10 CONGRESS ST - BUILDING PERMIT APP �` .
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� � � The Commonwealth of Massachusetts
� �� Depaztment of Public Safety
� Massachusetts State Building Code(780 CMR)
� Building Permit ApplicaHon for any Building other than a One-or Two-Family Dwelling
"- (This Secfion For Official Use Only)
� Building Permit Number: Date Applied: Building Official:
� SECT[ON 1:LOCATION(Please indicate Block#and Lot#for locarions for which a slreet address is not available)
� !� CCho�eSS St .�r/rih MA G�f7� So��t�r l�n�bc��/�cr�k:��i �m�crc,e'
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� No.and Street � � City/Town , Zip Code IVame of Building(if applicable)
� � SECTION 2:PROPOSED WORK
� Edition of MA State Code used� - If New Construction check here O or check all that apply in the two rows below
! Existing Building Repair❑ AlteraHon ❑ AddiHon❑ Demolition ❑ (Please fill out and submit Appendix 1)
� /N' G G Gf f JDl�
� Change of Use �. ❑ Change of Occupancy ❑ Other �Q Specify:Lt�ih[� ��(Jj'�/�) jj�- ��':��
` Are building plans and/or to�vstruction documents being supplied as pazt of this permit applicaHon? Yes_� No ❑
� is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
� Brief DescripHon of Proposed Work: LV' ' � �E'' - � �
�(C) GV C// :� G3 GG ' ' (J F d
� 1 / ' �r/7 - � 6 W. � G�/' Lc�/J
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� SEGTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDTTION,OR
i� CHANGE IN USE OR OCCUPANCY
� � Check here if an Existing Building InvesHgation and EvaluaHon is enclosed(See 780 CMR 34) ❑
�`"" Existing Use Group(s): Proposed Use Group(s):
� SECTION 4:BUILDING HEIGHT AND AREA
� ExisHng Proposed
� No.of Floors/Stories(include basement levels)&Area Per Flwr(sq.ft.) � �'/P��^�-j /�f k �(l�� . ,p(��,
� Total Area(sq.ft.)and Total Height(ft.) '� . ����7-�..
SECTION 5:USE GROUP(Check as applicable)
� A: Assembly A-1 ❑ A-2❑ Nightdub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: EducaHonal ❑
� � F: Facto F-1 ❑ F2❑ H: Hi Hazazd H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
� L• InsHtutiona] I-1 ❑ I-2❑ [-3❑ I-4❑ M: MercanHle❑ R: ResidenHal R-1❑ R-2❑ R-3❑ R-4❑
�.
� S: Storage S-1❑ S-2 U: UHlity❑ Special Use O and please_describe below: .
Speciat Use: �.. , �7 � / :� � �y}�6�
� SECTION 6:CONSTRUCTION TYPE(Check as applicable)
� IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB � IV ❑ VA ❑ VB ❑
� SECTION 7:SITE INFORMATION(refer to 780 CMR 1llA far details on each item)
~ Trench Permit. Debris Removal:
� Water Supply: Flood Zone InformaHon: Sewage DisposaL• (,icensed Dis osal Site❑
Public� Check if outside Flood Zone� I�dicate municipal ❑ A trench will not be P
required�or trench ur specify:
� Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ ��.
� Railroad right-of-way: Hazazds to Air Navigation: MA Historic Commission Review Process: ',
� Not Applicable� Is Structure within airpur[a proach area? Is dieir review completed? j
� or Consent to Build cnclosed ❑ Yes❑ or No� Yes❑ Nu ❑
SECTION 8:CONTENT OF CERTIFTCATE OF OCCUPANCY
�� Edifion of Code: Use Group(s): � Typc of Construction: Occupant Load per Flour:
� � Does flie building mntain an Sprinkler System?: �' Special Stipula6ons:
�
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
e;/'DZ e Gc - 5.94 -C -M AV7+ 171970
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
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 a2plication,
SECTION 10: CONSTRUCTION CONTROL (Please fill out Appendix 2)
If b ding is less than 35,000 cu. ft. of enclosed space and or not under Construction Control then check here and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Registration Number
Name (Registrant) Telephone No. e-mail address
Street Address City/Town State Zip
Discipline Expiration Date
10.2 General Contractor
f pwFr'
Company Name
,12maeL Fowy k?
Name of Person Responsible for Construction License No. and Type if Applicable f
Street Address wn State Zip
y
dl:✓.ifltr'oa✓t�CnF psi tf Go'7 f»
Telephone No. business Telephone No.(cell)a-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 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) _ $
Building Permit Fee = Total Construction Cost x (insert here
1. Building $
2. Electrical $
appropriate municipal factor) _ $
Note: Minimum fee = $ (contact municipality)
Enclose check payable to .
3. Plumbing $
4. Mechanical (HVAC) $
5. Mechanical (Other) $
6. Total Cost $
(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
apphcatio e and accurate to the best of my knowledge and understanding.
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Please print and sign name Title 'telephone No. Date
Street AddressCity/Town State Zip
G`
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i
Municipal inspector to fill out this section upon application approval:
Name Date
NAM
CITY OF &U.EM. -N-LA SSACHUSETTS
BumLmG DEPARTMENT
130 WASHNGTON STREET, 3a° FLOOR
T E1- (978) 745-9595
KINfBERLBY DRISCOLL FAX (978) 740-9846
MAYOR THo.%w ST.PiERRB
DIRECTOR OF PUBLIC PROPERTY/BU:LIMNG CONLIMSIONER
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 # 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:
G✓<.r� 1"Or t.'e, C'e, j ;j
(name of hauler) I
The debris will be disposed of in :
(name of facility)
&2 (/ (/4: f -/)
(address of facility)
i
signature of permit applicant
-29. 1.2-
date
a
date
Iebnsu1Tdiu
CITY ®F SEiE�N1, A- kSS-#CI-IUSETTS
'4T ° BumniNG DEPART-,W—\i
130 WASHLNGTON STREET, 3°O FLOOR
j8 a
T£Y.. (978) 745-9595
Fox (978) 740-9W
xIBFRi FY DRISCOLL
MAYOR THOMAs ST.PIFFvM
DL4ECTOR OF PUBLIC PROPERTY/BCILDD4G COXlJBSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Nainc t
L
60
F0-:7
le 7,'"/ 9 — 3
Are you an employer? Check the appropriate box:
I. ® 1 am a employer with -..) 4, ❑ I am a general contractor]andlemployees
roject (required):
(full and/or part-time)."
have hired the sub-contra
w construction
2.0 I am a sole proprietor or partner-
listed on the attached sheodeling
FE]
have no employees
These subcontractors haolition
for me in any capacity.
comp. insurance
workers' comp. insurancekers•'
5. 0 We are a corporation and
ding additionre
]
LE011
officers have exercised their
trical repairs or additions
meowner doing all work
right of exemption per MGL
I I .❑ Plumbing repairs or additions
No workers'sump.
c. 152, § 1(4), and we have no
12.0 Roof repairs
r required,] r
employees. [No workers'
insurance
13.0 Other
comp. required.)
t ih—cowmns who submit this of idavir indicating they arc doing all work and then hire outside contractors must submit a new affidavil indicating such
=Gmiry:ton that chirek this box must attached an additional sheet showipg the mune of the sub-euntmaon and their workers' coo li ho;
P Pu % ottnaiion
! ant an employer that is providing workers compensatlan insurance for my employees. Below is rhe policy acid job site
information n
Insurance Company
Policy It or Self -ins. Lie. tr; ��� —3/.3 — 3��l`(py — U/ / Expiration Date:_lb - /6 �— 4 __
Job Site Address: Cityistaw/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 ivell as civil penalties in the toren 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 ba forwarded to the 017ice of
Investigations of the DIA for insurance coverage verilication.
I do
pains and penalties of perjuy tltot,'the iafonnuriat provided above is true,Gitd correct.
- �Vaa(;�'_
O/jiciul use oily. Da not write in this area, to be campleled by city or town ojfciaL
City or Town:
Permit/License #
Issuing Authority (circle enc):
I. Board of health 2. Building Department .i. City/town Clerk 3. Electrical inspector 5. Plumbing Inspector
6. Other
r—/
Contact Person: Phone