0122 BOSTON ST -BPA-13-520 INTERIOR RENOVATIONS a-►4 3 4—
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code
Building Permit Application for any Building o than a One Two-Family Dwelling
"' �: -• .'•,°(This Section For.Ofhual se Only)(<, „
Building Permit Number: Date Applied. .i ' Budding tctal rt
SECTION 1 LOCATION(Please indicate Block#'and Lot#,for loca r r ddr s is no available):',
J
No.and Street City/Town Zip Code Name of Building(if applicable)
`SECTION 2:PROPOSED WORK—!`,
Edition of MA State Co a used If New Construction check here❑or check all that apply in the 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 N
Brief DescripHonof Proposed Work. 9 91, lnJ�iPiL ear.y/ �/nJn/� /6�/Pc.
vvF
O 69 o a G a
hon to — Du C. D P i
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SECTION 3:COMPLETE THIS SECTMNIF EXISTING BUILDINGcUNDERGOING RENOVATION,ADDITION,.OR: *'
CHANGEINUSE:OROCCUPF:NCY. . ., 'r
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)8r 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❑ B: Business O 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❑ I-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
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 ❑ VA ❑ VB ❑
SECTION7:SITE INFORMATION'(refer to 780 CMR 111.0 for details on each item) '*•
Water Supply: Flood Zone Information: r Sewage Disposal: Trench Permi • Debris Removal:
Public❑ Check if outside Flood ZoneV Indicate municipal A trench w' of be Licensed Dispos 1 Site❑
Private❑ or indentify Zone: or on site system❑ required or trench ors ify:
-11 permit is enclosed❑ of
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Re iew Prcxsss:
Not Applicable Is Structure within airport app ch area? Is their review complet
or Consent to Build enclosed❑ Yes❑ or No) Yes❑ No
" SECTIONS:CONTENTOF 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:
t... r
SECTION 9:i',PROPE'RTY OWNER'AUTHORIZATION _'
Name and Address of Property Owner
Tv �vt � Ma �22 SoS4op? 1am /i1a 0/q-7 �
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail adcvess
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 building permit apElicati2.
A SECTION lfl.CONSTRUCTIOMCONTROL(Please fill out Appendix 2) " Ki
-• If bmlami is less than 35,000 cu.ft.of enclosed s:ace and/or not Or Con'st<uction Control theri check here g -d ski Section 10.1
YOa Re 'steied Professional Res onsible for ConstructiortControl . =s.;, x f^ ,� ,
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
--10.-Z/Ge�neral Contractor ' �!
+.."' + ;
416P e, aY/
Company Name
/ c1 ri
7
Name of Person Responsible for Construction License No. and Type if Applicable
LJ 2 /tom,- T s;, hrl d,��lam, i 4
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION lli WORKERS'COMPENSATION INSli RANGE APLILiAVIT M.G.I:.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 42:,CONSTRUCTION COSTS AND PERMIT FEE'",
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
1. Building $ a d G, e'
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ p u u, appropriate municipal factor)_$
3.Plumbing $ o a u e J
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ U DDU= ` (contact municipality)and write check number here
SECTIb 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.
Wit~ e
Please pr' t an s m name Tit a Telephone No. _Date
Str e Address City/Town State Zip
LA
Municipal Inspector to fill out this section upon(application,approval:
Name, Date
5 c}y
u
tom[ Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supenisor
License: CS-077565
JOHN J MULDOOPf
MARBLEHEAD MA O1945 .
n is Expiration
Commissioner 08/01/2014
A CITY OF SM2115 NLiSSACHUSETfS
BL'R.DING DEPART%MNT
130 W.1SHL�IGTON STREET, Ya FLOOR
T EL (978)745-9595
Fut(978) 740-9846
IV�IgFRi RY DRISCOIl
THoMAs ST.F�RRB
(MAYOR
DIRECTOR OF PUBLIC PROPERTY/BUMDLNG CO.%L%IiSSIONER
Workers' Cofnpensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Amillcant information Please Print Legibly
Name(Ousitxss OrS.tniradarvindividuaq: V 0 1n' e"
Address: /,7 v7 13 m f 1 v ev S i
City/Statc/Zip:sa G ter^ /1,4. Phone N: 7L —� /%4//
Are yo n employer?Check the appropriate boxy Type of project(required):
1.9111 am a employer with 0 4. 0 1 am a Sensaal contractor and 1 6. ❑No construction
employees(fill and/or part-time).* have hired the sub-contractors
2. u I am a sole proprietor or purtn •
listed on the attached sheet I emodeling
ship and have no employees Thee sub-contractors have V. ❑Demolition
working for me In any capacity. worker'comp.Insurance. 9. 0 Building addition
(No workers'comp.insurance S. 0 We are a corporation and its I O Electrical repairs or additions
required.) o17)cers have exercised their
).❑ Iran a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.[Na workers'camp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)► employees.(No workers' 17 [1 Ocher
camp.insurance required.)
•Any applicant thad dimlis boa el mart alw rill uul IN sectloo balowshowing Chair wmkan'compensation pullcy inAirmaeoa
r 1 h+mauwnem who submit this affidavit indicating they am doing all work and Ihes him outside contractors must submit a new anidovit indicating such
:Cuntrouton that chuck this bon malt anachod as additlund shad showing the flans of the subatiatnclars and Chair worker'camp.policy Information.
I um utr employer that Is providing workers'comptrusadon htsurance jar my employees Below Is the pollcy and Job sift
ilrjorrmatlon.
Insurance Company Name:
Policy 4 or Self-its.Lic.0: Expiration Date:
Job Site Address: City/State/Zip:
attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failum to sccuru coverage as required under Section 25A of MGL a. 152 can lead to the imposition of criminal penalties of a
tine 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 SMAO a day against the violator. Ile advised that a copy of this statcmunt inay be forwarded to the Oflico of
Investiguttms ul'the DIA fur insurance covcrago vcrificalion.
I du hereby eerd ttt Are the In and pmruhles ujperiury that the hrjurmutlon provided above is true and correct
't Da aZ a /ol
OJIlriul use 0111)06 00 not arils in this arro,to be completed by city up iawm alliclat
City nr'ruwn: ___ _ . PermitA icense M
Imuing Aulliorily(circle one): --—
L llourd of Ileahh 2.Building Departtnuat .1.Cily/town Clerk a. Cieetrical inspector 5. Plumbing lnspector
6.Other _
Contact Person: Phone it:
I
CITY OF SALEll, NL-kSSACHUSETTS
4 i . BuLDLNG DEPARTNtEINT
120%V.AsHLNGTON STREET, 3° FLOOR
' TEL (978) 745-9595
F.+x(978) 740-9M
KINtBERLEY DRISCOLL
AWOR TmoNw ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BCILDNG CONWISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
SZ L -7:Zg,�-"-r_�..__
(name of facility)
_----__(address of raclllty)
signature of permit applicant
date
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