270 WASHINGTON ST - BUILDING INSPECTION The Commonwealth of tMassachusetts
Department of Public Safety
')( ! \la+sadul+ells Stale Builiilig Code(780(—MR)
1!J I3uilJing 1'cnuit Application for any Building other than aOne-ur l'wo-Family Uw Ting
(lhis Safi lion For O((iriei Use Only)
Buildi.. I'rnnit Nundler' _.... _._.- Date Applied: .- ?--Py-[-_ HEIddin i Official:
1.
S ECIION 1: I.00AI ION(1'Icase indicate (flock *and Lot N fur locations for which a street address is not available)
— --
,9-7� W407Omeril�,� _J- ... -OVA^- 1,— o1�7a
-- -- - - - -
\'u. ,Ind tilmct Cily;'futvlt lip Cudc Name of Building;(if appllr•nble) .. __
SECTION 2: I'ROIIOSED WORK
Edition ul::\I:\Sl,llr Code used It Now Construe tion thcck here❑or check all That apply in tilt-taco rma+bohmv p:(
1(\Isl ingi lluilding❑ licpair Alleratiun ❑ Addition❑ Demolition ❑ (Please till out.and submit.\ppoodis 1)
Change tit Use ❑ 1 Changeof Occupancy ❑ Other ❑
:\re I, Ill 1 1,11, Ind/„r construction it,x:untcnls bcing sit pplicd as part of this perulit applic,ltit lbs ❑ No /Is in hniepeodent Structural Engineering Pecr jk�icw eyuircd? Yes ❑ ,No LTtiriet Ucscriptiun of Proposed lVurk: /Ge SECTION 3:CONIPLErE THIS SUCTION IF EXISTING BUILDING UNDERGOIij
TION,ADDITION,OltCHANGE IN USE OR OCCUPANCYCheck here Ilan Existing Building Investigation and Evaluation is enclosed (Str 7411 C\ExistingC'seGnnap(s): Pnlpuscd Use .____—___ ._.—_SECTION is BUILDING ((EIGHT AND AREAProposedN'o, of Fluor.c/Stories(indude basement levels):k:\rea Per Fluor(sit. ill
1'utal:\n•a(.cy. R)and Rrtal Height(ft)SECI'ION is USE GROUP(Check as a HIcable)Assembly:\-1 ❑ A•?❑ :Vig;hklub ❑ :\-1 ❑ :\-! ❑ :\-i❑ B: Busli: Educational ❑F: Facto F-I ❑ 1:2❑ II: Ili h hazard FI-I ❑ H-2❑ 11-a❑ I1-i❑1: Institutional I-1 ❑ i•_'❑ 1-1❑ I-a ❑ \I: Mercantile❑ l Residentia -_'❑ It,t❑ R-� ❑S: Storage S-1 ❑ S- ❑ U Ul Special Use❑and please ec rlbe below:
L�Pectal Ust•
SECTION 6:CONS-I'RUCFION I"YPF(Check as a licable)
I:\ ❑ IB ❑ IIA ❑ IIH ❑ MA iuli ❑ TIV ❑ VA ❑ It 110
-- St.( VION 7: SII"E INFOR\IA IION(rcfcr to 7411 C\IR I I LU for details un each itmn)
Water Supp hood lone Information: Sewage Disposal: french Permit. I M,ris Itcnuwal:
Public Check itlnu+ldc I kwd /_I,nc Cllutliwta minliaiinll Cl A it,itch tcdl not be I.k vllwd Iai,p "'ll pile❑
f'ncaw0 or indeiuill' /one or,m +ne+%,Icnl ❑ w,piwd0:lr trench or,prrilr
ItailnlaJ right-Id way: Ilar.ards to. it...N.10gatiun:
\'ot \ppht.lbh•t7� I Is�Ir11,lim, ,,Ithm•urpl:rt.i ill, n,It on•a! j I+thrlr rrcirlt l Cnlplrlyd'
,-rL tiscnt to llud,i Cn,6nr,I ❑ lr,❑ „r\'t, lr,❑ \I: ❑
yF( IIO.V4:( O.NIINI'OF t'FRIIFI('.\1'EO1:c)('cl,VANCY
I Jileil ,q l:alr l .r l�onipt+) Inp, : t l":,n,lnn tiro n'„upaul l ,,.iJ gar lh,,,r
It,r, Ihr ludJwp ,:•nl.un.w �1mn61Cr tit+Irm' '1nr,.d' lipul.lho,l,
r ,
---
tilfCIION 4; I'1(UI'PIiIY UWNI[ft AUI'I I(1RIZ:\7ION
unt .m, \ddn vv nl I4a n lv Uantr �_
N,une ( roo n
t) 1 Ni,. id 51 ,1 Cit1'/ town /ip
110 sporty Ow nor Con tavt hdurr»etiun: 22C�j
_..--- -- ----- -- ,il address
tills rrlephunc No. (business) rcicphoneNil (�-
rnn
ItdlPplirahle, Ihrrr �, rlyrrw tr rcbv.,ulhuri s 7G•w'— �,0 �. ���/3�
lrvet Add ress City/fuwn State Zip
Nan_ __.—
Io,ti I on the pro arty owner's bohalf, in all mailers relative to work authorized by this building permit apalicetioll
SECTION 10:CONS'I'RUCC ION CON I KOL(Please till out Appendix 2)ontrol then check here❑and ski,Srdiun lo.l
-
If but It it g is Ic.S+than 33.000 cu.it,ul endused s Pace and ur nut under Construction C
` III.I Registered Professional Responsible far Construction Control
Mode(Regt' utt) fete hone Nu, e-mail ad,A s!7 �ly� Registration N»I tbcr��
r/�� �1�• t �km
titrrA, s Cit /Town State Zip Discipline Expimtiun Dale
10.2 General Contractor g
e T �l17VP/ a —
Con, ,,lll 11111L,
CS
Name of Perwn Res, isible for Construction /1License No. and rype if A��p�plliiicable Q L
Street Addfcss City/" t vn State Zip
rcle ,hone No. business Tote,hone No. (cull) a-m.,il address
SECTION 11:t„ ': .rl::, , (Wrly,,\Ip,� i`:� ur..(.\B-I ,uul.�,•,m M.G.L.c. 152. 25C6
A Workers'Compensation Incur!;,a.\ffidavit from the NIA Department»f Industrial Accidents must beiumplcled Pool
submitted with this application. Failure to provide this affidavit will result in the denial of the Lseuance of the building permit.
Is a si ocd Affidavit submitted with this a licatfun? Yes O No ❑
SECTION l2:CONSTRUCTION COSTS AND PERMIT FEE
r-,
EstimatedCosts; (Labor �—
Item and ::Materials) rural Construction Cult(from Item h)
I. Guild ill S d�D (Building Pen»it Fee'Total Cun.Struetion Cast x_(htscrt here
'. Electrical appropriate municipal factor) 5
It. Plumbing 5
Note: \lininuun fee'S_--(sun Ltit uuutieipalih)
1. \leehaniral ow IC) 5
7. \Icch•utiral Othor) ) Enclose shark payable to rP. I"utol Call 5 (roitlntt mmoirip,dit-- I vv rile r hrrk --I,e'hero
SECr1ON 13:SIGNAI URE OF BUILDING I'ERNIIT.\i'i'LIC.\N'r
Ilv rn h•rin tB my name below, I hcn•by attest under the pains end penallit'S Of perptry That all of the infnm»atwo ruru,imod w this
ephlir,ition in Irnt•a111,tC,ur tQ to the Peet ul my knmv IrJgr,nnl midcrsLmdiny,
i A,,
trlcphnne No. I,.ilr
I'L•,wo pnnl .ind alp, name
• tnrl Wd,,-\IuniciBPal InSpectr to fill oat it t. +evti n upon . , __ _ / .
Pete
° CITY OF SiU_.ENI ANSSACHUSETTS
BUILDING DEPARTMENT
4 r • 120 WASHINGTON STREET, 3w FLOOR
' TEL (978) 745-9595
FA.e(978) 740-9846
KI\BEILLEY DRISC011.
MAYOR Twlius ST.PI£RR$
DIRECTOR OF PUBLIC PROPERTY/BUQDING CO\62,1ISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Legib►y
Naiile(Busiti,ss Organizatiomindivid/u�al):— /�,t�
Address: ep(
City/State/Zip: 6i_ eel - dll7!i f/Phone lt: �fil �JC�- GY P
Are you an employer?Check the appropriateboa: 'type of project(required):
1.0 I am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction
}tt+»ployees(full and/or part-time).* have hired the sub-contractors
2.a I am a sole proprietor or partner- listed on the attached sheet.I 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
(No workers comp. insurance 5. 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 i LEI Plumbing repairs or additions
myself.(No workers'sump. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
Gump. insurance required.]
•Any applicarn dot dimla,box el most also till out the section below showing their wwkets'compenmdon potiry inlbrmadom
'I h+meuwnem who submit this affidavit indicating they am doing all wort and then hire outside contractor must submit a new atndavil indicating such.
:Conttns:ton that check this box must attached in addiliutmi sheet showing the name of the sups cantndon and their workem'comp.policy information.
/am an employer that is providing workers'compensation insurunce for my employees: Below/s the policy and fob site
information.
insurance Company Name:
Policy 4 or Sclf--ins. Lic.tl: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of�IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. De advised that a copy of this statement may be Purwarded to the Office of
Investigations ol'the DIA for insurance coverage veriticatian.
I do hereby renijy nfa the puins and peauh s a perjury that tire Dtforalatiort provided above is true and correct.
lien uurc �7 �J
Phone 1' / eZ
OJJiciul rase only. Do nor write in this urea,to be courpleted by city ur town n1j1cl aJ
City Or Town: _ Permit/1.1cense q
Issuing Aurlmrily(circle one):
I. Board of health 2.Building Department 3.City/fuwn Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Contact Person: _ ___.___----- Phone tf:
CITY OF S.UL EM. N-LuS.kCHUSE-FrS
BU=N,G DEPARTJIEZNT
: 120 WASHIINGTON STREET, 3eD FLOOR
T EI.. (978) 745-9595
F.Ax(978) 740-9846
KI1tBERi-EY DRISCOLL
�LNYOR T HOatAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COMMISSIONER
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 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # 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 MGL c
111, S 150A.
The debris will be transported by:
�A&- k "ems
(name of hauler)
The debris will be disposed of in
(name of facility)
- --(address of facility)
si.,nature of permit applicant
elate
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