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3 WEBSTER ST - BUILDING INSPECTION ck dt i The Commonwealth of Massachusetts h� Department of Public Safety 1V)�yVV Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 3 w asoa_ 51 , Snem MA nilo No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edifion of MA 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 ❑ Change of Occupancy ❑. Other 6215pecify: SELZM VC to G C"Wk7�_J� Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: 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 ❑ Ad❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi It Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ I-2❑ I-3❑ IA❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑ 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 ❑ IIIA ❑ HIB ❑ 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❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: NIA t ismric Commission R pie, Process: cess: 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: SECTIONS: PROPERTY OWNER AUTHORIZATION Name and Address of Proper Owner R w+�V Er�vel� I`l I I,JASO. sVA) +L01 M A- of 9 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: ` �-9� 9L _- - Io► Salo �c Title #I'J Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the pro2erty owner's behalf,in all matters relative to work authorized by this building permit application. SECTION.10:CONSTRUCTION CONTROL(please fill out Appendix 2) If buildingis less than 35,006 cu.ft.of enclosed space and/or not under Construction Control then check here[Iand 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 mpany N. Name Person Responsible for CF ns�tion License No. and Type i�f Apppplicable Street Address City/Town State Zip Telephone No. business Telephone No. cell a-mail address SECTION 11:l4Ol� KFRS'CON.II I:NSAI70\INSURANCF.AFFIDAVIT` 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) Total Construction Cost(from Item 6)=$ 1.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 4.Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ cj (contact municipality)and write check number here SECTlO 13:SIGN TURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby.ttest under ne pains and penalties of perjury that all of the information contained in this application is I ee and-aeeurate to the st of in nowledge and understanding. q'ry,' t,V� na 9 ( 's Please mt nd sig n ne Titl Tel No. Date e) ;xor-\eA--) f L' t� MA ©l w-z Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: - ' 3 Name -Date r` crry OF SiUE-Nm, 2ANSSACHUSETTS BUILDING DEP.-.RTMF.iT 120 WASHINGTON STREET, 3a°FLOOR oar TEL (978) 745-9595 FAx(978) 740-9846 }INtBFRi E F.Y DRISCOIJL Y DR - THONtAs ST.PIERRs t'�Y DIRECTOR OF PUBLIC PROPERTY/BUILDIN:G CONC.(ISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(l3usiiie ,:Organization/Individual): 1a I Address: ' �— City/State/Z.ip: ' A QM 10 Phone #: T I 2 t - Arc yo an employer?Cheek the appropriate box: Type of project(required): 1. 1 am a employer with t 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. El Remodeling ship and have no employees These sub-contractors have a. L eemolition working for me in an capacity. workers' comp. insurance. b Y P' Y• 9. ❑ Duilding addition [No workers comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.0 Electrical repairs or additions required.] of 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.)t employees. [No workers' i;,❑ Other comp. insurance required.] •Anv applicant Ilea checks box 91 mwr also rill out the section below showing their workers'compensation policy inil)mat!on. f I o'MeIMM"who submit this affidavii indicating they am doing all work and then hire outsido contractors most submit anew aof davit indicating such. 't.uPlmeiatY that check this box most attached an addiiiumal sheet showing the name of the sub<omraetons and their workers'camp.policy information. I am an employer that is providing workers'compensation iasurancefor my employees. Below is the po!!cy and job site information. Insurance Company Nmne: JC�. ��w�(A✓`cam Policy 4 or Self-ins. Lic. q: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the works sattion policy declaration page(showing the policy number and expiration date). Failure to secure co ge as required rider Section 25A of�IGL c. 152 can lead to the imposition of criminal penalties of a Fine up to S1,500: and/or one-year prisnnmen4 as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 day against the iolator. Be advised that a copy of this statement may be,forwarded to the Office of Investigations of lie DIA for i urance coverage verification. I do hereby certify de dre pains mad penalties of perjury that the information provided ubu1v+e i bra and correct S im 1 Irt p Dole: Phu e is e 2 OJfic•iul rue mrly. Do not write in this area,to be completed by city or town offlc•inL City orTown: PermitiLicense# Issuing Authority(circle one): - - 1. Board of health 2. Building Departinent 3.C'ily/fown Clerk 4. Electrical 6151)ector 5. Plumbing Inspector 6.Other Contact Person: Phone#: [ . !r CITY OF SOU ENM, NAksSACHUSETTS i . BI:imtzzG DEPARnaNT 120 WASHINGTON STREET, 3iiO FLOOR T EL (978) 745-9595 F.kx(978) 740-9846 KIMBERLEY DRISCOLL 1AVL-1YOR T mosw ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/912ILDNG COSNISSIONER 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 t 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 NIGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in ---'- (name of facility) (address of racility) signatu tcan �c df�t idbw Jfrd. ,