84 HIGHLAND AVE - BUILDING INSPECTION i
1
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use.Only)'
N 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)
Q �'I' �-Fi(1-I-LRND A•VE SAt-EM t t�A �la��
No.and Street City/Town Zip Code Name of Building(if applicable)
.:..
SECTION 2:PROPOSED WORK -
Edition of Mt\State Code used � If New Construction check here❑ or check all that apply in the two rows below
Existing Building❑: . Repair❑ Alteration ❑ Addition 11Demolitiod 11 (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
Is an Independent Structural Engine Peer Review required? Yes 11 No
4V !�
Brief escri tion of Proposedork:
S
SECTION 3:COMPLETE THIS S_ CTION 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.)
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❑. B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ - H: High Hazard- H=1 ❑ H-2❑' H-3 ❑ -H-4❑ 11-5❑
I: Institutional 1-10 I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2 O U: Utility❑ Special Use❑and please describe below:
Special Use. -
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
Lk ❑ IB ❑ IIA ❑ IIB ❑ IIIA q IIIB ❑ IV. ❑ 1 VA ❑ VB ❑
SECTION 7: SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water.Supply: Flood Zone Information: .Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal 11A trench will not be Licensed Dis aj Site❑
Private 11- or indentify'Zone: or on site system❑. .required❑or trench or specify: _
permit is enclosed❑
Railroad right-of-way: - - Hazards to Air Navigation: \b%Historic C n,missioo Review Pnrvss: -Not Applicable❑ Is Structure within airport approach area? Is their review completed?
_ or Consent to Build enclosed❑ Yes ❑_ or No❑ - Yes 0 No ❑
SECTIONS: CONTENT.OF CERTIFICATE OF.OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: _
Does the building contain an Sprinkler System?:_ Special Stipulations: _
SECTION 9: PROPERTY OWNER AUTHORIZATION
une and Add r of Proper Ownen
N une(Print) N .an treet City/Town Zip
aper }'Owne Conflict Information
X12 ']
Titlecf. Vroe. "+ 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. it.of enclosed s ice and/or not under Construction Control then check here O and skip Section 10.1)
10.1Re 'stered Professional Res onsible for Construction Control
Name(Registrant) Telephone No.' e-mail address Registration Number
Street Address - City/Town State Zip Discipline Expiration Date
10.2 Genera Contractor
I.IJA
o upany,Name c
)" t t��e�
Name of P rson Resp tble for C struct on rcense No. an#Type if A ipilicable
Street Address City/Town State Zip c
`t'e.lo phone No. (business) Telephone No. cell sail address y
SECTION 11:11'ORKEIti'C0MPENSA1 KIN INSL6ANCE AH[DAVIT M.G.L.x152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the NIA Department of Industrial Accidents must be completed and
submitted with tliis application. Failure to provide this affidavit will result in the denial of the ipKance of the building permit.
Is a signed Affidavit submitted with this application? YeVO' 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 $
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
SECTIONI3: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.
IllStd � l-��f7-J�f0
Please print andZi n, e -Z Title - Telephone No. Date
Stn•' ddres - - _— — - � 1� Torn to to Li
C-� u � p
Municipal Inspector to fill out this section upon application approval:
Name Date
The Commonwealth of Massachusetts
Departinent oflndustrialAecidents
I Congress street,Suite Joe
Boston,MA 02114-2917
www massgovldia
W7Nawe
ompensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FMED WITH THE PERMI MWG AUTHORITY.
Applicant Information PleasePrint •b
�� ��ugn&viduai):
Address: eli-t'i✓ 4-V0I/9 R k, ,
City/State/Zip.fa .�-�`�--2-.1} Phone#: ' r b )~-CQ 4-?-a1Fq b
Ara you an employer?Cbeck the appropriate bot.
Type of project(required):
11l�rI ar a employes with_ en�loytcs(full and/or part-tura).• 7. ❑New construction
2.D 1 am a sole proprietor or parmenhip and have an employees working for me in 8. Q Remodeling
any capacity.lNo workers'"comp.insurance required.]
3.E]I am a homeownes doing all work myself(No workers'comp.insurance required.)t i n Buil ing an
4.❑I am a homeowner and will be hiring contractors to conduct all work on m )0❑Building addition
amp y property. 1 will
ensure that all contractors either ban workers'compernation resonance or are sole l l.0 Electrical repairs or additions
proprietors with no employees.
22.E]Plumbing repairs or additions
5.F1 I an a general contractor and/have hired the subcontractors listed on the attached sheet. 13.Q Roafrepairs
Thew sub•conaactms have employees and lave workers'comp.insurinumt
6.Q We arc a corptuation and its ollicas have exercised their right oteaemption per MGL c. 14.0 Other
152,§I(41 and we have no employees.[No wrkers'comp.insurance required.)
*Any applicant that chxks box Nt must also fig out the section below showing their workers'compentatien policy information.
t Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such
IConnaemrs that check this bre must atmoired an additional sheet showing the name of the subcontrsetarr and state whether or not those entities have
emphoyas If the sub contractors have employes,they must piwAde thein workers'comppolicy number.
lam an employer rhat is providing workers'compensation insurance for my employees. Below is the poGey and job site
Information.
)nsuranee Company Name:
A/ AA f jd l A Jti —
Policy#or Self-ins.Lia#:LOUO -3 � CQd�i " d'W Expiration Date: _�jy'_e�•'a•.3' G�L7
Job Site Address: T4 GCi �-l����,_ � City/State/Zip:5;- W YL1. mA 1t)lq-M
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 fore of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
117
Ida hereby certify u er the
is a p Mies o e ury that the information provided abo a is true and correct.
Si D to
Phone#: U
Orieial use ontK Do not write in this area,to be completed by city or town ojjiciat
City or Town: Permit/Licease#
Issuing Authority(circle out):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
08/18/2016 13: 18 401-647-7067 SUGRUE & ASSOC 4-040C9 #4236 P. 002/008
Ap—61'
The 7Commot&641th.of Massachusetts
h9 Department of Public Safety.
VV��11 Massachusetts State Building Code(780 CMR)
Building Permit Application for any`;Building other than a One-or Two4amily pwelling
j` frh+s Secpor PotfEictal7Jse f]i?IY)
BuddiilgPernutNumber DateAppBed BulidingOfficurl,
SECTION 1:LOCATION,(Please irldicate Blpc"and Lot#for locations for.wWch.a street address Isnotavailable)
Shy �k ikai�aNa &C_s jI I: -W to 19M '
No.and5traet. . Qry/Town Zip Code Name of Building(if applicable)
'&TiCT10N 2,PRC1�'O&AD brQ.RK
I Eci it pn of MA State Code used__ _ If New constructiiln check Frere M or check an that apply in the two rows below
F:xtstirigBurkiing:13 Repair Alteration A AdditionA. Demolition Q (Pleawfill,outand submitAppendix;1)
Chprige of Use 'Q Cli'ange of Occupancy q father 0 Specify:
-Are building plans and/or construe6onc{ocumentsbeing siippliedaspartofthisperniitapplication? Yes a No
Is an Independent Structural Enginee ' Peer Review required? Yes M _ No
Brief T�escr tion of Proposed Work:
ll 'ID.�
1.1PoQ�ro4�21 .S_tq A.z
"SECTION 1 COMPLMTHIS SECTION IF Ma$TNG EUILAING UNDERGOING RENOVATION;ADDITION,.OR,
CHATTGE IN3":USE OR OCCUPANCY
Check;hei•e if an Existing Building Irsveatigatian aiid Evalii5tiori is anclosed(SeG 780 CMR.34) !a
Exoiuig Use Group(s): 1?roposed.Ilse Group(s):
SECTION 4 MLDING.HEIGHT AND AREA•'
Existing Proposed
No..of Floors/Stories(include base4nerit4evels)&-Area Per flow(sq.ft.)
Totil.Area(sq.,fcj and Total,Hetght(ft.) .
SECTIONS: a EGRO IP Ch'eckas.a Iicable).
A.
Assembly A-117 A-217, Nightclub Q A3.CI A-4 r7,. .A-5 0 " B: Business O E: Educational El
R .Facto F-1 ❑ F2❑ H: Hi H-1•q :H-2 A H-3 Q H-4❑ H-5 Q -
I:. IristitutiorW 1-10 1-2 Cl I�0 I.45 M::Mercantileq 1z JR: Residential R-1C7 R-217 R-3Q R-40
S: Storage S-1 A : S-2 O U.'voRi7m T Special Use M and please describe below:
Spepw Use: .
SECTION b:CONSTRUCTION,TYPE(Check:as i li3Oble ` .
IA: q iB ❑ : IL4. ❑ III: I7. IIIA13 IIIB []'. IV ClVA.I7 VB.p
. . ..
SEC ITON 7:SITE INFORMATION(refer 40 7811 CMR 1T10 for details on each item)
Water Supply; ,Floud Zone Information: S4Wage Disposal: " 'Trench Permit.. Debris Removal:
Public i7 . Check if outside Flood Zone q _Irtdreate municrpal I]•: A trench will not be Licensed,Dig a}Site M
Private Q,' or indentify Zone; or on site system Q required.C7 or trench or specify'
perm tis.enclosed Cl
Railroad right of-way: Hazards to Air Navigation: M n Pismric Cynnn ,ion R�_�ayy�i tt i
Not Applicable 0 . Is Structure:within airporEapproach amid Is their review completed?
or Consent to Build enctosed CI Yes p or No fa Yes 13 ' No p .
SECTIONS:CON'T'ENT OBCERTIFICATE;OFOCCUPANCY
Lddihnn of code: Use Group(s):. Type of Construction: Occupant Laad per Floor:
goes the building contain an Sprinkler,Sy#0M?r.; Special&npuiapons
W 1 n.,t�'' c�" .:tt1 t i.A;• (cJ .. ..:. ,:
08/18/2016 13: 18 401-647-7067 SUGRUE & ASSOC 94236 P. 003/008
SECTION 9: PROPERTY OWNER AUTHORIZATION
Mme and Addr of Proper Ow-nen
V mA
Name(print) N .an. treet City/Town Zip
oper -own . ontpct Information:
IaLZ�1 '����
Title rl. Prep.►dgf Telephone No.(business) Telephone No:. (cell) e-nail address
If applicable,the property owner hereby authorizes .
Name StreetAddress City/Town State Zip
to act on the property owner's behalf,in matters relative to work authorized-by this building permit aPlication.
SECTION 10;CONSTRUCTION CONTROL(P'lease fill'but Appendiz2)
(If building{s.less than 3510W cu.it of eruWsed Space and/or not nodm Canstrttetiea Control than check here L7 and skip Suction 10.1
10.1 Re •stetedProfessicnalAd oltsibleforConsttuctianControl.
Name(Registrant) TelephotteNo. e-rnailaddress Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10. General Contractor.
n tpany,Name t
Name of :son Resp tole orC Duct on cense No. an Type if Amicable
Street Address City/Town State Zip
HMike - je�c
fcle hone No. business Telephone No. ceil fail address
SECTION 11:tv "1=I's:C��'1Lh''n'S:\TIC.) 5 7„AteC•d;' •t1JAV1'I' M.G.L.c.15Z I 25C(6))
A workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents mast be completed and
submitted with this application. Failure to provide tNs affidavit will result in the denial of the Mance of the building permit.
Is a signed Affidavit submitted with this application? Ye5IX No 0
SECTION 7.2 CONSTRUCTION COSTS AND PERMI ..FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) $
'I.Building $ 0 Building Permit Fee-Total'Construction Cost x—(Insert here
2, Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Muchunical (HVAC) $ Note:Minimum fee=$ (contactmttnicipaiity)
5. Mechanical Other) . $
e� Enclose check payable to _
G.Total Cost $ S (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my.name below,thereby attest under the pains and penalties of perjury that all of the information contained in this
application,is tate and Accurate to the best of my knowledge and understanding,
Mase print and 11 e Title Telephone No. Date
titre• , cadres z /T�n tate Zi
Municipal Inspector to£U ant this;section upon application approval: ----�
Nanta. Date
08/18!2016 13'. 19 401-647-7067
SUGRUE $ ASSOC #4236 P. 005/008
The CommonitatM PfUessahttSefft
11epw*MW ojlW&s9ddAecidents
1 c wG4S. aveit,sAuille 1 tv
Boston,MA#2114-2017
tvwtttnaarsgotti/drta
workers'Compensation Iosuramc A8ldavitr BntldetstC lumbers.
TO RE FH"WITH TBE Pwanmm AVISORm.
MR Print 14oh
Name
Address:
city/State zip:.K . �,�o,_2- phone#: 40HR472—ay b.
Are you au employ"?cbeck on,sn"prWo bore Type of project(►e9 =
R'bAMA etAployawilstorpbYsaa{fldlaedbrpan-timel.� 7. 0Newconekackon
2Q lsmssata prop:*"orymmnabipaad hsvamtapleyYes WDA*foras in R. E)Remodeling
aw capeclb•{No wakae•'wmp.inasaaca l
l.Qlaatahaoeowmadaiataaam4aWM No warixm'comp.imtasctcem9uicatlt 100suildi9. nsoA
4.❑t am s bomcow•av and W$U Lehfrint ca=Mn m eaednen dl weds m aw mapaty. t will 10 Q$udldiag 8tiditiOA
cou"em an Oram sole 11.0 MecWcW repand or additions
pWrictm wilb no emob"m it[]Plumbing repairs or additions
5.Qlamatewaalcaguvaaraadlban hhWthe 06400badmKMduntlxanacbkl4acu 13.Q RootrepaiN
Thew=b•saaoaamneuroimploymsMud havaavdwa'cam innaauaax
6.Q we am a cmpmadde40 In AM=bave oxamieed1*006SMet8reaeCoa pa eati4c 74.00titer
" 132,§l(4)ard wa havemamPloWaa•pec wodcm5'awap.ioaanoca nqucad.]
`AayapplsWt thatcbcekshox at uton affix fin outthp saetionbabwaeowiva�eir wotkax• an PoUcl'iafmauaiau.
t aamoawaat who submit da afflvh WStaft diowedaiq as wartuddma kite attdocatfta=mass sataab a»awdstbvit iadi"*4 sorb.
;cun"aaathat cbt*dist box mat*Uwlwdm addidoasl aWmtslawina the ewaa oft o m64MMW=AW8=alatbaw mt*Am udties have
ai4,kyna. raw sub4am* M have a@ign that'maapmvide tbair urorYas'tartgn poll�y anmha. __ _—_ _.
Jam as emptayer,rhrntspravtdfagarorksaa'eOmpeNaattonkrsuraaarjwmJ employees Bdowisfhepoikyandjobske
tajprmmdau.
Inauraoee Company Name: AA.IAJ '7
Policy#or Self-ins.Lic.#: � ^�]� '� 1 tKrJ�f " � expirabon Date:��L�
Job Site Address, City/Swiziip.
Attach a copy of the workers'compeosadan policy deciarattaa page(sbawiog tbcpoffey aomber and expiraffon deft),
Failure to secure coverage as required unda MOL a 152,§25A is a akninal violation ptwisbable by a fine up to$1,500.00
and/or one-year imp'icotmreot,as well as civil penalties m the form of a STOP WORK ORDER and a tie of up to$250.00 a
day against the violator.A copy ofthis statenwat may be forwarded to the Office of htveatigariooa Of$tie DIA for iamtrarrca
coverage verification
I do hereby cerew the skier a ry thrQ rhe iajamadan provided abo it true amd carred
F
1e[asaont L Ito nor ttrke in AW area,to be eampksed by o y or cola ofJfciat.or Town-, Perdu!ulnae p
g Authority(circle one)r
ard of Baaltb 2.Building Department 3.City/Town Clerk d.Electrical Inspector 5.Plumbing Inspector
er
Contact Person: Phone k:
06/18/2016 13: 19 401-647-7067
SUGRUE & ASSOC #4236 P. 008/008
QW(WSAMK 117�4'1J4�11�i1K741.1r7
FAX T149B�6
)AIM 7Ma/�sS71.Aara�
OP
Constructfan Mbt* D&*vagyIAfflW'h*
(required for all demolition and,.renovation worki
in al wakmw with thes6rth edUm of theState MAW Co*,,reo CMIL SOAMULSDOW
and the t oaf MGLoto,S 5a;mi t# EsisWWwhh the
corrditiweOwdo deb*rmWft*am this wo*she5be+disposed of In a proper y lfo nsod
wasfe deMItbMyasdelMeld by M6i.c 327„S 156A.
The debris will be VanspoMW byr
Ld�� '�4i7P into j�C,
(name of hauler)
The debris will be disposed of in;
(name f�of facilityr)
(address of taciNty) (ff/
Signature of applicant
ate
08/16/2916 13: 18 401-647-7067 SUGRUE & ASSOC #4236 P. 004/008
F
!�f Massachusetts-Department of Public Safety
f Board of Building Regulations and Standards
f.`LicenO e: CS-09879 Supervisor
License: CS 06$r8,79`A
bUCHAEL P guo"OUE
72 HARTFORDEMMV-0¢
N SCITUATE RII7028
>'je" Expiration
i
Commissioner 0270i/2017
08/18/2016 13: 18 401-647-7067 SUGRUE 8 ASSOC #4236 P. 001/008
FAX COVER SHEET
SUGRUE Q ASSOCIATES, Inc.
72 Hartford Pike
North Scituate, Rhode Island 02857
Tel: 401-647-3890
Fax: 401-647-7067
Builders-Construction Managers-Engineers
Mike.suarueassociates(&verizon.net
www.maugrue.com
T0: —J" IGrZT
FROM: mimael 5ugrue
SUBJECT. f C
DATE:
NUMBER OF PAGES: (including cover sheet)
REMARKS