15 SUMMER ST - BUILDING INSPECTION r
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Department of Public Safety
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^ t Building Permit Application for any Building othAMtllaOne-or Two-Family Dwelling
(This.Section For Official Use Only) _
1 Budding Permit Number: Date.Applied: Building.Official:
' ^ SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a streetaddress is not available)
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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 O or check all that apply in the two rows below
Existing in
Wj Repair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use Cl I Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 1"
Is an Independent Structural Engineering Peer Review required? Yes 13 No m�
1
Brief Description of Proposed Work: u"I)EL_ Nd"A 4604, )e �z_
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.) �IfZ .21Z
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1 13A-2❑ Nightclub ❑ A-3 E3A-1❑ A-5❑ B: Business 13E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional 1.1 Cl I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ 5-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 13 13 (3 IIA 13 111) 13 1 IIIA C3 II1B ❑ 1 IVO 1 VA 13 VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Wafer Supply: Flood Zone Information: Sewage Disposal:
Trench Permit. Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench w4 not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system 13required Vor trench or specify:E0.[L Zpermit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA I li,toric Cmmiui_sion W,w,,_Pn._c_s:
Not Applicable❑ Is Structure within airport approach area? Is.tbeir review completed?
or Consent to Budd enclosed❑ 1 Yes❑ or No❑ I 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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner 1
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicablethe property owner hereby uthorizes
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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 buildin is less than 35,000 cu.ft.of enclosed space and/or or not under Construction Control then check here O and ski 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
1__0.22 General Contractor - -
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Company Name
Nae of Person Responsible for Construction License No. and Type if pplicable
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Street AddressCity/Town i State Zip
Telephone No. business Tele hone No. cell e-mail address
SECTION 11:1\'ORKERS'COMPENSA'I'ION INSURANCJi.N�Flbi\VPI' 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 0 No 0
SECTION I2:.CONSTRUCTIONCOSTS.AND PERMIT FEE -
Item Estimated Costs:(Labor OOD
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ 060 Building Permit Fee=Total Construction Cost x f I (Insert here
2.Electrical $ DOO appropriate municipal factor)=$
3. Plumbing $ Poo
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ ODD (contact municipality)and write check number here -
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I h reby att t under the pains and penalties of perjury that all of the information contained in this
application is true and accurate t the be of my knowledge.and understanding.
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Please�pprint and sign name - Title Telephone No. Date
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Street Address City/Town State Zip
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Municipal Inspector to fill out this section upon application approval:
Name Date
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The Commonwealth ofMassachuseta
Department ofln&s1rial.4eddents
1 Congress Swey Smile 100
UVBoston,M.402114-2017
www mastgov/dia
Workers'Compensation Insurance Affidavit-Builders/Contractors/Electricians/Plumbers.
TO BE FILED MON THE PERMTTING AUTHORITY.
Applicant Jbdormation Please Phot JAdbly
Name(Saamess/orgprirasonlmmvausi):. L. wL_ R,�tJ�boAt. LLQ .
Address: i>5 G O nitseESS __
City/state/Zip: MA- O I')?. Phone#:
Are you ao employer?Check the appropriate box' L(kh
project(1vouired):
employer wa 2 -evpbyees(full end/mpmt-time)•' - eW� CollF;buct_ion
I.Qlam e,sok propriuororparmershry and have oo empkryaee workg formem S. �"'�""""B
ooY eapeeity.(No wmketr'eomD•in6osoce reguoed]
3.p I am a homCowner doing as work my 9..[No wad m'Comp.imus oke 10loin d.J t molition .
4.tjI m a homeov cod wit be huiog eonaacm+s to conduct ill work m my property. l well 7tlmg additiba.
errame that all conhaaors either have workers'compemadon IDsmance or are sole ectrical repairs or additions
proprietorsw'�n° °? mbingiepsusoredditibns
5.01are agenualcon>rsctor and rhave hued the subtontraetme listed m the anached shat of
7bexaob-contrastoahave caployeesand bevewmketa comp. •MACCt repe>iS
6.0 we are a corporation and its office`;have exercised thekright of memptiod per MGL c. 1er
15Z 11(4),and we bove no employees.[No worriers'camp:ia9maom«gomed.) .
eAnyappliiantihatebeckebmin mustalso"6aora toe sectim 6ebwe6o`wnrg their workgs eamptaeapon pokey mf®etion.
t Homeowners wbo submit ibisat5davitihdimbng they,are doing as work and ism hive araide contractors must audit a o affidavit mdieetmg such
lCoatracters tom cbeck this tis¢must art whedan additional Awshowmg tla name of au sub•ca�as and state akGlier a noT tboae eo6ties have
employees. Ifthe eubcontractms have employees,they,noun provide the?-workers'camppolacynomber
l am an amployer that isproviding*vr*ors'Coinpemagon insuraaee for my emWpyeeL Below is thepoj(ry andfohAti-
information.
Insurance Company
Policy#or Self-ins.I.ic.#: - motion Date:
Job SitcAddress: IS cN)M i,46 —El t �tge�,vnPC– City/Stote/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage uired der MGT,c. 152,§25A is a tavnina]violation punishable by a fine up to$1,500.00
and/or onayear' as well civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a
day against the vin A copy of statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage vaificati
I do hereby certify un e p s and penafties ofpeduiy that the information provided above is tree and correct
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Offwial use only. Do am write in this area,to he completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/ own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
t
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
cuter 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. hinted Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other then 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 Departrnent 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 roust submit multiple pennit/licenn 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 pemmit 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
CITY OF SALSA ALISSAC HL SE M
BuuDnacDEPAR7mmT
120 WASHING7UNSTREET,3IDFioOR
7kL(978)7959595.
FAx(978)790-9846
Snv18ERiEYDRISODIL
MAYOR 7)1OA1ASSTJMW
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Construction Debris Disposa/Affidavit
(required for all demolition and,.renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL coo, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
�QtG �- 1�kSPbSR�L
(name of hauler)
The debris will be disposed of in:
zersco
(name of facility)
(address of facility)
Signat re of applicant
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Date