84 HIGHLAND AVE - BUILDING INSPECTION (2) y 2 t ID't 4
}� The Commonwealth of Massachusetts
00 Department of Public Safety
V� Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
J
-_, (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)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑ or check all that apply in the two rows below
Existing Building ff"- Repair❑ Alteration Z Addition❑ 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 Nr No ❑-/
Is an Independent Structural EngfneerAfnAg Pnee�r R.eview required? I Yes ❑ No Irl
Brief Description of Proposed Work:WK/I ja Q _ Ir,LL_s.�CL C
i S
M--r-S tl F Ir L.r-: � 1
FSS1 — I
SECTION 3:COMPLETE HIS 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 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.) OG OC3 O
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 ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 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 please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 111 [3 IIA 1113 IJ IIIA ❑ IIIB ❑ 1 N ❑ 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:
PublicA trench will not be Licensed Disposal Site
Check if outside Flood Zone Indicate municipal
Private❑ or indentify Zone: or on site system❑ required ff�or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable 0_� Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No IBS Yes❑ No ❑
SECTIONS:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: S Use Group(s): 0 Type of Construction: 2 t/ Occupant Load per Floor: 2 f3
Does the building contain an Sprinkler System?: VF S Special Stipulations:
103 cr��ttr� 4 P•v .
SECTION 9: PROPERTY OWNER AUTHORIZATION
ame and Ad us of Pro erty per
Name(Print) Mo.and Street City/Town Zip
erty O net tact Information:
Title`D;r OF pfd , µ t- Telephone No. (business) Telephone No. (cell) -mail address C,
If applicable,the property owher 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 0 and skip Section 10.1
10.1 Re 'stered Professional Responsible for Construction Control
>✓�2 VYsLt t21�L'� - �1 romeo 5 n- 21 OD
Name(Re strant) Telephone No. e-mail address egistration Number
�' g �imef�en IIA � 0 6�
Street Address City/Town State Zip Discipline Ex irati nDate
10.2 General Contractor
�Co1mpan Name// ,(� /� s
Imo-t CL Pel U . �LtL�2iA L 1, TV' 4v AC�'St l i''ll 'CZ ( .S 0(,PfYq j
Name f erson�ie foPgnstructi� icense and Tye i licabl-,�),)t!ie?
Street Address Jlrj/ City/Town State Zip
Telephone No. business Telephone No. cell e- ail address e 1
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 is ance of the building permit.
Is a signed Affidavit submitted with this application? Yes Q No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$ Z 3 4/, OOd
1.Building $ /`/O d Od Building Permit Fee=Total Construction Cost x // (Insert here
2.Electrical $ 30, o0c appropriate municipal factor)_$ Z Z y O
3.Plumbing $ C ac
4.Mechanical (HVAC) $ O Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ 21 CPC21�2
Enclose check payable to
6.Total Cost $ 47,!10 (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 andAccurate to the best of my knowledge and understanding.
q1-1�- ; gg c 4 as rtwo
Plerint an n e Title Telephone No. Date
t
Street dyes "' 'ty/T n� _ Zip
( � 5�?
Municipal Inspector to fill out this section upon application approval:
Name Date
Appendix 2
.r
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Re aired
1 Architectural k
2 Foundation
3 Structural
4 Fire Suppression ,X
5 Fire Alarm(may require repeaters) X
6 HVAC Y
7 Electrical
8 Plumbing include local connections k
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan(Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investiation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original pennit
fee.
Registered Professional Contact Information
romeo Y nrn
Name Registrant)�ephone No. e-mail addre Registration IN
Street Address �A�• 6ty/T�l State Zip Disc xpirahon ate
Registration Num er
�����Name(Registrant] Telephone No. e-mail address. O I
��.eJuAtL� SLS I Di5' line Expi ;t
Street Address Ci /Town State Zi
ioh Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address Cit /Town State Zip
C�
The Commonwealth of Massachusetts
Department.of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legib
Name (Business/Organization/Individual)"-`
Address: !
City/State/Zip: T Phone#:
Are y an employer?Check/he appropriate box: Type of project(required):
I. [ion a employer with employees(full and/or pantune).- 7. ❑New construction
2,❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
10 E] Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. [will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3 ❑goof repairs
These sub-contractors have employees and have workers'comp.insurance.%
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees. [No workers'comp.insurance required.]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors 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
employees. If the subcontractors have employees,they must provide their workers'camp.policy number.
I ant an employer that is providing workers'compensation insurance jar my employees. Below is the policy and job site
information.
Insurance Company Name: �y
Policy#or Self-ins.Lic, i#: �,�l_ — J 1 ��q''1�.r1�n Expiration Date:
Job Site Address:�q �lC���—� N� IiV� City/State/Zip�, rn� (AT)
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$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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify der the ins a enalties o fury that the information provided above is true and correct.
Signature: Date:
Phone#: _
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
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#:
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Constructibn Superivisor
License: CS-068879
cxr�s
MICHAEL P SUGJtUE
72 HARTFORD P;UMUM- 0
i N SCITUATE RI^0 IIV
7141 ��_ �rM ` Expiration
commissioner 0210112017