189 LORING AVE - BUILDING INSPECTION (2) �ct F,tCs22 7
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o The Commonwealth Aof pMppachusetts
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VVYY�� Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
r (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official: I
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street addr not available)
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(11)1-A N4 AOA S tkt,z-..n r4� O l9"1 0
-/` 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 Budding'B' Repair❑ Alteration 12" Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 0-
Is an Independent Structural Engineering Peer Review required? '/S Yes ❑ No fd-
Brief DescriptionofProposedWork- St"p tr.,mktoa Wq-ll9 A_,So t rpcl fNjT-b,LL Aja
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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): £-'fY.l-1 C_ Proposed Use Group(s): C ET
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.) - ( �
SECTIONS:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business 9E Educational
F. Facto F-1❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4 H_S❑
I: Inshtutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use 11and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable
IA ❑ IB ❑ IIA ❑ IIB ❑ .ILIA ❑ IHB ❑
- TV El I VA [03 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 2Check if outside Flood Zone Er Indicate municipal M' trench will not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation:
MA Historic Commission Review Process:
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:
AND TD 31 ��
' SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) and Street City/Town Zip
Property Owner Contact Information:
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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)
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
0
Company Na — I $
,N. ��,_I c, s S � --7 -1
Name of Person Responsible foronstruction License No. and Type if Applicable
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Street Address City/T State Zip n
tvo�9l �t dJers .cv
Telephone No. business Telephone No. celle-mail Actress
SECTION 11:WORKERS'COMPENSAIION INSURANCE AFFIDAVIT M.G.L.c.152.§25CL6))
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 ' uance of the building permit
Is a signed Affidavit submitted with this application? Yes the
0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ -2-c> , �o ^ -..
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ (7 1a C appropriate municipal factor)_$
3.Plumbing $ (0 .'j oo
4.Mechanical (HVAC) $ (o rcppp Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ -A-11 t sv-. (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name bel v,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application true an ccu to t the best of my knowledge and understanding.
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Pl ag!"t and gnn We ,, S A Title T�ph�ne7No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le2ibly
Name (Business/Organimtion/Individml): �1 Jc, (ya-t` tto44.56 k,J C
Address: `�> \ —3> o JL
City/State/Zip: M A O(`Q, j Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
LE3 I am a employer with 5 mployees(full and/or part-time).- 7. ❑New construction
2. I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'_comp.insurance required.] 8. Remodeling
3.[:]l am a homeowner doingall work myself o workers'co t 9. ❑Demolition
Ys [N comp.insurance required.]
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition
ensure that all contractors either have workers'compensation insurance or arc sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.EJ Plumbing repairs or additions
5fEl'I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13 ❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance 13.
i
6.❑Weare a corporation and its officers have exorcised 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#I 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 him outside contractors must submit a new affidavit indicating such.
tConuactors that check this box most attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have employees,they most provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: 5�
Policy#or Self-ins. Lie.#: L^' - r)CIO — 20 1 Expiration Date: '� [
Job Site Address: 6*'SMW � l 3'1 vA" txl"re'j 5 } City/State/Zip: S tl-1-e l t /411- 0/9 7 v
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 der the p 'ns and penalties ofperjury that the information providedaboveis true and correct.
Sienature: l�_
Date. � (I
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#• -
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Construction Debris DisposaiAfdn*
(required forall demolition and,.renovation work)'
in accordance wM the sbM edMm of Me State BuB W gods, 7W tai,Secd=111.5 DeM
andtheWvWdmofMGLGjO,S 54,&Aft Pemdt/ is h=W wM the
c"dWon t Wdw debris rewftw from this wwkshelf be deposed of in a properly Rend
waste y as defined by MGL c illy S l5d&
The debris wiU be transported by:
(name of hauler)
The debris will be disposed of in:
(name offadlity)
A-Q S S l t -
(address of fadlity)
Signature of applicant
Date