ❑
Brief Description of Proposed Work:
i. 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(Checkers a licable),
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ [-4❑ M: Meicaritile❑ 1 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 applicable)
IA•❑ IB ❑ IIA ❑ fill ❑ IIIA ❑ IIIB ❑ IV ❑ I VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone El Indicate municipal❑ A trench will not be P
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NL4 Historic G,n,mission Review Prkxvss:
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: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY O. ER`AUTIIORIZATION "
Name and dres�s f Propert,, vner yy p% yk 6r
li4 Y* e�oo`e� //,p zzy, �!/ot-vk �.�Pm /f19. 0�97r7
Name(Print) No.and Street ity/Town Zip
Property Owner Contact Information:
-
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applic le, the property-Qwner he eby authorizes
/Rey. Av /o �Ldf,A! :�a4J q 9` dig�v
Name Street Address Ci�n State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION idi CONSTRUCTION CONTROL(Please fill out Appendix#'i
` If buildin is less than 35,000 cit.ft.of enclosed s'ace'and or not under Constrtictiori Control then check here.lTand'ski Section 10.1 '
10:1 Re •'stered Professional'Res`onsible for Construction Cofttrol' .
�
Name(Reg�istra t) / Telephone No. �/ a-mail address Registration Number
/7 1✓Ane6 V;, V� .rar 26e V/��nPLy.:lT • U i
Street Address - City/Town State Zip Discipline Expiration Date
10.2 General Contractor , ////'� _�- ' ,' •� _
U .c AP �•liV C Qi /.( /�
Compa y Name �-
Name of Per Responsible forFonstructio License No. and Type if Applicable
//� Lo--ZI.4z /Cry/ �- �� o/,07,
Street Address / /City/Town State /Z'p
&41
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.
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 $ 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
6.Total Cost 1�111F 0 . (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT"
B entering m name below, I hereby_ , . .. __.
y g y 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 Stat Zip
Municipal Inspector to fill out this,section upon application,approval:.
Name.- Date
i CITY OF Sm Em. 1tLALSS:ICHUSETI'S
S BtiILDING DEPARTSMNT
3 � ' +r t• _ 120%VASH[NGTON STREET, 3}D FLOOR
TM (978)745-9595
F.k.�c(978) 1�i0-98-f6
KJ,,[B R. RY DRISCOII
MAYOR T HobIAs ST.PiFxM
DIRECTOR OF PUBLIC PROPERTY/BU M.OLNG COSIIItSSION ER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Legibly
/� s
Name(Busiix's Orgaan�nniizatiaruindividual)::/ P--/ A
/(p+,
Address: is LG'rlo.c. 4L yca/,(/'�y
City/State/Zip: �,��(��,, 1/l' O�/r70 Phone#:
Are yo an employer?Check the appropriate boat Type of project(required):
1. am a employer with a 0 -/' 4. Q I am a general contractor and 1 6. ❑New construction
employees(flall and/or part-time).* have hired the sub-contnctors
2.0 1 am a sole proprietor or partner. listed on the attached sheet t I. ❑Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
working for me in my capacity. workers'comp. insurance. 9. 0 Building addition
(No workeri comp. insurance 5. 0 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 111:1 Plumbing repairs or additions
myself.(No workers'cump, c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required)t employees.[NO workers' IJ.O Other
comp.insurance required.)
;Any applican tas chwks box a I most also,fill out IN tuutioo below showing Chair wmkars'campanutiuo poesy inea mado4
t I r.vnuuwm"who submil this alydavit indicating they an doing all work and thou him outside-contractor,total submit a new affidavit indicating such.
:Omtrwturs that chak this box must anachcd an additional short showing tho name of the mb-conlracton and Ihak workan'wrap.policy infammans.
l ant an employer that Is provldlnA workers'comprnsadon Ltsurance jar my employees, Below la the popsy and Job site
iujannarian. Li -J _�,.
insurance Company Name:. AA gq9•tr�0.(G7 .-r(�C.J� _ Gt
Policy 4 or Salf-its. Lic�/H: AfdP-014.c /Ppp �d* 141V Expiration Date'
lob Sitti Addruss: 14 zt ', ate �9'• a .71 Z-4 1 City/Statr/2ip:
Attach a copy of the workers'componsatlon policy declaration page(showing the policy number and expiration date).
h'ailuru to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
sine up to S 1.500.00 and/or one-year imprisonment,as well as civil penaltes in the farm of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. 13e advised that a copy of this statemunt may be forwarded to the Office of
Investigations oftha DIA fur insurance coverage verilicatium
l de hereby cerr jy under tho puma mid penalties ujper)ury drat than befornradae provided ubuve is true uud correct.
Sienamre: Data:
Phone 1:
UJ)icfal use dilly: cad not write itt ddr urea,to be completed by city or town n))lc lut
City or Town: _ Permit/f.lcenye 1f
Nsuing,%ulhorily(circle one):
1. Board of health 2.Ouilding Departinunt 1 Cilyffnwn Clerk 4. rfeetrical inspector S. Plumbing inspector
6.Other
Contact Person: _ Phenol:
I
CITY OF S.0 ENl, i XSSACHUSETI-S
B U UM LN G D E PA ftT'.%MNT
120 WASHNGTON STREET, 3i° FLOOR
TEL (978) 745-9595
FAx(978) 740.9846
KI.NQ3ERLEY DRISCOLL
11vt THOMAS ST.PIERAH
YOX DIRECTOR OF PUBLIC PROPERTY/8C11DNG CON IISSIONER
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 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit A is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility as defined by MGL c
I It, S 150A.
The debris will be transported by:
CAV
(name of hauler) �~
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
date
4abro:�i�Jx