29 LEACH ST - BUILDING INSPECTION e�
r,.
The Commonwealth of Massachusetts"l'tCIlDN14L'S�€R1 _ v
��c y� Department of Public Safety }
VJIU Massachusetts State Building Code (780 Cb1R) 1916 SEP I
QBuilding Permit Application for any Building other than a One-or Two=Family D 3e1Gdg 4
I (Chis 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)
a ci ke�ek 51—
No. and Street City/'rows Zip Code Name of Building(if applicable)
N 4-( 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 Repair Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix"I)
Change of Use ❑ Change of Occupancy ❑ 1 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? //0 / Yes ❑ No
Brief Description of Proposed Work: tM V;K 1CIJ4,lZ 4- 1/L
Z O Gc>{YL!>l
SECTION 3:COMPLETE THIS 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.)
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❑ I B: Business ❑ E: Educational ❑
F: Factor P-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ FI-4❑ H-5 ❑
I: Institutional 1-1 ❑ 1-2❑ 1-3 ❑ F4❑ M: Mercantile❑ R: Residential R=1❑ 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 IB ❑ IIA ❑ 1113 El IIIA ❑ IIIB ❑ IV 1 VA FI 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 ❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required ❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed Cl
Railroad right-of-way: Hazards to Air Navigation: x1A ITistoric Cocnmissum R_tviewProcesg:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Yes ❑ or No❑ Yes ❑ No ❑
SECTION 8: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:
-1 12'l0
SST T-D c,-c-.
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Ow
C�-e90P?q WCAa Puu
Name(Print) y No. and Street City/Town Zip
Property Owner Contact Information:
3
a7-- C 75
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 ermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(Il'building is less than 35,000 cu. ft.of enclosed s ace and/or not under Construction Control then check here O 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
fid?K_ 6 e Vn
compoan e
CS - 0762 �LG
Name of Person Responsifle for Construction License No. and Type if Applicable
'Wice�2�e ArSa lerM 0 pZ 6
Street Address j City/Town State Zip
6/7 -SyU �,33
Telephone No. (business) Telephone No. cell e-mail address
SECTION 11: WORKERS'CO%ADENSA"CION IN.LUPANCE 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 issuance of the building permit.
Is a signed Affidavit submitted with this application? - Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from item 6)_$
1. Budding $ a GOD Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ /, 000 appropriate municipal factor)_$
3. Plumbing $ 0
d. N'lechanical (HVAC) $ Note: Minimum fee=$ (contact municipality) y�
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ 3 00 d (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 anis accurate to the best of I knowt cl e a !!� ]erstanding.
G"!QO2 Vy�«slu . _- �� les��l{tom G!7 �G �s �r
a n
Please �nnt and sign ne "Title Telephone No. Dale
� y ker, S — 1a/_k� &9 ev
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name v
The CommonwepNh ofMassachuseW
Depotwent ofLvdwiiaAcc dents
I CoWs%xsSftw4 SrriteIN
Bostory M4 02114-1017
wwntmarsgov/dfa
WiWorken'Compensation Insurance Affidavit Builders/Coninctora/Eledriclans/Plumbera.
TO BE FRM WITH THE PF3UIIT77NGAWHOWIT
FINN P" 14MY
Nam(Basmess!Ospnization&Aviduel):
Address: ��lJ l�/�n� E /
City/Stat 44F.
j kLe��,t,7 Phone#: �
Are yes ao empbryer?AeSk the ayprW*t tray:
l.pIsmaemPloyorcod iupW=(Taitantvmpat=time 7. New construction
2.�lam 4wk proprieforapvpxahry asdlmve oo eagtdoxpp wow forme is g, INRumodeft
sarevamty.No vaatme cane. regniteal
3.plamaLomeoavado®g,a amkmyaex.[No wmlrma'emg�.;osiueace"q b d.)t 9: pDemolidon'
_ lop Buddmg'ailftoa.
4.p Ism a Lomeowaaaod�be liviu8 enbmactors k aaomalen avd:®my popaty. l wL
eav.e�tolleam�eaase;e�aavewmte�s compeamminao�ceasemk H-pBlechicalrepairs oradditiens.,
p°yq'etp"wxa p°myr°y"a
12. ] otiddltiens
S.plamageaenlammaoiaudlLeveLiiedlfiesubeoaeaetaatietadammeattnr3edaimst 13. Roof
1Lsae.aubtonnpaaaelaveempbyea and Leve wod:en'mp. !.T=:: . " mv _
6.pWeaa,acolpmationiadi$o8isashave eaesoitedauarisk01'eu�tibeP"MQ,a 14.pOtbec
4),aad we haeememplbyw:pqo wmlme'loa¢mamaoa rogoied.) - "
cheeft baxbl mug"fiR inn fin Sectim beb%,4owfoatSm vmd eD eongmo pWiry
t Homeownvs who aubini!ads afLd"anttudimlmg Poey:�t doiogaa aodiadd®ra titre oi�4ide anloM smart'soLmkaaewa$davit;odittlkg eucL:
rConaacma do cheek oris tion mug anichada edditiandshadab6mmg the nate ofare sub-r ®s and state.wheaQea am flmeetiia,have
eaQtlayea•.Ifthe"subc4oiYp A4egeemPl?Yeua,tbef.'ml!#PowdstLe?-x'mlaesS"romP•1mLeyaogd!v. .:. ::... . :.
jam anassyAeeTAWIspranddingWrkds'eoaipeataglxhrsanoxCefori4ea �B BelaMrrtbepOliryaa9d/ r'Bi/L -
Lifoimallod.
Insurance Company Name:
Policy#or Self-ins.Lic.M Expiration Date:
Job Site Address: CRY/SM572p: -
Attach a copy of the workers'compensation policy declaration page(showing the policy nemher and expiration date).
Failure to secure coverage as iequired under MGL"c. 152,¢25A is a aiaizzal violatim punishable by a fine up In 51,500.00
and/or one-year impviso�t,as well as civil peoallies in the form 61'a STOP WORK ORDER and a fine of up to$250.00 a
day against die viohaW.A copy of this statement may be fmwwded to the Office oflnveatipticus.of the DIA for ft=T ntie
coverage verification: "
1dohvrhycff*�AmjerJkep s of , that the informadod provided above is due and eortrad
Phone M
O(/ieial we only. Do aur tulle in this arca,to be cosyrlded by dry or town o fPeial.
City or Tows: PermWLieanse#
Issuing Authority(circle one):
1.Board of Health I Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined ss"...every person in the service of another under any contract ofhire,
express or implied,oral or writteA"
An employer is defined as"an individual,Partnership,association,corporation or other legal entity,or my two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of in individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the issuance
requirements of this chapter have been presented to the wntractmg authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checldng the boxes that apply to your situation and,if
necessary,supply sub ceortractoi(a)name(s),addresses)and phone numb a)slang with their certi5cea(s)of
insurance. United Liability CmMpmies(LLQ or Limited Liability Partnerships(I.p.P)with no employees other them the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sore to sign and date the affidavIL The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Deportment of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
conryensation policy,please call the Department at the number listed below. Self-insmed'compmies should enter their
self-insurance license number on the appropriate lime.
City or Town OHieials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be awe to fill in the permit/icense number which will be used as a reference number. In addition,an applicant
that must submit multiple permst/license applications in any given yes,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town) 'A copy ofthe affidavit that has been officially damped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out as&
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017,
Tel.#617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CY7 YOFSAL A MASSAMSE7T
BUZDMDEPAXnWff
iM WA=VMSnWT,3'DRDM
skr. »s-mss.
K>AMBRIBYL FAX 7*49�/6
MASK MSDIAtS7•.PUM
DmK3cacFptmxpxapmylBuumccammacmm
Construction Debris DisposaiAfdwit
(required for•all demolition and,.renovation work)
In aoaordance with the sixth edition of the State BuIMIng Code, 780 dNR, Section 111.5 Debris
and the provisions of MGL c00,S 54; Bufidhlg Permit B Is issued with the
condithm that the debris resuid►t from this work shell be disposed of in a properly license
waste deposit facility as defined by MGL c 111,S 156A.
The debris will be transported b
Gywt�,
(name of hauler)
The debris willbedisposed of in: �
(name of facillty)
JCisv02-( S._
(address of facility)
Signa Of IqlPt
Date
Thank you for your prompt attention.
Greg and Sue Maitland
1�� �b l d 4
\1
The Commonwealth of Massachuseus
Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,AL4 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 Leeibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
pe of project(required):
1.n I am a employer with employees(full and/or part-time)."
❑New construction
2.Q I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.] ❑Remodeling
I E]I am a homeowner doing all work myself[No workers'comp.insurance required.]/ ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on m
]F7.
Building addition
Y Property. I willensure that all contractors either have workers'compensation insurance or are sole E]Electrical repairs or additionsproprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub<oaracmrs listed on the attached Sheet.These sub-contractors have employees and have workers'comp.imannee.t 13.❑Roof repairs
6.E]We sre a corporation and its officers have exercised their right of exemption per MGL c. 14.Q 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 shout showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
lam an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
^� information.
X Insurance Company Nam4/
olicy#or Self-ins.Lic.#: Expiration Date: '`S�/%J�0 �-6
Job Site Address: City/State/Zip:
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 cer[ijy under the pains and penahies ofperjury that the information provided above is true and correct.
Siatature: - Date:
Phone M
EOfficial only. Do not write in this area,to be completed bycity or town official
n: Permit/License#
hority(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia