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3 WEBSTER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts °• ° Department of Public Safety Massachusetts State Building Code(780 CNIR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (this Section For Official Use Onl ) Building Permit Number: Date Applied: _ 'Building Official:: 1:LOCATION(Please indicate Block ff and Lot N for locations for which a street address nota " AWArt— 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 0�'- Other ❑ Specify: t Are building plans and/or construction documents being supplied as part of this permit application? Yes 0�' No ❑ Is an Independent Structural Engineerin�Peer Review required? f 1- Yes ❑ No ®' Brief Description of Proposed Work: - 'c-� (o {�t�¢'2IY`t-� l�ylt7s L+� Kl6Ina 2 lion, bt1'GIC.— 1n�i if 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 CNIR 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.) ,2 p0 56 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❑ B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ L• Institutional I-1 ❑ I-2❑ 1-3❑ 1-4❑ NI: Mercantile❑ R: Residential R-10 R-2❑ R-3 f� R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCFION'IYI'E(Check as applicable) [A ❑ IB ❑ IIA ❑ FIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) Trench Permit: Debris Removal: W1, pl Flood Zone Information: Sewage Disposal: A trench will not be Licensed Disposal Site lr Check if outside Flood Zone Indicate municipal required�r trench or specify: or indentify Zone: or on site system❑ permit is enclosed❑ ad right-of-way:- Hazards to Air Navigation: \I�\_lhlu t Applicable Is Structure within airport approach area? Is their review completeJ? t to Build enclosed❑ Yes❑ or No®' Yes❑ No ta' SECTION 8:CON",ENT OF CERT[FICA7"E OF OCCUPANCY ode: Use Gruup(s): Type of Construction: Occupant Loud per Floor.ilding contain as Sprinkler System?: Special Stipulations: t/ t SECTION 9: PROPERTY OWNER AUTHORIZATION Name and r1u,LLdress of Property Owner �V iA l GC.�C t7�. l OAS h l4 &,L, � — Name(Print) No.and StrewCity/Town ip Property Owner Contact Information: _ qI IV qZ� Tille Telephone No. (business) Telephone No. (cell) a-mail address If applicable, the property owner hereby authorizes N,une Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this budding permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (If budding 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 1a�S N ^e( �'`%�- �ekphone No. e-mail ac Ire s ens rat'm Num er Street rlddre s V eCtiAtyO//WTo`vn State Zip ciplme xpiration Dote 3©1to 10.2 Gen^ - �t Oa\nc "Pab;r.� _ Name of Person 2!Z on ible for nstruction License No. and Type if Applicable Town pplicable Street Address Ci t3'/ State Zip Telephone No. business - Telephone No. cell e-mail address SECTION 11:V4'OltKlfltS'CONII'I NSi11'ION IiC,SUIL�:y f:APPII)Ab'I'1' M.G.L.C.152. 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of IndustrN Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is ance of the building permit. Is a signed Affidavit submitted with this application? Yes Cr No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE. Item Estimated Costs:(Labor �{t' and Materials) Tot:d Construction Cost(from Item 6)_$ T d� t. Building $ - ��� Building Permit Fee=Total Construction Cost X. (Insert here 2.Electrical $ � appropriate mumn�ipal factor)_$ ` 3. Plumbing $ coo p 52$$ d. Mechanical (HVAC) $ p� Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ D 000 p`Y (contact municipality)and write check number here SECTION II'SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I 1 attest under the pains and penalties of perjury that all of the information contained in this application is tme and accurate the be. of my knowledge and understanding. Pleas ru and sig xame ('\ l cTitle Telephone No. Date t Street Address Cit Cown Y/ State Zip Municipal Inspector to fill out this section upon application approval: Name - Date CITY OF S.=%I 2ANsSACHUSETTS ;�y u BU=ING DEPARTMENT •� C yl�c r",. 120 WASHINGTON STREET, 3w FLOOR $ TEL. (978) 745-9595 Rmx(978) 740-9W !V,,CBEA FY DRISCOLL T vYaiYOR t�fonlAs Sr.PIFRRF DIRECTOR OF PUBLIC PROPERTY/BCILDNG CONNISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers applicant Information Please Print Legibly Name (L3usincsvOrgmtiradon,'Individual): VLL V//Yv\ I N�!�W�� LLC_ Address: �i Wet City/State/7.ip: VA(aWL A 0J Phone N: 2 ,1re you an employer!Check the appropriate box: 'type of project(required): I. I am a employer with 4. ❑ I am a general contractor and 1 6. [1 New construction employees(full and/or part-time).' have hired the sub-contractors ,—� v.1—] I ana a sole proprietor or partner- listed on the attached slicer. LY eet.: 7• JRemodeling ,hip and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers'comp. insurance. y_ ❑ Building addition (No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions },❑ 1 ran a homeowner doing all work right of exemption per MGL 11.❑ 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 camp.insurance required.] . -Any applicant slur checks box xI must also fill out he section chow showing their workers'compensation policy information. s I horeoo m"who submit this aftlavit indicating they arc doing all work and then hire outside contractors most submit a new afrdavit indicating such. $$lnameWn that chcvk this box mart anachcd an addaiurul ghat showing dv mm.e of the sub-coniracton and their workers'comp.policy information. 1 ant an employer that is providing workers'conrpeasadan insurance for my employees. Below Is ilia policy and fob site iujorrnution. I (� Insurance Company Name: Policy 4 or Self-ins. Lic.tl:�.._._- _. Expiration Date: lob Site Address: V V�C,CJ. City/State/zip: &6,, Il?t ,\teach a copy of the workers'corn Ion policy declaration page(showing the policy number and expiration date). Failure to secure coverag required under. •ction 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a tine up to S1,500.00 un or one-year imprison ent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip to S2a0.00 a day 'ainst the vlolamr. I advised that a copy of this statement may tx forwarded to the Office of InvoAgaiians oflhe DIA orinsurancecov ragevcrificalion. Ida hereby certify under se pa a J penaltles of perjury that the iufornruthut provided abo a is/rr///�e and correc•L "i-vi I Date: 1 a-J L 3 P n d: 01 Oflicial use only. Do nor write in this area,to be completed by city or town a/Jlcial . City nrTuwn: _-,._. . .__ Permiul.lcenseq__.,_ ___.. Issuing Aulhurily(circle one): I. Board of health Z. Buildim; Departuleat 3.Citytrowu Clerk 4. Electrical Inspcctur 5. Plumbing Inspector 6. Other Contact Person: .. ._. _ Phone B:— -- --- CITY OF Sc1LE.M) 1AXSSACHUSETTS ' )+ BUILONG DEPAR-MENT 110 WASHIINGTON STREET, 3'D FLOOR ` TEL (978) 7d5-9595 KI3L3ERL.EY DRISCOLL FAX(978) 740-9845 NL.%YOR Tuosr sST.PmRRs DIRECTOR OF PUBLIC PROPERTY/BUILDCg1G CONOQSSIONER 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 I 11.5 Debris, and the provisions of MGL c 40, S 54; Building Permit fk 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 tNIGL c 111, S 150A. The debris will be transported by: ti y �r1�� oQes �g1_ (nanic of lta ler) The debris will be disposed of in (name of facility) _----_--(address of facility) daft' Ichii.]If dux