266 WASHINGTON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
� 1
3{ t Department of Public Safety
}�, �• \I,)SS.IClItLWHS Stale Building Cute(780 C\IIf)
Building Permit Application for any Building other than a One-or Two- amily Dw , in
(I his Section For Official Use Only)
f
Building l'cnnit Number: DaleAppled: Z _/ Building Official: _
SECTION 1:LO 'A HON(Please indicate Block Nand Lot p for locations for which a street address is available)
No.and Street City/lown /ip Code Name of Building;(if applicablc)�--_,
SECTION 2:PROPOSED WORK _
Edition of AIA Stale Code used ,If New Construction check Isere❑or check all that apply in the two rows below�—
hxisting;Building Repair :\Iteauiun ❑ Addition❑ Ucmkht it'll ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ ChangeofOaupancy ❑ Other ❑ Specify:-- _
Are building plans and/or construction drx'U111ellil being supplied as part of III is permit application? Yes ❑ No --
Is an Independent Structural Engineering peer Review required? Yes ❑ No ❑-�'
Brief Description of Proposed Work:_ _
Li u H-e /�4/o a.X DN d R �/% iAHt! •
SECTION 3:CONIPLETE TI IS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,AUDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 CAIR 34) ❑
Existing Use Gruup(s): Proposed Use Group(s): __
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flumes/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 Cl A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: I h Hanazard H-1 ❑ H-2❑ H-i ❑ 1-1-4❑ 11-i❑
1: Institutional 1-1 ❑ 1-2 Cl 1-3❑ ❑1-4 M1I: Merctile❑ R: Residential R-ICI R 2❑ R-3❑ R-4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑anal please describe below:
Special Use
SECHON 6:CONSTRUCTION 1-YPF- (Check as applicable)
IA ❑ IB ❑ HA ❑ [Ill ❑ 11L% ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SI"1"E INFORMATION(refer to 780 CMIt 111.0 for details on each item)
Water Supply: flood Zone Information: Sewage Disposal: 'I-rench Permit Debris Removal:
Public(9
-"/ Indicate municipal ❑ A trench will and be Licensed Disposal Silk'ClCheck it outside Ilnod Zane❑
required ❑or trench ur specih':...._: __..
Priv.tic Cl or indvnlily Lune: or on site cvstrot ❑ prrmil is cnclused❑ _ _
Railroad right-of-way: I lizards to Air Navigation: \1 I 'k , • „ .11. , .. I i, ,
Nut Apl,licable❑ Is'itruc ture within airport approach area' Is theme%vw camg+lrird'
Of C omcnt to liluld cnclowd ❑ 1 rs❑ or.No❑ Yes❑ \'o Cl
SEC'r1ON a:('ON TENT OF CEITrIf I(',\lli OF OC('U'I':\NCY
1:dihwm i 1 Code: _Car l n up(S): _ _ I\prat Conslructn n: _.Ott it Iant L od pvr I Ioor.
Doi, Ih, budduq;Cimlam mSprm KI rS% tvtn? SIigmininnS:
Sl:(:'TION 9t PROPF:R'I'Y OLVNI::It AUTIIOI(IZA'1'ION
%mile and Addre I Pr pvrh' > - --
Name(Print) Nu.and Street City/Town Zip
Property Owner Contact Information: .
9.7 ZKS ys�i3
Title --- Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby;utthurizes
--- Name - — Street Address City/Town State Zip
to art on the property owner's behalf, in all natters relative to work authorized by this building permit a „lication.
SECTION 10:CONSTRUCTION CONTROL(Please fillout Appendix 2)
1f budding is less than.35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and ski section 10 I
10.1 Registered Professional Responsible for Construction Control
?61s y;13
—Jte j�tegls ant) '/ Telephone u. c-snail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
i
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Tcle,hone No. business Telephone No. cell e-mail address
SECTION 11:m11,i,.ft2,'( kImi'r%,,;\u(+,, lx',Ijw\.vv,N).1lI,,kvLI M.G.L.c.1511 25C6
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 a lication? Yes O No ❑
SECTION 12;CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=S_
I. Building $ D Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor) 5
I Plumbing S
1. \ledwnical (IIVAC) 5 Note: \linimu m fee'S (contact municipality)
3. .Mechanical Other S
Endosu check payable
I,. ota Cost y (contact numicipality)and I%rite ncvck nu littler here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
14s entering nut name below, I hereby,ntest under the p unS and penalties of perjun, that Ill of lh Zr, ton contained in this
applie dram isiG ai d accurate t pest of ntr kn a!; ,ua�ulld ing
I'1 c priot,m. sign noon• title Telephone No. [late
'trrct .\Jd rCss Cih'i Posen Stale Zip
Municipal Inspector to fill out this suction upon application approval' __.__. ._ _____--_- __...... . .. .. . .. .-
`-- -- ____-- -- _ —N,une _ I t,uc
l
1
CITY OF SAL&Nr, t%L1SS,kCFjUSETI"S
SULDtvG OEP.1nnjLNr
120
W.u11(NGTON STREET, Jw Rccit
rM (978) 745-959S
KIAMER,SY DUXOLL FAX(978) 740-9846
MAYOR TkowuST.Pt XXA
DIBEcralt OP PLSLIC PROPHRTY/BCQDLVG CONOUSSIONEA
Construction Debris Disposal Ait'IIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1
Debris, and the provisions of MGL o 40, S 54;
Building Permit p 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 NIGL c
111, S I SOA.
The debris will be transported by:
(namaufhauler)
Thene debris will be disposed of in
(name of facdily) �-
-1L 70
(�Jdrar of ft.ii,iy)
uynamt ofpermit 3pppc4nt
'life
Feb.13.2012 04:21 PM NORTHEAST 9787455892 PAGE. 1/ 1
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/lam/,•. rO,..a/ nJv...�,, BL•ILOING 1�EPAftTMPNr
/(.W 4r, v - 1_10\V.1SMN(;Y0hl SYREET, ]v'hLUOR
�/ n� 17M 1,978)745-9595
f7le"11 MAIL /'C/r/x.�/- � �o
FAx(978) 7*-9846 ----
tiI\(DE:RI.EY DRISCOU
AMR j}iO11AS ST•PIExRa
01RECTCR OF PL'OLIC PROPERTY/8URDrNO CONL\II'SSIONER
Workers' Compensation insurance A171davit; Uuilders/Contracture/Plectr)cians/Ptumbers
1ppllcant Informatlnn / Pleaxe Pt�s t� f_ lylr
V IIIIIc IRueilu/a�UrWmralinrr/lm�livil1gn11:�?'�- �•�-s �—�y i
City/State/Zip: of /•x �9 O/57o phuneq: 6W 7Y5 ` S d_y 7-
,vre you an employer?Cheek the appropriate boa: F��
ro)ecl(required):
I,LS I am a employer with-�__ a• O 1;vn a gunuml cuntrxlor and I
mnpinyew(Ihll and/or part-lima),• have hind the eub•camractanNew eonatruclion
2.0 lam a sole proprietor urpannu. listed an the attachadshecL t odeling
.hip and have no employee, These subcontractors have S. olition
working ror me in any aapuiry. ,vorken'comp.insurance.
Jing adJilion[, o workericomp.inauranca !. ❑ We are a Corpnmtion end its
equired.( afOcem have exercised their trical repairs at additions
3.❑ I ad'a homeowner doing all work right or exemption per MGL I I.[]Plumbing repaid orndditieN
myself,(\o worker,'cump, C. 112,11(4),and we have no 12.❑Roof repairs
q
insurance required)I employee,.[No workers' 12, Othrr pairs
cump•insuranoenyuired.)
•.beyapplh:uadh.dlwW hu,rlmwlrndnil,tshe ,.dai bvte� ,I,,,gIAeewwY,n'rsmryny,lun Iwllry uuiumuliun.
'II•vn.•wlw„Hhr wfoae h,, lmthrit indiaLinY Ihry an daisy al walk aM Ihtyl hill""We ralllnem,must tnhtnll a new amder
�r.mlrnalun Ihll t'hr�ea this hu d ildlating wrlL i
x TwI Jllachd m WaniuroJ.hl.r ahuvinY the nwnu erlh„uh.uenlrKyn rnJ Iha7r waArn'wmp,palely inramwtlal.
!om un rurpleyrr rhnr h pwvlJlnX Ivarfen'cu,nprn.rallun Lr.u,runce for my empluyeer. Bedew 1,rile pollry and fu6 rlh
i a�lO,utla/x /
Innunmce Company`lAlna: /Clue�/r/.c,_4.. q y /_ •r . Cv
Paliry dur Scl(-im.Liu.n: T/V•/c � ,�f�Z" /—s'/;r, Expiration Data:
lab Site Address; ,C '�•r1.3s'r•'%� /v SAC, Cit iSlale/Zi :y p- .•+i�
.Macb x vopy of the workers'eomponsalloq policy declaradats page(showing the policy number and aspiration data).
"ilare to sulnlre cuvcogo a,squired under Section 25A ul'SIGL c. 152 can lead to the imposition of criminal penaltiesofa
lino Ilp m SLSOO.dn and/or m1e•ytar impriamm�anq as well as civil peoaltids in the I''"ul n STOP WORK ORO6R and a fine o(:ql ua$2i0.(10 Jay,yainet the vialamr. Ile advised thati copy of this atitdmcnt may be furwardud to Ilse 011ice of
Iarhlig�liull, rl•utc DIA I'ur insurance.overage viri4caliun.
/Ju hrrrbY r/rri/y nn Jer d, u/nr loud/, raf/res fperJury rhnr r/�a info/nrurlun provided about it true urJ iorrrra
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.
!71/ilia/rue only. /hv aal twirl be INIV urru,ro be ounlplerud by vity ar lawn.•f W.1 --_
City or iutnl;- _ _ __ Permiul.4ense r
Lt uie \ulhuril --
I, Ilanrd al llcahh !. Iiuilding 13,04thueut 1.Cilylfnwl Clurk J.Electric allmpevtar j. I'In nt hinl;la.peetar
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