7 LORING HILLS AVE - BUILDING INSPECTION (003) The Commonwealth of Massae .,.W 9¢
Department of Public Safety
Massachusetts State Building Code(780
amilCCMR)„ o "; 3
lf Building Permit Application for any Building other than cath - y Dwelling
_ (This Section For Official Use Only)
'^ Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION
O✓t Gc i e UCZr !' /�c
No.and Street City/Town Zip Code Name of Building(if applicable)
iAssessors Map# Block#and/or Lot #
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 ❑ Addition 11Demolition ❑ (Please fill out and submit Appendix 2)
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? 1 Yes ❑ No Er
Brief Description of Propose Work: �-`� V Dk a -(�k.'f- J✓5aP �S -
P�(t t �,// e 4 i, e e 1� ,L/1n
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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5 11I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M.
Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA [3 IIIB ❑ 1 IV ❑ I VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Hood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public ❑ Check if outside Flood Zone❑ Indicate municipal❑ A 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:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print)TI —F No.and Street City/Town Zip
Property Owner Contact Information:
'149trcfS 04mak-co"V_ 17q 97(99 -
Title
97(9 -
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
t-, F0 F0 qLowel�5� eeLw 0t 6_0
Name Street Address City/Town State Zip
to apply for and 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 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑.
Otherwise provide construction control forms see section 107 in the code as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordinating document submittals)
Name(Re,istrant) J/ Teleph(Of�lee No
e-mail add� D Registration Number
/ GLI S P Y
Street Address City/Town—� State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. celle-mail address
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 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.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor) _$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact
-RalitY)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ �� r V (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 and accurate to thebestof In knowledge and understanding.
Please print and sign na Title Telephone No. Date
U� L9 Weld
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval:
Name Date
Appendix 1
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. 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 Incom tete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
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.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Cit /Town State Zip Discipline Expiration Date
it
Name(Registrant) Telephone No. . e-mail address Registration Number
Street Address Ci /Town State Zi
Discipline Expiration Date
Please follow this link for construction control forms to be used by Registered Design Professionals.
Appendix 2
(For total demolition only)
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit application.
The building permit applicant attests under the pains and penalties of perjury that the following is
true and accurate.
Property Location
No. and Street City /Town Zip Name of Building (if applicable)
Assessors Map # Block # and/or Lot #
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
i
\ The Commonwealth ofMassaehusetts
Department of IndustrialAccidents
NEAT 21 � 1 Congress Street,Suite 100
Boston,MA 0211 4-2 01 7
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Eleetridans/Plumbers.
TO BE FILED WITH THE PERbM`MG AUTHORri'Y.
Aonlicant Information �- Please Print Legibly
Name (Business/Organization/Individual): t"Val fS
Address: 416
City/State/Zip: �e.c Zd w D L`f 60 Phone#: 9/�S`
Are you an employer?Check the appropriate bux:
Type of project(required):
l.pj'l"� a employer with—!L51—ploy—(M and/or part-time).• 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working forme in S• ❑Remodeling
any capacity.[No workers'comp.-required.]
3.E]I am a homeowner doing all work myself.[No workers'comp.insurance required]t 9. [1 Demolition
10E]Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
grime that all contractors either have workers'compensation insmance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.E]Plumbing repairs or additions
5.❑I am a general contractor and I have hind the sub-contractors listed on the attached sheet
These subcontractors have employees and have workers'comp.insmance.t 13.❑Roof rep alis
6.❑Weare a corporation and its officers have exercised their right of exemption per MGL c. 14.
152,§1(4),and we have no employees.[No workers'ramp,insurance required]
-Any applicant that checks box#1 must also 511 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
tContractors that check this box must attached an additronal sheett showing the name of the subcontractors 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 poltry and job site
information. - ��,/
- Insurance Company Name: 2V r-i L(.r_ - /fr L'-('P ✓I�C4LL4 .1✓LS C-0 r
Policy#or Self-ins.Lic.#: LA-)e - S�b- U_ 7 L3 5-- 07 Expiration Date: j / o f (.!�
Job Site Address: 0fl k S �r` /5 f/ (f City/State/Zip: S g./�yct / A/V-z91 9/-cg
Attach a copy of the workers' enation 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
under the p/airs and es ofperjury that the information provided above is true and carred
Signature• �,t� Gt//` Date: d l,�
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#:
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-contractors)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 511 in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/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.
P P
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