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59 FEDERAL ST - BUILDING INSPECTION $1aaI� YS The Commonwealth of Massachusetts # Department of Public Safety f JL Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This-Section ForcOfficial Use:Only), ` . i._ t Building Permit Number: Building Official: j SECTION T:LOCATION(Please indicate Block if and Lot#for locations for which a street address is aot available) No and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED.WORK `- Edition of NIA State Code used If New Construction check here❑ or check all that apply in the two rows below { Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition nlf5iease 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 ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ d!i Brief Description of Proposed Work: SECTION 3:COMPLETE THIS SECTION IF EXISTING:BUILDING UNDERGOING RENOVATION,ADDITION,OR ,' t 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 r No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(sq. ft.) and Total Height(ft.) i . SECTION 5:USE GROUP(Check as applicable) -;- 1 A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business O E: Educational ❑ F: Factor F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ ' S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and pleasedescribe below: s Special Use: - SECTION 6.CONSTRUCTION TYPE(Check as applicable)'- - IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA 13IIIB ❑ 1 IV. ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 fordetailson 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❑ + J Private❑ or indentify Zone: or on site system❑ permit is required a or trench or specify: enclosed❑ , 1 Railroad right-of-way: Hazards to Air Navigation: NIA Historic Commission Review Pro:rsa: i Not Applicable❑ Is Structure within airport approach area?-- `- ' Is their review completed? or Consent to Build enclosed ❑ Yes ❑ or No❑ Yes❑ No ❑ - y - - SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY - - _ i Edition of Code: - Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: t"I LCD Tz� C-1 C_ t i :. SEC_TION 9: PROPERTY OWNER AUTHORIZATION ' Name and Address of Property Owner 111 b6i tD Paal a{ €3 t�At Q-V► y � g err- Mk 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 s ace and/or not under Construction Control then check here 0 and ski b Section 10.1 40.1 Registered Professional Responsible for Construction Control`r - Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip - Discipline Expiration Date 10.2 General Contractor - i Company Name p PAS817 �� �� + ( I OI ""S Name of Person Responsible or Construction License No. and Type if Ap h ble LUNCs12t_'S� �� At��l"L ©t Street Address City/Town State I Zip Tele hone No. business Telephone No. cell e-mail address SECTION 11:fVORKERS'C'ONlPENSATION INSURANCCAFP[DAVIT M.G.L.c.152:§25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and 1 submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. t Is a signed Affidavit submitted with this application? Yes 0 No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT:FEE Item Estimated Costs: (Labor - I and Materials) Total Construction Cost(from Item 6)_$ 4 t 1.Building $ t 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 $ (contact municipality)and write check number here S - ION 13:SIGNATURE,OF BUILDING PERMIT APPLICANT: : . .By enterin my name below, I h eby attest under the pains and penalties of perjury that all of the information contained in this t a plication is and accura to the best of my knowledge and understanding. Please prKand si nam Title Telephone No. Date 1 StreetAddress City/Town State Zip t Ce7N I , . 0 Municipal Inspector to fill out this section upon application approval:.- '"'v - Name Date i The Common w4a"ofi mTSSOC�t1tSC1L{ Departhrent oflndustririlAecidents I CongressS&WOr;SU#el00 Boston,M4 492114-2017 wwwmaMgov/dk Workers'Compensation Insurance Affidavit;Bniiders/CoMractora/Lleebkians/Plumbers. TO BE FU"87TH THEMil9T77NG AU771OR17T AnolieantlfaformatMn. /� PkaBePsbrt Lealkly Nath(Busot tionRndividn D: Address: %0� CoN � �rl Cityistate/,Vsp: )qP Phone#: . Areyaaao employer?c]M:lk apprepr(ah boa: Of To cert . Type p j ' C►e9°►ed):. l. m a employee w6 - ttao aa�mvan-+mei 014,pw qatptruciiiat 2. alaaynpsole ty.Ihlo . es , g; �bvto topicar mcin rwcdpf � M14 lawman iral 8 . 9: Hdbn' 3.01amsbomeownadodogaflwo&n"W..lNoamim 'comp.iasma nquimdjt 100Bui7dmg'addlioa. . 4.01am a homtow end wig be Langmon m cmdugall work onmypwpety. lEvia . emmre dw an conaeom eidakave vorkem'eampemmum iommamee aram sale 11.0 Electrical repairs or additions psoprretpma waLnompiopm. - 12:0P urili grepairs or additiotls s.�i,maaeaweo mels.vikkedEa:autmareaotsr�aamda,a ea.trcei 13 QRoofrepava Mmw=tbm mmh—mployees and Leve wadrm•.-emp.nmaameGi . 6.Owenea colpomtimmaic:officeiahavee eaeieiadPomrigbs oteicemptionper.MQ.o. - 14.Q0lber 157,11(4),and vnL"atviaa emphyees.pin wmloie'eoapm+maoee iegoireA.) ' - •Arryapplkaoa�at box pl most Mico anontdm eeeuom bete. �drirad5le ., pr t Homxowms wLo cairn,dm a6ida4liadigdrcyale doing a0 aor9F and dra biie outside WalmCmamuet aabWa a mvaffidavrtHfdiotros sae6: rComoairom dm check 46 box moa atmrLed aa'addidonal sLeetabowmg da aaaorof sob•coauWioa amz ivlie�voi sot dmoeemupa have employees.IfB,e,aubcgrr_aaeabaye.employs+Leymu#p.wide8�ebwods'-:e�RpoYkyu .:. ;'... l soot ag a�gloyer lJiatvproridfng rnarkera Co , . . ' wpeaea4vninrtp�asaelorm!`�+P�.Yees. B�ivistheP�i'itulJabsaro - insurance Company Name: tf-j ✓S IJ Policy P or Self-ins.Lic.# C`11�t-) FtA:5— Expiration Date: Job Site Addresss: City/StateMip: Attack a copy of the workers'compensation policydeclaration page(showing the policy another and aspirsiiondate). Failure to aeaue coverage at ie ands MGL'c. 1 s2,§25A u a reel violation punishable by a Sae W to$1,500.00 and/or ono year' as well ci. penalties m the form of STOP WORK ORDER and a fine of up to$230.00 a day against the btolitcr A copy oftli' teinmt may be foiwa ded to$e Office oflnvestigetica s.ofthe DIA far instil. nce coverage veri5catiaA. I do hereby eertijy Ihep ' andpenakier ojperjary that the it formation provided above'a ba and torrrd Signature: Daft 1 6/26 Phone#• 'ISR T717i TX OBJcla/use only. Do not wm#te in this area,to be coempleted by sty or to o,(/IciriL City or Town: Permit/Llemn M Issuing Authority(circle one): 1.Bond of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Phmbiuglaspeetor 6.Other Canted Person, Phone N: 07Y MASAGHUSETV. BULEiMDIKPAXBWU JM Wim VfflWS"MtT rFtoCR DL T4s-mss. SIMBRIBY2. Dnmcrmcrpuuxmw#tKm/sumEmo%AaWCMM Construction Debris Disposa►iAffldavit (required forall demolition and.renovation workj In accordance with the sbdh edition of the state Buihfing Code, 780 CMR, Section 111.5 OWWt, and the provisions of MGL coo,S 54; Buli ft Permit Ii Is issued with the condition that the debris resulting from this work shell be disposed of in a properly rrcensed ' waste deposit fatuity as defined by MGL c 111,S 150A. The debris will be transported bv: (name of hauler) The debris will be disposed of In: (name of facility) (address of facility) Signature of applicant Date