B-19-1265 - 0129 BRIDGE STREET - Building Permit The Commonwealth of Mg6MaNhiifSUsA
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Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This.Section For Official Use Only)
1v. Building Permit Number: Date Applied: Building Official:
I SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
i13 R 1 D G c sl--R soc cA 1 0 1 c170 --
,�� No.and Street City/Town Zip Code Name of Building(if applicable)
�) SECTION 2:PROPOSED WORIE.
\ Edition of MA State Code used if New Construction check here❑or check all that apply in the two rows below
Existing Building epair C� Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑JR
Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Of—
fs an Independent Structural Engineering Peer Review required? '/ Yes No I�
Brief l) criptio of Proposed Work: C—PL r���/��7�l1rS OD) 5'[Ep�
L60 u4t&
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION.,ADDITION,Olt
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): r
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) 0 00 /O Oil
Total Area(sq.ft.)and Total Height(ft.) i '310 0 d 0
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 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❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 R4❑
S: Storage S-"1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
[A ❑ IB ❑ [IA ❑ IIB ❑ IIIA ❑ IIIB 711 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Zone Indicate municipal A trench wilof be Licensed Disposal Site
required or trench or specify;5C--&
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ G—
Railroad right-of-w : Hazards to Air Navigation: NIA,.1_I.isl,ori;.!,'.�.,Commission Itevi�.�w,,.Proc"s:
Not Applicable El Is Structure within airport app ach area? Is their review comple d?
or Consent to Build enclosed❑ Yes❑ or I Yes❑ No ;7 '
'SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Constriction: ?A � Occupant Load per Floor:
Does the'building contain an Sprinkler System?:"' =�- Special Stipulations:
. ` 1
tr,
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner ®� '7
Name(Print) GIGS e`�}f /� No.and Street City/To n Zip
Property Owner Contact Information:
KG6r�c2 67/- ,PaL L4 MoR
Title d t_I N Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes l
Name Street Address City/Town Stater 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 6ildin is less than 35,0.00.cu ft.ofenclosed space and or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
t
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
) C-
None of Person Responsible for Construction License No. and Type if Applicable
C*4L� !%l?Pr c G �1�, t A—. O/ O
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS`CONIPENSA11ON INSUR:ANC E 4I F'IDA'FF. 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 is�ance of the building permit.
Is a signed Affidavit submitted with this application? Yes Mr No ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE:::
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
1. Building $ C�. C)(OCR Z
Building Permit Fee=Total Construction Co"st x (Insert here
2.Electrical $ ! D c>d
appropriate municipal factor)_$
3.Plumbing $ 6 0 C,(2
4. Mechanical (I-IVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $
Enclose check payable to
6.Total Cost $
(contact munici ali ty)and wr
ite check number here
SECTION 13:SIGNATURE Of BUILDING PERMIT APPLICANT.
By entering my name below,I hereby attest under the pains and penalties of perjuyy that all of the information contained in this
application is true and accurate to the best of my knowled a and d s din
=' ✓�0 2 fir
Please print nd sign name Title Telephone No. Date
Street Address City/Town State Zip
Nlunicipal Inspector to fill out this section upon application approval: _/(q
Name Date
CITY OF SALEK MASSAQRUSEM
BUILDING DEPARTMENP
120 WASHINGTON STREET,31D FLOOR
11!L.(978)745-9595
FAX(978)74L19846
KBEERLEY DRISCOLL
MAYOR THOMAS STYMME
DIRECTOR OF PUBLIC PROPERTY/BummiG OMMSSIONER
Construction Debris Disposal Affidavit
(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,S54; 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:
DagUr--
(name of facility)
(address of facility)
i ature of applicant
/0//?/�Ul
(today's date)
CITY OF S.,UEIN4 I LkSSACHUSETTS
BL1tn1NG DEPAR-n..ILNT
120 WASHINGTON STREET,32D FLOOR
'lid TEL (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
,MAYOR THOMAs ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUMDLNG COMMMIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name BusinessiOr nizatiorvindividua) :
Address: R 0C& ,t 4- Iti1` /f' of Oo,
City/State/Zip:a/2-1 GH !MA- 41`I0!2, Phone#: tag 3 g
Are you as employer?Check the appropriate box: Type of project(required):
1.❑ I 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.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. LrJ Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.QkElectrical repairs or additions
3.5a 1 am a homeowner doing all work right of exemption per MGL l I-G2rPlumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 13.❑Other
comp.insurance required.)
•Any applicant that checks box#1 must also fill out the section below showing their worker'compensation policy information,
r I Iomeowne s who submit this affidavit indicating they ate doing all work and then hire outside contractor must submit a new affidavit indicating suck
=Conlawson that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy infomaation.
ION an employer that is providing workers'compensadon insurance for my empoayee& Below is the policy and Job site
information.
lnsurtnce Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 S1,500.00 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. Ile adviwd that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cent u ti the J It alai o f duty that tie information provided above ' true and correct
Sienat car • Date: �J?/�Ot l
P o #:
OJjcial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/1.1cense#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.CitylPown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person:-- Phone#: