CHILDRENS ISLAND - BPA-13-48 re
_.
=� The Commonwealth of ivlassachusetts
Department of Public Safety
11.I.,,tr1111+r11s ti1,111'14u ildi119 Code(7,81)C,\IIt)
Building Permit Application for any BuiIdingother than a One.orT vo- anti) � illil
(I his Section For(lffirial Use llnly)
Huildiog l'cnnit Nu Ibee _-_ U,ue:\ rdicd: Iluild ing Official: •'�"II
S FCnON l: LOC:\LION(Please indicate Iiluck II and Lut N fur locations for which a street addre. is n vailible
No.'old Slnvt Cily /ruwlt Zip Curie Name titRuildin); if,t r dicably -. _
.SECI•ION 2: PROPOSED WORK
-------------�., anon Ill .\1:\Stalk,Code usu•d ____ If�N'vw Cunslrurtiun i hot k here❑ur iln•ck all Ih,lt apph' in the Inv nnvs below
E\isling Building ❑ Rrpair)� I Alteraliun ❑ :Addition❑ Demolition ❑ (Ph"Ise lilt out and snbntit.\ppcndix 1)
Change of Use ❑ Cltangeotot'Lupancy ❑ Other ❑ Specify:-____----
Are building plans and/or construction d,Kuntcnts being supplied.Ls part of this penniLt}rplicah,m? Yes Cl No -- ----Is an Indepvndcnt Structural Engincerin• 'ter Revi,w required? Yes ❑ No -�[•
Brief fX-scri¢rtiun of I'r posed Work: IF
p
—/U-4.r2L t LQh_L..CPI SECTION 3:COMPLETE-1.111S SECHON IF EXISTING BUILDING UNDERGOING RENOVA'rioN, AUDI'HON,OR
CHANGE IN USE OR OCCUPANCY
Check hem+if an Existing Building Investigation and Evaluation is enclosed (Sec 7,40 C:\IR 1-I) ❑
E\isling Use Gruup(s): _ Proposed Use Grmp(s):____—___.____
SE-11UN 4: BUILDING IIEIGIIT AND AREA
F"sisting Proposed
No.of Flours/Stories(include basement levels)lr Area Per Fluor(Al. ft.)
Fuld :\r'a(Sq. it.)and rutal Height(ft.)
SFC I'ION is USE GROUP(Check as a licibie)
A: Assembly:\-I ❑ A-2❑ ,Nightclub ❑ :\-1 ❑ ;\-4,❑ .\-3❑ B: Business ❑ G: liducitional ❑
F: Facto F-I ❑ 1:2❑ 11: Ili h Hazard FI-I ❑ li-2❑ I ht ❑ 11•4❑ li-i❑
1: Institutional 1.1 ❑ 1.2❑ 1-3❑ ❑1-4 ,,\I: Jlercantilo❑ R: Residential R-10 R-2❑ It-3❑ RA ❑
St .Storage 5-1 ❑ S'_❑ U: I...... ❑ Special Use❑and please describe below;
Special U'se
SEC PION 6:CONSI'RucrION 1'YI1F- (Check as applicable)
IA Ill ❑ 1 [IA I'll IIB ❑ III:\ ❑ 11160 IV ❑ VA 13 \'li ❑
-_-- SUCTION 7: Sl'I'E INFORMA PION(refer to 740 C.\IIt I 11.0 fur details on oath iteut)
611 Supply: cloud Lune Info tit atiun: Sewage Disposal: French Permit Ovbris Itcnwval:
Public ❑ Check II oul IJv Flrnal Zunr❑ ln,liL•Ilc nollootntl Cl A lunch ,call nut be 1 tit n.rd Ilisln wul silo Cl
I'm.rly rA nr indvnlil\ /,mr . _- nr,m .uc st gcltt ❑ n•yuin•d ❑nr Irt „r.prcde. _
ILiilm,ad right-uf-way: Ilaiards to .\ir.V.wigation:
11,-Irm htry lr tllun.urpnrt.,l•pma,r( han'al .� .. Ic thrtr rr,�lr I, „veld,wd ' I
� nmrirt l„ IludJ rn,L�.rd ❑ i 1rs CC ar \'„❑ 1,sO \ . L
` I:( IlO.V4. l ONII.NIOFI F R I IMAI1;OF O( C UI'.\.V'( Y
I fill ova I. ,Ic l .r _—
It i I prr I Lvr
14„ . Ihr buildury',,rnLun en �pnnAlrr ti+.lrm' �Inx i.tl'�hpul.ln,vi.
Sl:( II )N '): 1'ROlIliltIY O%VNLR AU I'Ill 11tIYAlIUN
N.n nr.inJ .\Jdress.d I'ngn•rly Chvner
City
No-ind Streetj Town
V,uur (Print) .
Prol,crly (Avnar Cuntarl Inturtn•lliun:
-- ---'
C-111jil address
ress
I'rlvphane No (business) Telephone Nu. (tell)
It.ip{,Iiclblc, the properh' owner hrrcbY aulhoriit•s
Na Strel.t Address City/Town Slate Zip
lu art on thr property
n•rt owner's bchalL in all nl•mtcrs n•lative to work authurirrd 6v this build in; remit I'll licatioll
SECTION IU:CONS'1'ItUCT1O N CON-1 RUL(('lease fill out Appendix 2)
If buildin a is less than J5,0M Cu.it.of enduxvi s teCe and or not under Construction Control then check here)4and ski +Section III.I)-
to.I Registered Professional Res onsible for Construction Control
-.felu hone Nu, e-mail address Registration Number
Name(Registrant) V
city/Town Stale Zip Discipline E.piratiun Date
Greet Address y/
Io.2 General Contractor
---
Compan Nime
Hanle of Person R x unsible fur n sin... License No. and Type if Applicable
—T-- City/Town State Zip
Slrcat kldruss
-�Y z o9 C 178 P�°IG,,T
e-mail address
—
'I+hunt No. business Tcle+hone No. cell
SECTION Ii:lu �c�.rt::r r l�,vrrv, HON,.i�:a n:.��y r ,\t t u \\'I I M.G.L.a 152. 25C 6
A Workers'Compensation Insurance Affidavit from the\IA Department of Industrial Accidents must be cumplOuLl and
submitted with this application. Failure h+provide this affidavit will result in the Ielli ll of the issuarlce of the building perlllit.
Is a si med Affidavit submitted with this application? Yes O No 17
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Casts: (Labor
Item .uml Materials) rohd Construction Cost(from Item III) - S—__--
I. Building S suilding Permit Fee 'Total Construction Q+st x —(Insert here
a. 171wrical S •appropriate municipal Llctur) ' S
t. 1'Iund+it+t, b ianlact numiei tatty
Note: \lininuuu (ce'
{. \leehanirol (1IVAC) S
i. \"Manic 11 (Other) 17nclose check payable to —
n. 1'.aal Cost 5 � (contact nnulicipality)lilt[ to rite check number hrre
SECTION 13:SIGNA1 UllE OF BUILDING PEIt\I IT API'L IC'AN"r
M vntrrint; nry name brin+v. I herobv ittv,t under the p.iins end penalties of perjim that all of the iuforn.nion cm, t.tiiird in Ihis
applic.ttion is trill.and accurate to the hret of nil kaol+Icdp;••,iad understanding,.
.. . - - -- _.. - Iltle Trltphtnp• \'n Ilalc
I'Ir.�sr pool drat .q;n nenic
'�irvrt \.Llrros
Clly, coon ;I,da /gyp
i
I \luniol"ll Inspector to fill out dais+e,tiun upon .application approval: ._.._ .._
Nome I Milo
: CA [Y UN SaLE.M, NWSACHL;SE'ITS
1 BUILDING DEP.\ MENT
120 %V.\SHLNGTON STIEET Y°F1.0O7
Y TEL (979) 745-9595
Rkx(97,9) 7149844
!<j>tpFF,UEY DMCOLL
AYO a MO\L\S ST.PIE,aRs
DIRECTOR OF PLOLIC PROPERTY/OLRDING CO\NlSStONER
Workers' Compensation Insurance At7idavit: !)uilders/Contractorv/Electrictan.eJPlumbers
li \ illeant Hformatinn !case Print Leaihl
V:IIn lllwil of)rgurorariomindivJiJu/dq: G (� A rC ro r
wdress: Z rc / (,Gca� .J 4�'P
City/State/Zip: /r fy l hone At! e7
,tire you an employer?Check the appropriate boat K
project(required):
I. I am a employer with 2— A. [] I am a general contractor and INew construction
employees(roll and/or part-lime).* have hired the sub-canlractars
2.0 I•un a sole proprietor or partner• listed on the attached.nheet 1I. modeling
.hip and have no employees These sub-contrseton have molitionworking for me in any capacity. workers'comp,insurance ilding addition(No workers'camp. insurance 5. ❑ We are a enrporstlon and itsrequired.) otflcers have dsercised their ctrical repairs or additionsJ•0 1 ran a homeowner doing all work right of exemption per MOC mbing repairs or additionsmyself. (\o workers'sump. c. 152, 11(4),and we have no of repairsinsurance required.) f vmployees. (No workers' er
rump, insurancomquircd.)
they uppikum OW ahecke but At mwl.bu Oil nut Ills weliuo baWw.howing Choir"llsre'eemponudun puhky'n4i"W lon.
'I hvnvuwtwa who whmlt this ailtdavit indleaing thry,rr doing all twre and then hire outside eoninteno,miwi,,hmlt a new untdavil indicting,ucb.:C—Inwto,that chwk this bwt must machod an a,Walurud.heal,hawing the nutna of the wb.untrutore and that#wnrken'wmp,pulley inru lino.
/one an employer that is pravf ling,workers' my employees: @#law fs the pollay and Job aUe
irrifonrrudnrs,
Icnunutee Company Nmne: _....._.._
Policy J ur Sclr ins. Liu, to: Expiration Dale:
fub Site,\ddress: (r 4 ir��rPws 1SLuT � CilyiStuti ip:
.\Uacb a copy of the workers' compamalloo pulley declardtlen pigs(showing the Polley number and etplralloe data).
F.liluru to secure cuveragd us required under.Sectlon 2L\ot•\lGL c. 152 can lead to the imposition of criminal penalties of s
tine up to 11,500.00 unt.Vur are-year ilrprimnment.us well as civil penalties in the farm of a STOP WORK ORDER and a line
.:r.Ip rn S2:O.CO a Jay against the violdmr. Ile advised that a copy of this aratement may be iurwarded to III*011%d of
Iat�Jiyaliun.a�tflllC 01,1, tar lniurillCe covcflye cfiileatian.
/Flu hvrrby rrni/y tin dre pains m r w/l/e.e ,I perjury r/Iut r/v provide)above i1llrue nJ eorfret
Uorv: L
I)//ice me n,tfy. oaf nvirt in r/rir vrru, ra bt runrplrloJ by rity ur to ron nj/lefv[
Gry er ftn ._ _ i'crmiti Llccnie i
h,niej.\ulharily (CirClu one): --'. -_ .—
I. L'uanl ill' IlruUb !. Iluildlnq ❑cp.tr tolcnt 1, i itylfnwu Cldrk 1. lilccrric.d 6npcchlr i. Plnmlli m; fntp.Oar
l.nni.l�, i'er%... 1 hone h
I y
,- ClTYOE5.ILE,�i, Atiss.IcHuSETTS
8l'UNG DEP.%AnLLNr
I '0 ,VASHNGTON STA8g7', J'0 FtCCA
r2L t973) 743.939f
'UJ®EAf Y DRLSCOLL PVt(973) 1149g."
MAYOR IkO.WI ST.?MRs
DIRE�rpR OP Pl 8t1G PRC)PIRTY/Bt;aZC4 D C0-%011MIO.V ER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, Igo GMR section 111.J
Debris, and the provisions of MGL o 40, S 34;
Building Permit /f is issued with the condition that the debris resulting from
I f, I J 3 13 OA."I be disposed of in
1 I1 a properly licemed waste disposal facility as defined by xICL c
The debris will be transported by:
CO
(n,un ur hauler)
The debris will be disposed Orin :
LU Or.�..i. ti✓J7�,
(name or rac,lay)
P ► OC3 /t-op+
r,ddree,or n.,I„y)
revrperm pph.,nt