B-19-915 - 0061 BRIDGE - Building Permit The Commonwealth'of Massachusetts
Department of Public Safety AUG Massachusetts State Building Code(780 CMR) 7 _ 2
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)-
Budding Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations forwhich`a street address is•not available).
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❑or ch all that apply in the two rows below
l PP Y
(� Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ Demolition (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: .h A' °
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 Description of Proposed Work:
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING.RENOVATION,ADDITION,OR
j CHANGE IN USE OR OCCUPANCY -A�
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
,Existing Use Group(s): Proposed Use Group(s): j J k 1
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: Assenibly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business E: Educational ❑
F: Factory F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institukional I-1❑ I-2❑ I-3❑ 14❑ lVI: Mercantile❑ R: Residential 9-113 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)
IA IB ❑ HA IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7-.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public A trench will not be Licensed Disposal Site❑❑ Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
-.
Railroad right-of-way: Hazards to Air Navigation: ;),I,i\.L.'I,i;l; ri;_4.isi,i_in Commission kovii._ty.,Proce s:
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: Occupant Load per Floor:
Does the Building contain an Sprinkler System?: '- ` Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
/"/'A✓ISi,s!!� 6 Ellit/t j (°,d� /`rY�M ��: C.al luv1 /VIQ �lLv ��
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
To►n P�10,LA�W-`j yto mer g-t mAtncwRr A4&--
Name I 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. r
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(if buildin is less than 35,000.cu.ft:of enclosed space and or not under.Construction Control'then check here 13, skip 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
10.2 General Contractor
J'i_P C,6vn&j:yge f;opt serlli c-- LLB
Company Name
Talr J�210.✓\L43 - Z If LI 2-
Name of Person Responsible for tonstruction License No. and Type if Applicable
Street Address City/Town State Zip
o i QW S V-
Telephone No. business hone No. cell a-maid address
SECTION 11:1�'C")IKERS`COMPENSATION 11VSUR:INC:1s Af{Fll:)r\�rr. 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 .
Rem Estimated Costs:(Labor
and Materials) Tot-1 Construction Cost(from Item 6)_$
1.Building $ - Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
d.Mechanical (EIVAC) $ Note:Minimum fee=$ (contact municipality)
5.klechanicail Other $ Enclose check payable to
6.Total Cost $ ( municipality)contact munici ali and write check number here
ty
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 edge and understanding.
Please runt and sign name Title Telephone No. Date
v",<r n Jl cCereer M o f q
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: 4W Agg"
Name Date
i
C[TY OF SALE
M, MASSACHUSE 7T5
BUILDING DEPARTSMr4r
120 WASHINGTONSTREET,3'DFLo oR
TEL(978)745-9595
K. v1BERLEYDRISCX)L , FAX(978)740-9846
MAYOR THOMAS STAERRE
DIRECTOR OF PUBI.ICPROPERTY/BUILDING 0C)MUSSI011ER
Construction Debris Di •
sposa/Affidavit
(required for all demolition & renovation
work)
In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 De
and the provisions of MGL c40,554;Building Permit# bras,
s 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:
(name of facility)
(address of facility)
Signat of applicant
(today's date)
' CITY OF &M-EINI, N xsSACHUSETTS `
:, i • BUILDING DEPARTNELNT
` 120 WASHINGTON STREET,3w FLOOR
TEL (978)745-9595
FAX(978)740-9846
KI,.\iBFYaEY DIUSCOLL
MAY01L THOMAS ST.PMRRE
DIRECTOR OF PUBLIC PROPERTY/BU DLNG CO\L\aSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
An»lipint Information Please Print Legibly
Name(1lusin,-, Organization/Individual): alp 6Qr1gtrVC+bh cwy," PLC
Address- 6-r.
12
City/State/Zip: /U�WLO-Sw-e N&N US44 Phone #:
Are you 3+n employer?Check the appropriate box: Type of project(required):
I.VI
'a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
loyees(full and/or part-time).' have hired the sub-contractors.2. a sole proprietor or partner- listed on the attached sheet. ❑Remodeling
ship and have no employees These sub-contractors have 8. 91!iemolition
working for me in any capacity. workers'comp.insurance. 9, 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.❑ I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions
myspif.(No workers'comp. C. 152,91(4).and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.❑Other
comp. insurance required.] tOI`
Any appliiWit that chutes box#1 must also fill uut the section below showing their workers'compensation policy information.
I Gxneuwrxxi who submit this affidavit indicating they ace doing all work and then hire outside contractors must submit a new affidavit indicating such.
=CuntrxKon tUwt check this box must attached ar additional sheet showing the name of the sub contractors and their workers'comp,polity information.
1 am an employer that is providing►vorkers'ronipensation insurance for my employees. Below Is the policy and fob site
informadour.
Insurance Company Name: W C ,pl,g)gYl
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a,c�opy 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 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. lie 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 under the pains and penalties of perjury that the information provided above is true and correct
. i en:t u • Date:
OJjcial,use only. Do not write in this area,to be completed by city or town official -
City or`town: Permit/ii.icense# __ _
Issuing Authority(circle one):
I. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Otheir ...__
Contace Person: Phone#: