0007 WINTER ST, U2 - BPA q 2- _
j The Commonwealth of Massachusetts
A Department of Public Safety
yU Massachusetts State Building Code(780 CMIR)
www... Building Permit Application for any Building other than a One-or Two-Farru Dw ling
("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)
No.and Street City/Town Zip Code Name of Building(if applicable)
�A" -*Z SECTION 2.PROPOSED WORK -.
Edition of MA StateCode used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair Alteration ❑ Addition❑ 1 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 r"j"
Is an Independent Structural Engineering Peer Review required? Yes ❑ No l3"
Brief Description of Proposed Work: IDof>' rV�aaL SC7c nk(o- J » '
I �cra ro Rc.n�, d "or 4- r Roof rao— Ta r/ fvi i��� (1
'1.2, --iuin -Pia 4 !'arIn f- t �-L Fn.<h hs21woci
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 CbIR 34) ❑
Existing Use Group(s): IProposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
" Existing Proposed
No.of Floors/Stories(include basement levels)&a Area Per Fluor(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❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-l❑ 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 ❑ 11113 ❑ IV, ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for deiails 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❑
b y; 'g lit ru t mnmisu n I c�wvv I i x�ss:
Railroad right-of-way: tluards to Air Navigation: nl��_i,
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 Flour:
Does the building contain an Sprinkler System?: Special Stipulations:
� hT
•f
SECTION9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner o Z
YVev.at corfre— 7u:'"nknS(- f70
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title 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 property 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 building 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 Registeredg Professional Responsible for Construction Control -
:C ems : wrnc�,� ehaxcU, � .�
Name(Registrant) �7�Tele hone No. e-mail address Registration Numb/r
Ij LPG 55uYrY _ `Ny. O(C (��g
Street Address City own State Zip Discipline Expiration Date
1/0.2\�General Contractor
6 GSC '7 4
e t _
Company Na,n}}e
91 ( 1, _ CS
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town - State Zip
Telephone No.(business) Telephone No, cell e-mail address
SECTION II:bVORK1-:16'CObIPENSA FION INSURANCE AFFIUAVII' M.G.L.c.152. 25C 6 -
A Workers'Compensation Insurance Affidavit from the NIA 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 $
T. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose duck payable able to
6.Total Cost $ / //�
(P 7, (/ 16, (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I 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
Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: 3-d o 'lq
Name Date
CITY OF S�UENI, XWSACHUSETTS
• BUILDING DEPAR-11MNIT
• p 120 WASHINGTON STREET,3"FLOOR
TEL (978) 745-9595
FAx(978)740-9846
KISIBERLEY DRISCOLL
MAYOR THoMAs ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUILDIING CONLUISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(BusinossiOrganization/Individual): 4 Se t (L
Address: // C'vs-s S1 3-
City/State/Zip: &0ZVLdAA6lV5 Phone#:
Are you an employer?Cheek the appropriate box:
� Type of project(required):
I;O 1 am a employer with -9' — 4. ❑ I am a general contractor and 1 6. ❑New constraction
employees(full and/or part-time).' have hired the sub-contractors
2-0 1 am a sole proprietor or partner- listed on the attached sheet.: 7. ❑Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp,insurance S. ❑ We area corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
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 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
•Any applicant thar checks bon el most also fill cut the sectim below showing their workers-compensation policy infona uioo.
'I lomeownen who submit this affidavit indicating they are doing all work and then hire outside comsat t, must submit a new affidavit indicating such
=Comractoa that Litak this box must attached an additional shad showing the tame of she sub-eomrwu s and their wohes'comp.policy infamution.
l am an employer that la providing workers'compensation Insurance for my employee& Below is the policy and job site
information.
insurance Company Name: LSSOC 4 Fr4 lwfi S
Policy#or Self-ins.Lic.#: k1ce -sae• 50( 20'/7 2011 Expiration Date: A
Job Site Address: 7 (w a,,(� . 61• 'Y 2— City/State/Zip: .41
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Invesiigmitnts of the DIA for insurance coverage verification.
l do hereby eerd/"Jy deer the/pt ains and penalties of perjury that the information provided above is true and correct
Sienatttre� (,/L�'1 C.��. Date:
Phone#:
Official use only. Do not write in this area,to be completed by city ar towm of friaL
City or Town: PermillLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person• Phone#:
}4 CITY OF S'ILEIN[, AXSSACHUSETTS
?� t3U=LNG DEPARTNONT
120 WASHLNGTON STREET, 3"w FLOOR
TEL (978) 745--9595
F.C.�c(978) 740-9845
KI\�EliLEY DRISCOLL
A-1YOR Tlto+Lu Sr.ptERRa
DIRECTOR OF PGBLIC PROPERTY/BCILDLN(;COSp11SSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit N 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 Im L c
111, S 1 SOA.
The debris will be transported by:
(name ot'haulerJ
The debris will be disposed Of in
-_---- (name of racdity) —
—_--(address of racility)
srgnarure of permit applicant
Marc