24 CONGRESS ST - BUILDING PERMIT APP r.
4
�\ The Commonwealth of Massachusetts
Department of Public Safety
�� �➢u Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(ThisSechon For,Of6cial UseOnly) r• s ,
BuilclmgPermttNumber: ':DateAppled ` " + 'ButklingOfhctal
SECTION 1:LOCATION(Please indicate Block#and Lot„#for locations for`which a'streefaddiessis not available)'
sf- v
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 Repair❑ Alteration._tK_ 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 ❑ No lac—
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Propose d Work:
` 1Z M ,,f ke t- 111o7 D/S�l�-E�' r.✓C Pv� .o C9'r ov1 lie
SECTION 3i COMPLETETHIS 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❑ 1 B: Business E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 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 ❑
SECTIONS: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❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ •required ❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hrds to Air Navigation: NIA Historic Conunisslon Review Pr(Ns s:
Not Applicable❑ F1sStructu'r` awithin airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes ❑ or No❑ Yes❑ No ❑
SECTIONS: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:
i y '
` SECTION 9:,PROPERTY OWNER AUTHORIZATION
:. ..
Name and Address of(f PProEerty Own
Name(Print) No.and5,tree City/Town Zip
Property Owner Contact Information:
JSV K✓/C�/H+� S('1/'✓I Lam/ CO �1
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 application.
SECTION 10 CONSTRUCTION CONTROL(Please fill'out Appendix 2)';
If buildui' is less than 35,000 cu��Fti of enclosed s'ece and%or.not under.Construction Control then check here'L7and ski Section 10.1
10.1 Registered Professional Res 0onsiblefdr Construction Contioli
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
i0.2 General'-Contractor
%
ompany Na
E�f )4�'Name of Person ResponsibWfor Construction License No. and Ty e if Applicable
f�L ��u r7�,-e �7� v� it -z7l �
Street Address City/Town State Zip
�Lz-fig �S-9S •ey's.�i JOL� gn�ar•l. �o�-,
Telephone No. business Telephone No. cell e-mail address
SECTION 11:..WORhER9COMPENSATION INSURANCE.AFFIDAVIT M.G.L.c.152`d -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 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 $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ p�S� Q (contact municipality)and write check number here
SECTIONI3:SIGNATUREOFBUILDINGPERMITAPPLICANT'
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 besLof my knowledge and understanding,
Please print and sign name , Title TJeleph e N
at
if t 7 �r-7/r° � h dPYS /�l/l _._Lcl
Street Address City/Town State i
/l
Municipal Inspector to fill out this section upon application approval:, / ~/ 1-Y IIII13
Name. Date
U +
CITY OF S:U.EM, NL-1SSACHUSETTS
BUILDING DEP.1RTNtEVT
130 WASHLNIGTON STREET, 3'a FLOOR
T EL (978) 745-9595
FAIL(978) 740.9844
MNfBERL.EY DRISCOLL
Tl
MAYOR IontAS ST.FtERRI;
DIRECTOROF PUBLIC PROPERTY/BUILDLNG CONLWSSIONER
NVorkers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Ptumbers
Anolieant information Please Print Legibly
Maine(Uusilw•ss,Orgini:atiamindividual):
Address:
City/State/Zip: Phone M:
Are you an employer?Check the appropriate best 'Type of prefect(required):
1.0 I am a cmploycr with 4. 0 1 am a general contractor and 1 6. 0 N w construction
nployecs(fltll and/or part-time).* have hired the sub-contractors
2.g atn a sole proprietor at partner• listed on the attached.sheet t ?• Remodeling
ship and have no employees These sub-contractors have bi. 0 Demolition
workin for me in an capacity. workers'camp.insurance
g y p h'• 9. 0 Building addition
(No workers'comp.insurance S. ❑ We are a corporation and its
required.] ol6cers have exercised their le,.❑Electrical repair or additions
3.0 I am a homeowner doing all work right of exemption per MOIL 11.❑Plumbing repairs or additions
myself.[No workers'camp. C. 152.1110),and we have no 12.0 Roof repairs
insurance required.]r emplayees.LNo workers' 13.0 Other
camp.insurance required.J
•Any appikam uvts monks box rl must also,1111 out the snliw bdawshowing their worketa'ampenudun poary intormallum
r I bvnvuwners who submit this sttidavit indicating they am china all work and then hire outside contractors must submit a new anidavil indicating such
'C ntr s ulon that check this box must anachad an uleioutml ahwl showing the name,of the tutFa'emraclars and their workers'comp.policy Intomution. sees
l utn an employer,that is prov/dlnR workers'companradoo lururencs jer my employers: Below is the Polley and fah site
Injoraration.
Insurance Company Name:
Policy 4 or Salf•ins. Lie. 0: Expiration Dote•
Job Ske Address: City/State/Zip:
%INC Is a Copy of the workers'compensation policy declaration page(showing the policy number and explratloa date).
Failure to secure coverage as required under Section 23A at'vIGL 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 ponallies in the form of a STOP WORK ORDER and a tine
of up to S250.00 a duy against the violater. Ile advised that a copy of this statement may be furwarded to the 011ica of
Investigudons otthe DIA for insurance coverage verilicutiun.
l do hereby crrrljy nuddr III_ u/nr UJ pro uhles ajparJury thus rife brjuratudms provfded above is true and correct
si,. . t —a Data: /i ;
ftonc,l.
1[6.
/J/cial use aady. Oa nat virile in drir arras to he completed by city ur town alj&la t
ity or frown: __. Permtr/T.Icemek
suing Authority(circle one): —
Uoard of Ileallh t.Uuildim;beparbnual J.City/fown Clerk J. Electrical inspector 5. Plumbing luspeetor i
other
ontact l'ersmu. . ..__ _.. Phone 4:
i
~' y CITY OF S.1.Czm; L1SS.kufusETTS
1'1 {yt BI:=L\G DVARTMENT
120 WASNLYGTON STREET, ] FLOOR
TEL (978) 745-9595
I<!J[6FJiLEY DRISCOLL
FAQ<(978) 7.10-9346
A L3Y01� THOmm ST.PIERRS
DIRECTOR OF PCOLIC PROPERTY/SLMDLY(;CC-NaUSSIONER
Construction Debris Disposal Aftldavit
(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
--in
this work shall be disposed ofproperly licensed waste disposal facility as defined by bIGL c
111, S 150A.
The debris will be transported by:
S�hir o Die v✓�
bladia uf hauler)
The debris will be disposed Orin :
r(namc of racitity)
fits—
` (address of facility)
signature ofperntit applic t
I
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