166-168 BOSTON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a - Two- mi in
(This Section For Official Use Only) !
Building Permit Number: Date Applied: Build' Offici
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations fo which a s dress frnot available)
JU/ I �PSI �J�ah -A7 . xicM
No.and Street City/Town Zip Code e 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❑ 1 Repair❑ Alteration Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ Nq.9-
Is an Independent Structural Engineering Peer Review required? Yes ❑ NoC�-
Brief Description of Proposed Work:
,u yr
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 ❑ A-4❑ 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 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-12— 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 ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
Water Supply: Trench Permit:Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public Check if outside Flood Zone❑ Indicate municipal A trench will not be P
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not ApphcablpZt— Is Structure within airport approach area? Is their review completed
or Consent to Build enclosed❑ Yes❑ or N 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:
05=°' S% The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code (780 CMR)
Building Permit Application to Construct,Repair,Renovate or Demolish any
Building other than a One-or Two-Family Dwelling
Code and Other Requirements for,Building Permits .
The Department of Public Safety has issued these building permit application forms so that municipalities
across the state can move toward use of a single permit form and consistent permit application process.
The MA State Building Code specifies the requirements of building permits and the applicant is advised,to
review and be familiar with these requirements in order to avoid some of the common permit application
problems. Likewise the applicant should be aware that some municipalities require that the owner confirm,
even prior to acceptance of the building permit application, that no outstanding property taxes,water fees,
etc. exist.
Filing Instructions
1.Please contact the city or'town where the work will be done to ensure that the city or town will accept
this application form and if any additional information is required, and obtain the correct mailing
address. After doing so, print the application, fill in completely and then submit to the local city or
town where the work will be done.
2.All applications shall be considered complete and will be reviewed if construction documents,
specifications, fee, and other materials that may be required as indicated in the Building Permit
Application are included with the application.
3.Please include a check for the Building Permit fee. The fee may be calculated using the information to
be supplied in section 12 of the Building Permit Application. The check is to be made payable to the
local city or town where the work will be done.
Sperling
Conssmaion 8 Pmperry
Richard J.Arnone,Jr. ufy
Sterling Construction
® 285 Comm Way
Chelsea,isea,MA 02150
Phone:781.953.7112
Fax:617.884.7745
richard@sterlingconstructionboston.com
w .sterlingconstructionboston.com k
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and ddress of Property Owner -
- K�U6 A gta- -(Print) No.No.and Street City/Town Zip
Proper e C Inf mation:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, to property owner hereby authorizes A ,� L -
f ►�� (ov^�y> iL vJch �1 A1,a—_ 5�
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 application-
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and 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
Name of Pers R nsible for C ns uction + License o. and pe if Applicable
- d LicC"-t r+
Ad ss City/Town State Zip
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 ust be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the' uance of the building permit.
Is a signed Affidavit submitted with this application? Ye No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 1500 Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable .to
6.Total Cost $ 1 (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 an enelfies of perjury that all of the information contained in this
application is true and accurate to th f my owl a and understanding. .
MPry
Pl a. print an nime Title Telephone No. Date
UU� Gu c
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
x
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location(Please indicate Block # and Lot# for locations for which a street address is not
available)
No. and Street City /Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
a
CITY OF & .F.M. N'LASSACHUSETTS
BUILDING DFPA .%R- w-4T
120 WASHINGTON STREET,Sao FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KINfgFRT FY DRISCOLI
MAYOR THoMAs ST.P[ERRH
DIRECTOR OF PUBLIC PROPERTY/BuMDL!IG CO.%L%DSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information Please Print Legibly
Name(BusinK Organizationtlndividua!): lakk, ✓ M1�
Address: / ONIN\of/. ^ta
City/State/Zip: ��u� Phone . �Y) !�V 7I/D
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a g'meral contractor and 1 6. ❑New construction
employees(Poll and/or pan-time).' have hired the sub-cotwactors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7•JEWemodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. Q_workers'comp.insurance. 9, ❑Building addition
[No workers'comp.insurance S. a are a corporation and its
required.) officers their
have exercised the I0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MOL I i.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,01(4),and we have no 12.❑ Roof repairs
insurance required.)t employees.[No workers' 13 ❑Other
comp.insurance required.]
Any applicant that checks box#1 must also fill out the feeds)bdow.dtowmil their worker'comttensadun policy infuunatioe,
'l lmneowners who submit this affidavit indicating they are doing all work and then hire moside eantremrs must submit a new affidavit indicating such
=f',mtm.xors that shmk this box most anached an additional sheer showing the name of the sub-contractor and their worrier'comp.policy intermatiou,
l um an employer that is providing workers'compeamdon Insurance for my employees. Below Is the policy and Jab site
information
Insurance Company Name:
Policy b or Self-ins.Lie.#: EEp/xp* tiontDa/tye;
Job Site Address: V/ '�l/ bCity//rSl
64P, tate/Ziipl:
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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby c y ur er the a! nd aloes of perjury that the information provided jabovy is true and correct.
gnat tr Date:
Ph onc# XZ
-
Official use only. Do not write in this area,to be completed by city or town oTIefaL
City or Town: Permit/l.lceuse#
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
safety
1 Massachusetts -Depart" ndards r
Board of Building Re9tiConstructionSup License: C&08RICIL4RDJA"9'NE J14TYLERST#gaSOMERVILLE MA 022Expiration0813012014Commissione
Sterling
Richard J.Arnone,Jr.
gsterling Construction
285 CoWay
ChelseanMA 02150
phane:781.953.7112
Fax:617.884,7745
richard@slerlingeonstructiOnboston.com
www.sterlingconstructionboston.com