257 WASHINGTON ST - BUILDING INSPECTION (2) AM
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
'r r Building Permit Application for any Building other than a One-or Two- 1
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building 'cial. 2
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is hatavailabl
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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 below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 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 Engineer in Peer Review required? Yes ❑ No ❑
Brief Description of Prop sed Work: 'e k' V% CA Ck5 AA( S 1 k ew4, 1 3-a
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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) Cl
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 ae a plicable)
A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ 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 ❑ IIB ❑ IHA ❑ IIIB ❑ 1 IV ❑ 1 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❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private El indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: I Hazards to Air Navigation: MA Historic Commission Review Process:
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:
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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:
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Title �— Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes c
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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)
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
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Company Ikame
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Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT 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 isms lance of the building permit.
Is a signed Affidavit submitted with this application? Yes Er No
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ 0 Q
1.Building $ 0 D b Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact�; �jPality)
5.Mechanical Other $ 2^ (J6
Enclose check payable to
6.Total Cost (contact municipality)and write check number here
SECTION 13:SIGNATURE OF 1BUILDING 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.
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Please print and sign na e Title Telephone No. Date
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Street Address City/Town State Zip /
Municipal Inspector to fill out this section upon application approval: ' 7l l
Name Date
' The Commonwealth of Massachusetts
Department oflndustrialAccidems
Office of Investigations
a I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dta
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (Hasiness/Organization/lndividual): Supreme Builders & Design,lnc
Address: 58 Glad Valley Dr
City/State/Zip: Billerica, MA 01821 Phone #: 781-953-6036
Are you an employer? Check the appropriate box: Type of project(required):
1.Q I am a employer with 2 4. ❑ I am a general contractor and 1 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑■ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in an capacity. employees and have workers'
y p ty� 9. Buildingaddition
[No workers' comp. insurance comp. insurance.: ❑
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
'My applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. Vthe sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information.
Insurance Company Name:Travelers
Policy#or Self-ins. Lic. #:7PJUB-4768P16-5-13 Expiration Date:7/21/14
Job Site Address: 257 W"h kV410 R f ('2— City/State/Zip: Salem
or
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 of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 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 certify under the pains and enaIt* of perjury that the information provided above is true and correct.
Signature: ,1 � Date:6/14/14
Phone#: 781-9536036
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#:
I.
CITY of S'U E.Nf, ItiL1SS.ICHUSETTS
/ BUILONG DEP.IR-neNr
V.
120 10.1SHLYGTON STREET, T°FLOOR
T!.L. (979) 745-9595
K(1WERLEY DUSCOLL FAA(978) 7-10-984S
N LA YO;It ,-to.LAS ST.PtE.vts
DIRECTOR OF PUBLIC PROPERTY/aUUMLNG CC% MISS[ONER
Construction Debris .Disposal At'ttdavit
(required for all demolition and renovation work)
In accordance with Debris, the sixth edition of the State Building Code, 780 C!,(R section I
vtd the provisions of MGL c 40, S 54;
Building Permit y is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed wasta disposal facility as defined by 1�(GL c
I 11, S ISOA.
The debris will be transported by;
(.numc ut'haular)
The dehris will be disposed of in ;
(Ilan;e of l'acdity) —'
EVe
(.IdJrts.t of liltility)
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