70 WEATHERLY DR - BUILDING INSPECTION (2) Eb.
The Commonwealffi setts
Department of Public Safe
W
Massachusetts State Buildjj,,y f�e 41,14
• Building Permit Application for any Building er than a One-or Two-Family Dwelling
(This Section For Official Use Only)
r Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a skeet address is not available)
I^ 7y (tJ� sic PnA- AAA *yd
l5 J No.and Street City/Town Zip Code Name of Building(if applicable)
t SECTION 2 PROPOSED WORK
ryn1� Edition of MA State Code used 72f4 If New Construction check here❑or check all that apply in the two rows below
�J Existing Buihling❑ Repair❑ 1 Alteration er— Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
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 hidependentStructural Engineering Peer Review required? Yes O No ❑
Brief Description of Proposed Work; -S"q t,, K-7-chA (^1vert7- n 4nrl! S ll tN/
VA t ` " J?A/1 7,y.; txi'17r' .f'�iva.•rT 7 -✓t
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❑ fl: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I.1 ❑ 1-2❑ [-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
Ilk IB ❑ IIA ❑ IIB ❑ ILIA ❑ 1118 ❑ I IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water SuppI 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❑ or indentify Zone: or on site system❑ hermit is enclosed ❑
Railroad right-of-1
_ay/: Hazards to Air Navigation: %1\I l a r r n......i n I r�"I.. p a:
Not Applicable fS Is Structure within airport appr xh area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ I Yes❑ No t3
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: ll•• ,� /`__._
��11..ti� .��Z� 1 5 "3'O CON-� rlk• I l /J 1 Da lr�r(,7fp�
SECTION9. PROPERTYOWNERAUTHORIZATION
Nany-Ind Address of Property Owner
Jon -Pr Sy/cA4 ,W,4-
Name(Print) Nu.and Stree City/Town Zip
Property Owner Contact Information: . . p�ay� ;
/7- ,1 1 7C9a
Title Telephone No. (business) Telephone No. (cell) a-mail address
If applicable,the property owner herebb authorizes /
lQ. C. /, fin I tbn/ Gt/��c S.7 7 J�J//frke/ IYl/� /Sys l '
Name Street Address City/Town State Zip
to act on the property owners behalf, in all matters relative to work authorized by this budding ermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed s ace and or not under Construction Control then check here 17 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-nail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
i i'moikI I -I o f C 5 o Fr6 I o
Name of Pers i Responsible for Construction License No. nod Type if Applicable
MA �S
Street Address City/Town State Zip
(9/Vlat ,Con/1
Telephone No. business Telephone No. cell a-mail ac dress
SECTION 11:WoRKFRS COM'EN5A I10N INSURANCE AFFIUAW 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) 'Fold Construction Cost(from Item 6)_$
1. Building $ 8 oo U Building Permit Fee=Total Construction Cost x_(Insert Isere
2.Electrical $ 1 J 00 appropriate municipal factor)_$
3.Plumbing $ o v
4. Mechanical (HVAC) $ Note:Mininuun fee=$ (contact municipality)
5. Mechanical Other $ Enclose check a able to
payable
6.Total Cost $ ` (fj _,y 0Q (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 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.
Please print and sign name Title Telephone No. Date
Sloe Address Cil /"Fo wn State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF SALEallo NWSACHUSETfS
BL•LLimr,DEPAMIEI\T
120 %VASHLNGTON STREET, are FLOOR
TEL (979) 745-9595
F.L.r(978) 740.9846
KI.\IBERLF,Y DRISCOLL
%NLAYOR THoliw ST.PiERRE
DIRECTOR OF PUBLIC PROPERTY/BUB.DING CO\LMLSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information _ _ Please Print Legibly
NainC pluaitttssUrganimtinn•Individu:di: . C . '14ayc/l S t.SGnf le7 C
Address: (,✓��rlv� STrc e-�
City/State/Zip: 1,V7 14LJLL4 Y11 Yr Phone #: -r3 S7/ S
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ i am a general contractor and I
employees(full and/or part-time)." have hired the sub•contrsctors 6 Nety construction
2. lain a sole proprietor or partner- listed on the attached sheet.) ?• emodeling
ship and have no employees These sub-contractors have 11. 0 Demolition
working for me in any capacity. _ wogs'comp.insurance, 9. Building addition
1 No workers'comp. insurance J. a are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.41(4),and we have no 12.0 Roof repairs
insurance required.) t employees.(No workers'
comp.insurance required.) 13.❑Other
•Any appliram deal checks bar e I mint also rill out tltn occliud bclaw showing their wodeo'compemadua palmy inrurmaeon.
'I hovuownwa who about this 1171davil indieadns they am doing oil weak and then him outsidocontncmn mint ruhmil a rest,amdavil indicating such.
$lnurwtur thus chock this buto main attached an addoiurvd,hots showing the name of tha gubeontrulon and their workers'comp.policy information,
f unr um earpluyer ilial is providlnx ivorkers'cwnlpeasadon insurance for my employees. lielinv is the pollry and job site
infuraradon. / _
Insurance Company Name: qT/'✓.•sT nSUn/'�NCC_ /;✓n p
Policy it or Srlf-its. Lie.d: /�— ��y`,p�.t� Expiration Date:_-a 6 O/
Job Site Address: 70 City/State/Zip: Sde" n// q-
Attach a copy of the workers'compensation policy deelaratlea page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 2JA orMGL e. 152 can lead to the imposition of criminal penalties ofa
line up to SI•500.00 und/or one-year imprisonment,as well as civil penukies in the form ofa STOP WORK ORDER and aline
of up to$330.00 a day against the violator. De advised that a copy of this statement may be furwarded to the Orrice of
Investigwions of the MA for s Minsurance coverage verilicatiun. -
/du hereby eerrijy Iar e puLrs�J penalties ujperjury ilia!the Jnjvrorrurlon pravfdad ubuvu iv true unJ currecr.
.:,.., i t Date:
c
Phoned �6 I -7 s71,5-_
Of/idol use only. Do tour wire in tide urea,to be compleraJ by city or town n/Jiclul
Citynr'futrn: _ .. .__ Perm(dl.lcemeq__........ —. . .---
Issuing A ulhorily(circle one):
I. lloard or ileahh Z. Building Departuteol .1.Cityffmso L•lerk J. Electrical Ltspector 5. Plumbing Inspector I
6. Other
Con lard Perron: _ Phone 'I: i
�1
QTY OF SALEK MASSACHUSEM
7i BUILDING DEPARTAmNT
120 WASHINGTON STREET,3AD FLOOR
TEL. (978)745-9595
KBOERLEYDRISOOLL FAX(978)740.9846
MAYOR Tfiomm STYIERRE
DIRECTOR OFPUBLICPROPERTY/BUIIAINGGUIS SSIONER
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 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
�. ( /lamenS +.Suns T4C
(name of hauler)
The debris will be disposed of in:
(name of#acility)
(address of facility)
S
Signature of applicant
Date