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Bakers Island building permit application The Commonwealth of Massachusetts Department of Public Safety Massachusetts State BuildingCode 780 ¢ ::Building Permit Application for any Building other than a One- Two-Famil Dwellin Y g (This 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) L' 9 pA O19`l No.and Street'' City/Town Zip Code Name of Building(�f aPP i limbl SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here)Kor check all that apply 1 inthe two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (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 Engineering Peer Review required? Yes ❑ No)< Brief Descrip -o,of Proposed Work- Al Ls-�r.��(y.3.F� S�r o�l�a+l.��lr�ae.,�,� _ _ h 11_.. ... r_{ c.[ .... - SECTION 3:COMPLETE Tlii$SECT N 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 CUR 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.) 1 Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a livable) A: Assembly A-1 0 A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ R Educational ❑ F: Facto F-1❑ F2❑ H Hi Hazard H-1❑ H-2❑ H-3 Q H-4❑ H-5❑ I: Institutional 1-1❑ I-2❑ I-3❑ 1-4❑ M. Mercantile❑ R: Residential R-10 R-2 q R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Cheek as a livable) IAD IB ❑ IIA ❑ IIBl7 IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111A for details on each item) Wafter Supply: Flood Zone Information: Sewage Disposal Tech Permit: Debris Removal• Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A �will not be Licensed Disposal Site❑ Private OPWi or indentify Zone:_ or on sits ALA, n❑ required enclosed❑0 or trench or specify:_ — ++1T""' 11VV''�� Pe Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable PL Is Structure within airport ap ri each area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No Yes❑ No ❑ SECTION&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: S ECTION 9. PROPERTY OWNER AUTHORIZATION rName ddress of Property Owner �n/swa«� _) No.and Street City/Town y Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail add If applicable,the property owner hereby authorizes revd -- Name -- — _ Street Address- — — Ci Town ate Zip reRe e ro r owner's behalf,in all matters relative to work authorized by this buildin Stmit application. SECTION 10:CONSTRUCTION CONTROL(Please fill outAppendiac 2) il, ' ,is leas than 35,OpU cu.It.of enc]osed s.ace and/or not under Construction Cool,then check here El and sid 9echon 10.1 lrred pmfesional R onsible for Construction Control gistrant) Telephone No. e-mail address Registration Number dressCity/TownState Zi P Discipline Expiration Dateral Contractor Name erson Responsible for Construction License No. and Type if Applicable Street Address City/Town - — State Zip Tele hone No.(business) Telephone No.(cell) — — e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c 152. 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'ssuance of the building permit. Is a si ned Affidavit submitted with this application? Yes No p SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$Aft- 1.Building $ p p v 2.Electrical $ Building Permit Fee=Total Construction Cost x_(pert here 3.Plumbing $ appropriate municipal factor)_$ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality} 5.Mechanical (Other) $ 6.Total Cost $ Enclose check payable to ©- C� (contact nun d ality)and write check number here — SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby attest under pains and penalties of perjury application is true and a� the best of owledge and understanding. that of the information contained in this Please print and sign name Title ' 3 �L � ?�Telephone No. Date �11a 'N `r• 1 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Narne Date - zQO �fi � O�H O S ._• - z YSae m Na �.e Y c�cWi�' � a•� V � � 0 ��y e m H 1-4 a m ]£l, Y LOT 47 od � 2 W 10 I'ml AWNU ----- 1 42.79 79.85' 62.58' 'x � Sg Sf U y, N Uf W< N cli Ego FFms k ;� � ro� r. �•m r.N 'B � �1 ago�rss mn CITY OF S.,UZtii, ,jASSACHUSE- TS Bull MG DEPAR'I1LiE.NT 120 W'UH'NGTON STREET.3w Roolt TEL(978)745-9595 KMBERLEY DRISCOLL FAX(978) 740-9W �+IAYOR THOMAS ST.PMAM DIRECTOR OF PI:BLIC PROPERTY/13CUMLVG C01L%11SSl0,NFR 11orkers' Compensation Insurance Atl'idavit; Buitders/Contractors/E A iicant Information Iectricians/Ptumbera Name(ilusinesw(Or ; Please Print Le i gars ra totvindividual); +' u c� Address: Phone#: 3c:L33 q -3 Are you an employer?Check the appropriate 1•❑ I am a employer with box: employees(full and/or s 4 I am a general cohu►r and 1 TYPO of project(required): 2-❑ I am a sok - ) have hired the subcontractors 5• New construction Proprietor or pater listed on rhe Ship and have no e►nployecx attached sheet • 7. Remodeling working for me in any capacity. Tie sub-contractors have [No workers'comp, insuranc 5. workers'comp.i $• 0 Demolition required.] We are a corporation.VW ts 9• ❑Building addition 3 l aryl a homeowner do' °��have exercised their 10.[]Electrical airs or additions Myself rng all work right of exemption per MGL rep[No workers'comp, ! 1 l•❑Plumbing r insurance required.j t , 4( ),and we have no repairs or additions emc. 152 Ployees-[NO workers' 1 1❑Roof repairs Any applicant thatch comp.insurance required.] 13.0 Other txks bent iY l ur must also till out the section below t l Inmrow nos who submit this affidavit indicating ate wing all s+rorkaed g thpr �cote:C�racton that check this tort must a. theis hits:outside� Pol�''ntonnatFoa nached an additiormt sheet sho must submit a now I am air earpleyer that ifProvidln 1V1px the name o[the sub fytyctort and their woe"i afl?davit indicating� infonii inn. X workers eosrtPensatdon Insu �.�"y'"�1l ranee for ray ersplol'eesc Below Is the Insurance Company Nlame: Policy atldM It, Policy#or Self-ins.Lic.#: ` Job Site Address:' - - ~- Expiration Date: Attach a ropy of the workers'com City/State/Zip: �~~� Failure to secure coverage overs a as t?ensatioa policy declaration pegs(showing the Fne u to SI Spe g required under Section 25A of MGL C. 152 policy number and expiration date p 00 and/or one-year imprisonment,as well as civil can lead to the imposition Of up to S250.00 a day against the violator. Ile advised that a copy of this statement may of criminal penalties of a lnveatigatiutts of the D!A for insurance coverage visethatcation. Penalties in the form of a STOP WORK ORDER and a f� y be fo>wttrded to the Office of I do liereby rs at e1 Pains acid Penalt rrfirty Mat the urjornrat/an provided abot+a if trrte and come — c; 13 a z3 3 3 si3 Dare: L Or irc,s!aar only. Do not write in thlr wee,to ire cvrttpl by city,or City or Town: town Official Issuing Authority(circle one): -_ Permit/llccnse#- _ I.Board of Health 2.Building ocpartm 6.Other 'at 3.City/Town Clerk 4.Electrical I - - -nspector 5. Plumbing Inspector Contact Person: - - _ Phone#: — I I I jI j l l I i ! I � ; I � ; 1 ! ! iI rvc � _ � � II - , _ � - � - I ! � � I �� i i l -► i I j l j I �I i - I ` j � I I i � ► + --f ` ;lam I _P i ��. �j ' I `s - { � i i � t - s I { •--1- ' � i I I � - I i - i I i - I - 1-_ ► 1 I � ! If II yI � III ; I � Id ij i - �I'. i i I ' I I i r I � - it ( I 1 ii ; � j iII ! I I Ij . l ! � � ► it i - I � il ili Ilf , t I rr I I i i ! i 1 1 ! 1 1 I .. i