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39 CEDAR ST - BUILDING INSPECTION The Commonwealth of Massachusetts Department of Public Safety R(NI�s RECEIVED S Massachusetts State Building Code(780 CtviK)PECTIOPt/�I SERVICES Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Ont ) 2115 NOY I U AID y Building Permit Number. Date Applied: 7 Building Official: J..\ SECTION 1.LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) �V 2 9 ('e du✓ Sf Set le 8/4 0/ 970 1 No.and Street City/Town Zip Code Name of Building(if applicable) LD I SECTION 2:PROPOSED WORK t Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building lff'� Repair 151 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No We— Is an Independent Structural Engineering Peer Review required? Yes ❑ No alb Brief Description of Proposed Work: Lee4rkeol V- P640-4 6 14 /ct-ucbA.rc i P/L GIS/i GALT_ �SNap �.,?!L i{i /I OK SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check hese 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.) / g$ S� e Total Area(sq.ft.)and Total Height(ft.) . SECTION 5:USE GROUP(Check as applicable) A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ P. Facto F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ E Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R. Residential R-10 R-2❑ R-3 IYR-4❑ S: Storage Sl❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION&CONSTRUCTION TYPE(Check as a licable IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 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 OP� Check if outside Flood Zone Indicate municipal A trench will not be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ required L9f trench or specify: permit is enclosed❑ Railroad right-of-way. Hazards to Air Navigation: MA Historic Commission Review Proms: Not Applicable 1.9' Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or No Ee- I Yes❑ No 01� SECTION&CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): /Z3 Type of Construction: Occupant Load per Floor. Does the building contain an Sprinkler System?: ND Special Stipulations: V),ePL kc,� 6 ) 9 Py SECTION 9 PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 39-y/ Cela✓s/✓ Its 7-ZG4er✓y S/; [yeHlawt . MF/ 0 98 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Dices /{rx✓C/9otW7 _-_- 6//-306- o1-7S1 of*.. ctN4*k,*"I Con Title Telephone No.(business) Telephone No. (cell) �c. ml adial ad� 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 budding 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 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 Zip Discipline Expiration Date 10.2 General Contractor / �/�f��k�{-ierlpc�GE� d �d KSYfYu-CX'1rC7? Company Name Groff lyofF GS- 0 8 90 7 `p.c5/ci KLoTr Name of of Person Responsible for Construction License No. and Type if Applicable /SSualle ✓ .52� RoSl�d+ + 4 0a// Street Address 14City/Town State Zip (Zh-536 ci900 6/7 5- P630 SCof��: a/ns�roa�er7/��5 _ cory Telephone No. business) Telephone No.(cell) e-mail address SECTION 11 WORKERS'COMPENSATION INSURANCE AFFIDAVIT QvLG.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 O No O SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 65000 1.Building $ /5000 Building Permit Fee=Total Construction Cost x (Insert here 2 Electrical $ 000 appropriate municipal factor)_$ 3.Plumbing $ a©pop 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact in �ity� 5.Mechanical (Other) $ Enclose check payable to G 6.Total Cost $ 5-000 (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. Ila w L4 ✓./ i— l�� xur eG✓ 4 -306- eZ7S/ al sign name Title Telephone No. Date Please print 7ACLe✓- S� itieH koLr cr ^^T Street Address/ City/Town State Zip Municipal Inspector to fill out this section upon application approval• Name Date Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction SupenIsor License: CS-081907 SCOTT D WOIY 696 TREMONT Si#11WRJ BOSTON MA 02118 Expiration 05/18/2016 commissioner CITY OF SALSA MASSACHLISE TIS BuiLD1NGDErar7mEw 120 WA9mc7mS7REET,3'DRom 7t?L.(978)745.9595. FAX(978)740-9846 KIIv>SERLEYDRISflOIl MAYOR THOMAS STREM DIREcIcR cF puaucrxopERTr/BumDzw omoomoieR Construction Debris Disposa/Affidavit (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 00, S 54; Building Permit lt 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 111, S 150A. The debris will be transported by: (name of uler) The debris will be disposed of in: /2,42osu f (name of facility) `TS 7e_x*tet/ .524- Georye / ©le 3 3 (address offacility) Signature of pplicant � ate