0008 CLIFF STREET - B-297-13 �O rao
the Conunonvv(alth of (Massachusetts
\ I Department of Public S,Ifety
is Stair llu ddl ng Cud II C'.%IfO
Ruildifig Permit AppIication for my lsuil (it1, 11,I1, .I On¢_ kvo-Farb ))welling
(IIlis Scition For Official C' Ouly)
Iluildiug Permit Number' _ _ - Rlic Al'Plied: _ .._ - _ IIuilJil Icial:
V -- res ---. - .SE(:'fIOIV is COG\1lON(('(rase indiarte Illuck M and Lut M fu a .loal vhich t re4s is av e
- - - CDa-lem --- .. -0197p
No mid Sirco
City, 1'a+`'!I ZiPGnlr Name o)u I I upplitahlc)
.SECTION 2: I'ROPOSEU WORK
Fdilion of .MA titer Cndc u,od -'---
... . _ If Nov Cu Lis[flit'iun thvtk here❑ar i hrtk all(hat,q+plr in tho hvu run', brlusv
If,i,l it 8 um If III;❑ Rvi'mr❑ Auennio.I ❑ Addition❑ Ucnnditlon ❑ (I'Irase fill out and 4ml+n +
II
!it�\ +
t lulix I)
Cho, Of C'4e ❑ 1 Ch,utgc of OrcupaltrY ❑ Olhcr ❑ Specify:----- _ _
Are buildingPlan4,otd/ortotstmctiond,kuntcnlsbeing4upplied,Is part tit III
izprnnuapplir,!ti"It? 1'cs ❑ 1Vu
Is an Independent Stntctuad Engineering PVVr Review na(uired?
1'c4 ❑ No
ltrivf Dr4triptiun of Pro tit al Work: gtrci �'aS'� to•I� Or�_�-p �r,m„y.
.2rb-r,.r,t,e m
II
Qe�$-@�nh �'he_,r•.2 eS_1�Yt 0+�,�+11 A2e_4�M1hrS._._.
_i .1Z,rg ,� —Y----�TS- . ---
}��,r�vto-i, tr,l `p� �c�L�✓xM1 2� =nc-A--
'
v t 1 tat r\d r ,sll --`-� vcr t�� vu L..�� --1-== �--- --—t'—�•
') 'T1UN J:COhll'LE'(E i'FIIS SGCI' N IF EXISTING BUILDING UNUERGO1NG I ENOV,\TION,AUDITION,OR
CIL\NGE IN USE OR OCCUPANCY
Check here if an Existing Ifuilding Investigation and Evaluation is enclosed (See 79110IR 14) ❑
F,i4ting C'se GruuP(s): _
--..--- _ I Proposed Usc Cnmp(4):._,----.'—__
SECTTION J:BUILDING MIGHT AND AREA
Existing PnlPo,ed
No.of Fluor4/Stories(include b,lscntcnl Ievcls)dr Area Per Fluor(sq.ft.)
I'otal .\rr,l(sq ft.),unl rot i Height(ft.)
.SF.CI'IONS:USEGROUP(Checkasa licable)
A: :\ssembly A-I ❑ A-_'❑ .Vighldub ❑ .L-1 ❑ A-4 C] ,\-i❑ u: Business ❑
F: Facto F-I ❑ 14_'❑ F.: Educeliunal ❑
II: III h Wizard !I.1 ❑ 11-2❑ I1.1 ❑ I1-4❑ 11•5 p I: 111411ilutimnil 1.1 ❑ 1.2p I-1❑ 1-4Q JI: Jlercantile❑
it: Hv4iJenHal It-I❑ R-?❑ R,l❑ it-I ❑ -
.S: .Sturage 5•1 ❑ S-'❑ U: Ctilily❑ tipeualUse❑and dcasede,inbcbclmw;
�pci ial C'se -
SECHON 6:CONS I'RUCTION I'YI'F. (('heck as a, licable)
L\ ❑ III Cl IL\ ❑ Ilu ❑ IIIA ❑ lllu ❑ IV ❑ \':\ ❑ \'0 ❑
SR NON 7: SI f F I.V FORMA TION Irefer to 790 C.MI( III 1)fir details un each itcnt)
W.Iter Supply: hood Lune Information: .Sewage Uispu4al; french Permit: llebri4 lte!nuval:
Public ❑ C bv,k It,w,Ide 11001 G,IW❑ IuJi+,nc Imo lilt iPA❑ \ In'n+h Icdl not h I Ivliwd Pl'p,-,.d ;,t,.Cl
I'm.l lc❑ „r odr IIIIIi ?w .- ,Iroo ,ucss,lvllt❑ rcyuirrd ❑nrlrL,m1 I,r,pr,Ih-
{•vrnld I,rrh hard ❑ i .
i Itailn,aJ rigl!Lu( wdy. Ilarards Io Air.N,I%iptiun:
l \ I Cl I L.ltru,luronu6o!.Io arl.I • rtr,nh.rt.o'( ! I l I,Ilh•!r n't Ir+c„ nlldrlrJ '
r l vnrul 61 lAnid",I,t:,r,l ❑ l r,O •-r \',I 0 I
yFCI l(1.V 9:( UV I I f UFIFR Ilil('.\Ili OF O(( CI'.\.V( Y
I ,IIIIrn d l-,•Jr L .,•lnvf'I•I --It ,I l'•,n.11u,h, n
I!,•„ lb, Uu.Id ll) , nooi III "piliMt
F I()N ), vl(ov Ifit I Y owm:a AU I I W It I z A I ION
\mllv jold Address I opc 0 Vr
roll,it
N,
s -
Njmv Ar I, mill SIrvet
Ior'.0 Into 111.1tion:
--- ---- 1:eit-phou No. (cell) k-Ilmil address
ille f,,it-filione No. (business)
Itopplic.it"I 1 ,
Name StrvetAddircs-s City/I*owli slate /ip
hl,ntI on the prolivirly omilor's 1101,11f, In 111 tuttvri relative to%,korkauthorIA'd by thiq buildn", lerinit'11'elicatioul.
SECTION to:CONS1 HUQ'lease fill out Appendix 2)
If buddin is Ices than 03i)(A)Cu.ft.olvildoled S1,ace and
1() 1 life'' ere Profes iunal MeH onsible for ConstruL1101-Control
Regisir,lition Nuiubc,
i if lit
Nante LR'Ilate Zip Discipline
Sllvvt Address City/pawn m
10,2 General . ntracto T7 I/ P,
A/ V
ColliIhIlly I , me b'14
1 13 a/ A-- z
Mine of Past n isible for Cues actin License No. and rypou if Applicable
city/Town state Zip
Stive Address
rely ,hone No. ([Ili it rov flione No, Cut C.Illailoddro*s I
Li
SECrIUN IT:at 1\�, ( k 1\11.1 V'Allo\ V11111 k\k "'k,I I IM.G.L.c. 152.4 25C(6J)
'
Workers'Compensation Insurance Affidavit 91,111,the
submittedsubmittedv,with this,tpplication. Failure to provide this affidavit will result in the denial Of the Lqsu,lllce of the building permit.
licationi Yes 13 No 11
SECTION 121 CONSTRUCTION COSTS AND PERMIT FEE
Itum Estimated Costs:(Labor Mawri'll total Construction Cost(from Rent 6)
1. ouildin 5 Building Permit Ft%--Total Construction Cost I (Insert hereI
1:1voricol appropriate IntilliciP,11 factor)
I'lumbille, Note: 'llivilluill fee-5----(ct'llt.lo
I. \tcdwIli,,Ij (IIVAQ 5
i. MktIl'illit'll (Other) SFildt'sk. 'Ilk"
5 (ollit.ht numit "116),ind write t llctk tinjoler liciry
-
SECTION j�,,e1,N,jIUI(EoFBUILDING PERMIT APPLICANT
i.it .I the kiformattoll ,101,1111-1 "1 [Ill,
Ilk,volviring III% ll.11110 below, I horvilv itcst kid vir the JIMIT4end
application i,true and ot,urolv it,the llclt ul M$ k1wl\lodge and uIldvirstali'llog.
I tile plionc No
I'mil and1?;Il 11.1111k.
Ilk /tI,
Wdl,"
fill not this settilill ip,i application approval:
°a CITY OF SM-EMI NW&S ImusETTS
BUILDING DEPAR-r-,W-NT
120 WASHINGTON STREET,3'o FLOOR
T EL (978) 735-9595
F.M((978) 740-9846
KINfBERLEY DRISCOLI.
NLAYOR T�30MAs ST.PmRR13
DIRECTOR OF PUBLIC PROPERTY/BUrLDLNG CONNISSIONER
Workers' Compensation fnsurance Affidavit: Builders/Contractors/Electricians/Pl umbers
Applicant Information Please Print Lepibl
NamC(Busiiws&Organizatiorvindividuul): -
Address: l V w 5 FIE
City/State/Zi i� ] 0 C/11 Phone K: ` O 0
Arc yo an employer'Check�th�e�appropriate box: 'type of project(required):
1. 1 am a employer with-+�-14= 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employee(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These subcontractors have H. []Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
[No workers*comp, insurance 5. ❑ We are a corporation and iu
required.) officers have exercised their ME]Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions
myself.[No workers'cutup. C. 152, 41(4),and we have no 12.❑ Roof repairs
insurance required.1 t employees.[No workers'
comp.insurance required.] 13.❑Other
,Any applicant that checks box el mutt atw fill out the sedioa below+hawing Chair workers'compensation policy inl'umation.
i r,"aownem who suhmit this stnrLnvit indicating they am doing all w°rk and then hire outsidttcontractors mint submit a new afRdavit indicting such.
:Cuntmcturs that chuck this box mutt anachdd,in addidurud sheel showing the none of the mbKanlrutm and their workers'comp.policy infw•malion.
f um an employer that Is providing workers'compensation insurance jar my einployers. Below!s rAe policy ureaJab site
laferrnallost
Insurance Company Name:
Policy p or Self-ins,Lic.N: 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).
Failum to secure coverage as required under Section 25A ot•MGL c. 152 can lead to the imposition of criminal penalties of a
lint 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 aline
Of up to S250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Of Lice of
Investigatimut of Ilse DIA for insurance coverage verification.
/do hereby certify under rite pains rnrd penuhh s of periury that rile hifaronutlon provided above is true and correct.
JgLdllim Date:
Phone d1•
OJJiciul use only. Do not write in this area,to be completed by city or town gj1clu2
City or'fown:
__.. Permit/l.lccnseL
rily(circle one):alth 2.❑uilding Deportment 3.Citytruwu ClerkCfectrieal Inspector 5. Plumbing inspector
n: Phone d:
[
CITY OF SaUEM) i�L1SS��CHL'SETTS
BUILDING DEPARTNtENT
120 WASHCJGTON STREET, 310 FLOOR
TEL (978) 745-9595
F.tx(978) 740-9846
KIJtBERLEY DRISCOLL
,MAYOR THOSLu ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILD44G CONNISSIONER
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 1 I L5
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 MGL c
1 11, S 150A.
The debris willW(n
bt-t
ansported by:
ulu)
The debris will be disp/sed of in
-- (name of facila --
Y)
(address of facility)
sig re of •r it ap cant
date --