B-19-1030 - 0038 1/2 BRIDGE STREET - Building Permit °.The.,Comm_ onwea'lth"of'Massachusetts
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Department of Public Safety ��
Massachusetts State Building Code(780 CMR) A $ �]iy
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J4 Building Permit Application,for any Building..other than aOne-or Two- ii . elling .
(This Section,Fi r Official Us_e Onlyj
Building Permit Number: Date Applied Building Official:
( w. SECTION 1:LOCATION
iL ►mil a L O . a
No.and Street City/Town Zip Code Name of Building(if applicable)
1
Assessors 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 ❑ a ;Addmon l7:: .DemoliCion-b (Please fill'out and`'submit Appendix 2)
Change of Use . I? Change of Occupancy . .0 Other ❑ Specify:
w r; _ YA •
Are building plans and/or.construction documents beingsupplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required?/ es ❑ No ❑
Brief Description of Proposed Work: ,th S Yt 11 Gw "r &-o 1 d v t r x�S�t',Y
Q ii e, !Q 'e I" CL T10
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION;OR
r. CHANGE IN USE OR OCCUPANCY-,
Check here if an Existing Building Investigation andEvaluation is enclosed'(See 780 CUR 34) ❑ •• •• ;'t ✓ '- i
Existing Use.Group(s): Proposed Use Group(s):
SECTI011t4 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❑ 1 B: Business ❑ E: Educational ❑
F. Facto . F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I4.❑ M: Mercantile❑ R: Residential R40` R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S 2❑ ,u: Utility❑ Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIBO IV 1 VA ❑ VB0
SECTION 7:SITE INFORMATION(refer to 780 CMR 105,^3,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❑
Private O or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way*,, Hazards to Air Navigation:c g MA Historic Commission Review Process` Y
Not Applicable❑. Is Structure within airport approach area? 'Is their review completed?
or Consent to Build enclosed D Yes❑ or No❑ ', `
:' .`', G,, Yes❑ No.❑,_
"SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
IRT 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: '
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SECTION 9: PROPERTY OWNER AUTHORIZATION
N e and Address of Propertywner
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Name(Print) No.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: LL
c r kk �rl Sykmmds S r SakW A/ '0_1470
ame Street Address,' - v " ';..City/Town " State ' Zip y '
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 E3.
;
Otherwise provide construction contiol forms see section 107 in the code as required.
10.1 Registered Professional Responsible for Construction Control(the pr6fesslonal coordinating document submittals)
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ctr at_- - JC�Ft'ytar l�a,.1 C 5.0 S'3 7 3.3
Name_ egistr Tel phone No. e-mail address Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor'` l
_Teffir K\oi rk kavA C 6vi+r&J(
Compa4 NamA
Name of Person Responsible for Construction -License No. and Type if Applicable
1 -1 S y moV45 s� S a lfw►. , Vnk o 1470
Street Add ess —City/Town State Zip
1I-7.qO- ZS1 q 3e-f 1Marlt�taw�_ Q cnim
Telephone No.(business) Telephone No. cell e-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 $ 6 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipa/ty)-
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ fj' O Q . 0'0 (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 the best of my knowledge and understanding. 7 /f 7 Z (Q
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Please print and sign name/ Title D f Telephone qo. Date M Q 1,h`f
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Street Addre s City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval: — r 0 0
Name Date
CITY OF S�UEM NLkSSACHLSETI'S
BUILDING DEP ARTNtE►NT
120 WASHINGTON STREET,3w FLOOR
TEL (978)745-9595
FAX(978)740-9846
KI,.,igF U EY DRISCOLL
MAYOR THOMAS ST.PIEM
DIRECTOR OF PUBLIC PROPERTY/BL'IIDLNI G COMfISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information j Please Print Legibly
Name(Busitn-WOrganiration/Individual): J—� rr t r/(�ai t I,,! Q M
Address: / 7 S 0 KJS S 7L
City/State/Zip: Sq.��wl,l Ol77 U Phone #: t' 7-
Are you an employer?Check the appropriate box: 'Type or project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.pk1 am a sole proprietor or partner- listed on the attached sheet.2 ?• ❑Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
workingfor me in an capacity. workers'comp.insurance.
y9. Q Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL i I.Q Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12 B Roof repairs
insurance required.]t employees. [1\.o workers' l3.❑Other
comp. insurance required.]
•Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
?1 kmeowners 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 sheet showing the name of the sub-contractors and their workers'comp.policy information.
1 am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: �- .�i_- City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirstioa date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do hereby certify rr er a pains and penalties of perjury that the information provided above is true and correet
i>n;t are• q q Date: g- /7- Z 0 /j'
Phone
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/I.icense#
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#:
. " = OF $e (]'Tyli
ALEM, MASSACHUSE'I7'S
I BUILDING DEPARTWNT
120 WASF INGTONSTREET,310FLOOR
AL.(978)745-9595 s
KHVIBERLEYDRISGIOLL FAX(978)740-9846
MAYOR THOUM ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING OOW&SSIONER
Construction Debris Disposal Affidavit
p ff davit
(required for all demolition & renovation work
In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris,
and the provisions of MGL c40,554; Building Permit#
. —is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111,S150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
0
(name of facility)
(address of facility)
Sign re of applicant
7- 2. c�/ _
(today's date)