B-19-1023 - 0077 BRIDGE - Building Permit r
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iH s ` ist_
The Commonwealth of Massachusetts
De artme , f 1' afe
p 'h Massachusetts Sta i g e(.
1, Building Permit Application for any Building other than a One-or Two-Family Dwelling
' (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)
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 check all that apply in the two rows below
Existing Building❑ Repaii[3 Alteration O•,_, 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 require i? Yes ❑ No ❑
Brief Descriptio of Proposed Work: �/ � A/
T C .
b-j
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.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ 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❑
1: Institutional I-1❑ I-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)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ I 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 t1or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: �I\I Liitin i�:Cununivsion K»iuw Proc"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 Addr,ss of rope ty ner
Name(Print) No.and Street 61 City/Town Zip ,
Property Owner Contact Information: J-G�' 9r-L_ -X6 7 1
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill outAppendix 2) .;
If buildin is less than 35,000,cu.ft:of enclosed space and or not tinder Construction Control'theit check here❑andski Section 10.1
10.1 Re istered Professional Responsible for Construction Control
Name I Registrants Telephone No. e-mail address Registration Number
Street Address ity/Town State Zip Discipline Expiration Date
10.2 General Contractor
b
Company Mime
Name of Person lResponsible for Construction License and Type if Applicable
Street Address ity/ own State Zip
Telephone No. business Telephone No. cell -e-mail address
SECTION 11:I-VORKER5 CS)nIP,A r ON INSURANCi::v.rrl:��wrl` 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 $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
1. Mechanical (EIVAC) $ Note:Minunum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ Q.CI& (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 vledge and understanding.
Please pAnt anff sign name / Title Telephone No. Date
L
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
' R e` f
SALE
QTY OF
� � 1V� MASSAC�-IUSE'I7'S
BUILDING DEPARIT1ENT
120 WAsI fNGTONSTREET,3RDFLOOR
'AL(978)745-9595
KAMERLEYDRISOOLL FAX(978)740-9846
MAYOR THOMAS STAERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING OOWUSSIOMR
Construction Debris Disposal Affidavit
(required for al/ 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:
2
(name of facility)
l 0
(address of facility)
Sig at of applicant
(today's da e)
CITY OF S.,U EINI, INLxSSACHUSETTS
B1:UMMIG DEPART-MIUNT
120 W ASHINGTON STREET,r FLOOR
Tom.. (978) 745-9595
F
KIMBERLEY DRISCOLL FAX(978) 740-9846
NMAYOR T Hoxu ST.PIERRB
DIRECTOR OF PUBLIC PROPER-rY/BUUZ1 SIG COMMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 1^ Please Print Leaib11
Na Me(Bush>`•ssiOrganization/individual); �l p-t EGn lG
7
Address:
City/State/Zip: 4 G� Phone 7
Are you an employer?Check the appropriate box:
am a em to er with 4. TYPe of Project(required):Ilp y ❑ 1 am a general contractor and 1
6, ❑New construction
e ployees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.: ?• Q<Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp,insurance.
[No workers'comp. insurance 5. ❑ We are a corporation and its 9 ❑Building addition
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4).and we have no I2. Roof repairs
insurance required.] employees. [No workers
'Any appliwM that checks comp. insurance required.] 13. Othechecks box t/l must also fill out the section below showing their workers,compensation policy in
t t t(xneuwnus who submit this affidavit indicating they arc doing all work and then hire outside contractors must sub nit a new.allfdavit indicating such
=Contractor that cheek tbis box must attached an additional r'hael showing the name.of the sub-contractors and their workers'comp,policy information,
I am an employer that Is providing workers'compensation insurance for my employees: Below Is the policy apdJob site
information.
Insurance Company dame:_ I►'�v✓1 e L�//t,c ti
Policy#or Self-ins.Lie. 151 P Vfj
1 � Expiration Date:
Job Site Address: - 77 6 rid,e— 3)
— 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
tine 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. Ile adviwd that a copy of this statement may be forwarded to the Office of
Investigalions of the DIA for insurance cover verification.
l do hereby certify under alns rd puralt/es of perjury7hat the information provided above is rrrea nd correrL
�n•t u Dat /
Phone#:
Fuse only. Do not write in this area,to be completed by city or town official
Town: Permit/1.1cense#
Issuing Authority(circle one):
I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#•
Cominonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Const`+>,%A10,Lbo�rvisor
CS-087225 {L E�Lpires:06/0812021
JERRY SCOP)OETTIJO -
463 LOWELLST c
LYNNFIELD M9 01940 - C '+
> y
Commissioner
� ,,,s�-� �,,. //:�j • ����„,::�, � --tea+ * ..,
ys Office of Cons mer Affairs&Business,Regulation r l w i
` HOME IMPROVEMENT CONTRACTOR c� �• .rr r
TYPE'-Individual Y
ir glstratfa h Ez p ation,
408/28Y2WO I,
3` ,JERKY SCOPPETTt�~
r JERRYSCOPPE O'L a` \"> ��:
z ,,4M LOW
ELL ST
'xLYNNFIELD,MA:01940. si
f J L Undersecretary
; �.1�. ,�` r9Py1� '�yA.0 -5e-�'�cC".«o^'„s. �•,�'2'"•'" �r&E•.tt�',�., 4
ell ill 17'
a �i CJ `�PpIYU�YROI7.RI1P�O�i�!2LG!ckk� !•� s -;QVI"
;'. Office of ConsumerAffairs&Business Regutatlor { `.
HOME IMPROVEMENT CONTRACTOR.: *1�• 1.
Individual
Registr' fbE iration� `
162428 08/28(2020 = }
JERRYSCOPP
F .
}�, JERRY"SCOPPE
463,LOWELL8T
LYNNFIELD MA 01940 l '
Undersecretary s
v
Commonwealth of Massachusetts
.® Division of Professional Licensure
Board of Building Regulations and Standards
Cons,kr�t-*A%bp�rvisor
�t
CS-087225 Eicpires:06/08/2021
JERRY SCOFf�E'fTUOL
463 LOWEL T
LYNNFIELp M� 01940 r +.
/6`
t x
Commissioner
f
lilxtlA Cons
• r
tructon Control: Document
1 i To be stxbihittecl with the biiilciing pefmit applic t .h by 1
' d `Registered`DesigA Professional r
w I
v4 for zvorlc per the ixnt6i edifilon of'the 1
t Massacht'setts State`But el rgrCMe, 780;CMR, Section:107
Y
i Title ., �.. � -Itm -LPD t .
Project "" ..
r '
$ Property`Addue$s: 'l64t'rbjcct; Check:one or both as applicable; f New cons ruction I' C clsting Construction
Project doscriptian:
I •
•
r �
IA046605KYA.;Registration Number {Cap Expiration date: 6 m a '
r r cg sler era ebib�n`�aru ssioncil, and<l have;prepared or directly supervised the preparation of all design i s,
I computations and specifications.concernin ; �.
l
X-Aroh,iiectural
[ St:ructural' [ `] .Mechanical
j
.Fire Protection ( J ,Electrical [ Other
for,the above naineci project rind that to the,Best of my knowledge, info ration,Wid belief such,plans, con pe to"tionsktrnd
specifications ►neetthe applicable provisions of the`Massachusetts State'Building Code,:(780 CIvMR),and accepted"
i engineering practices for the p:roposetI project. Funlerstancl and agree that I (or my clesignee)shalt perform the necessary
.pr•ofessiorial services aid°tbe present on the construction site on a regulartnil periodic basis to:
r 1. .Review,.for conformance to this-code and the design concept;shop drawings' sainples and otl�er submittals by the i
t contractor in accordance with the requirements of the construction documents.
2, inform the.dutres'`forregistered design prol°essionals in 780 CMR,Chapter .l7,as applicable..
3.- `Be present flt intervals appropriate to the stage of construction to become genera Ily fainiliar with the progress and
quality"of'the work and to determine if the work is being,performed•in a inanner consistent with the approved
eonstrtfction.:doctimen s and1his code.
1 Nothing;arth.is document relieves the contractor of its responsibility regarding the provisions of780 CMR ,107.
i "When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent 1
ciornments, in aforn acceptable to the building o:ffi ,!
Upon completion of the work,'l shall submit l it a`:Final Cons.tructio.n Control Document'.'
.EnterAri the space to the right.a"wet"or {
;electronic,signature and seah
•
Phone G number: 4-w ' Email: Zi I ✓V1 I .• �.iW '
'BUitduig-OClicial Use Only
IiuilclingC�flicial Name: V.ermit"No.: