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18 WILLIAMS ST - BUILDING INSPECTION (6) 1 REGEIVED The Commonwealth of MassacliV41HIO►AL SERVICES W Department of Public Safety A MassachusettsStateBuildingCode(780CIvllllb MAY 17 pp 44 Building Permit Application for any Building other than a One or Two-Family bwe'llfn1 (rhis Section For Official Use Only) Budding Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) cy i ll r t _SST S l�lew� ►�� Ol9?D No.anti Street City/Town Zip Code Name of Budding(if applicable) SECTION 2•PROPOSED WORK Edition of MA State C •used If New Construction cheek here❑or check a8 that apply in the two rows below �L Existing Building Repair Grj Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 111/- Is an Independentstructuml Engineering Peer Review required? Yes ❑ No IDS Brief Description of Proposed Work: 44C ' SECTION 3:COhIPLETE TH[S SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Cheek here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O Existing UseGroup(s): Proposed UseGroup(s): SECTION4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)k Area Per Floor(sq. ft.) Total Area(sq.ft.)and Total Height(it.) SECTION S.USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 Cl A-i❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ - H: High Hazard H-t❑. H-2❑ H-3 Cl H4❑ H-5❑ 1: Institutional 1-t❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage Sl Cl - S-2❑ U. Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) - IA ❑ 1B ❑ IIA ❑ 1180 IRA ❑ IIIB ❑ 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❑ Cheek if outside FIooJ Zone❑ buiiwte municipal❑ A trench will not be Licensed Disposal Site❑ required Cl or trench or specify: Private❑ or indentify,Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: %I_\I li=tone Commksion Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No❑ 1 Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: . (Xcupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: mf�1L TO (74r - slzt-A SECTION 9: PROPERTY OWNER AIATHORIZATION Name and Address of Property Owner eftle,Y i/lt'�f�tS �� l�/ ffaz�r�-BG� 'S'lle- f Name(Print)! JAV, No.and Street - City/Town Zip ,R Property Owner Contact Information: c �I'PI�St� V; vas = �17-sffooY,;Z-- Title Telephone No.(business) Telephone No. (cell) a-mad address If ap licable,t e property owner hereby authorizes 61yt Hoke.-e% Toe 6-40L e Ste- S,/9/P,O'+t mA el 120 Mune Street Address City/Town State Zip to act on the property owner's behalf,in a6 matters relative to work authorized by this building ermit a lication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less thin 35,0M cu.ft.of enclosed space and or not under Construction Control then check here 0 and 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 Ztp Discipline Expiation Date 10.2 General Contractor - Shn Lw=y k/ /Zc Com y Name f,nhyv 42-v-c-Y 093--?66 Name of Person Responsible for Construction License No. and Type if Applicable 30A 20fie s1 10W107 _ oi5;:">0 Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSUItaNQ:.APFIUAVD' 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? Yea 0 No 0 SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Electrical $ O © Building Permit Fee-Tot. Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ J.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ municipality) P y (contact municipali )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering any name below, I Iiereby attest under the pains and penalties of perjury that all of the information contained in this application is trued accurate t the bed o my knowledge and understanding. P cue rint and sign name Title Telephone No. Date t,- F21P .li CT SYI/PGA— 1� 70 Street Address V City/Town ate Zip Municipal Inspector to fill out this section upon application approval: Name CYTYOFSALE14 KWAa-REEM BEuxmDaPA 1201 ASIMYOMS ERT3,3MRDCX IkL(971)745-9595. SIA96ERIEYDRiSaDIl FA (M)74D-9W MAYOR 1 SZPn= Dnu;amcrPLzucPFnFwY/BumDmammwxm Construction Debris Disposo/Afdavit (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 coo, S 54; Building Permit#t 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 ill,S 151)A. The debris will be transported by. (name of hauler) The debris will be disposed of in: (name of facility) (address of facilit i atu e o icant °1 s 6 Date The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02I14 2017 www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Name(Bwiness/organintiontlndividual): T �¢,�?I�.� j -�' C— - Address: �L-b 0 � � 5t7�/<f-, City/State/Zip:_ Z21 At- ©"9 C) Phone#: Are you an employer?Check the appropriate box: UV Type of project(required): I.Q 1 sm a employer with employees(full an&orpen-time).• 7. New construction 2. am a sole proprietor or partnership and have no employees working form in any capacity.[No workers,wrap.insurance required] 8. Q Remodeling 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition 4.Q I s m a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. S.Q I am a general contractor and I have hired the sub-conhactors listed on the attached sheet 12.QPlumbing repairs or additions These sub-contractors have employees and have worker'comp,insurances 13.Q Roof repairs 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 15Z§1(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowner who submit this affidavit indicating they are doing all work and them him outside contractor must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employee. If the sub�contiactors have employees,they must provide their worker'comp,policy number. I am an employer,that fs providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S 1,500.00 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 ag ' the violat .A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage Agificqtion. I do hereby ader aims and penaties fperjury that the information provided above is t ue and correct Si ature• G_ Date: Phone M 00icial use only. Do not write in this area,to be completed by city or town ofciaL City or Town: PermWLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. ' Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or otherlegal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any compliance with the insurance coverage re required." 'cant who has not iodated acceptable evidence of p9 applicant P PP P Additionally,MGL chapter 152, §25C(7)states'Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should - be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSA-FE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia