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75 CONGRESS ST - BPA-16-573 RENO TO REST The Commonwealth of Masse , l 'Efi�'(G~ Department of Public Safety Massachusetts State Building Code(780�j R)�t�l� _ /� �t Building Permit Application for any Building other than a OYt1E�;AJ4wc FaA-ly Y7Wling (This Section For Official Use Only) �- Building Permit Number: Date Applied: Building Official: I !1 SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 1 S e D9 No.and Street City/Town Zip Code Name of Building(if applicable) iSECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑ or check all that apply in the two rows below L Existing Building Repair❑ 1 Alteration 0 1 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 Pe r Review required? xes ❑ No JI Brie Description of Proposed WoS5k: Du A 2 Yt h rd 2 Y 0.1-1 i 2 iS n i 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❑ 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 I-1 ❑ I-2❑ I-3❑ I-4❑ 1 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 ❑ SECTION 7: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: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ 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: A OV44:-4� -To N tJ c-G SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner �C'A n +or\ GPI j LL D —TVo,I©o s IOMOP V" lie wiY3 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: �p O U)lire r" W-9)/1- 72 Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the prope owner hereby authorizes Arno (OtI54 u it)rx ;1 p"5 Mel Cftlj Sale.ty,\ Lila r710176 Name Street Address dress 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 building 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 Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General) �Contraactor Arno Company Name k;10' A L CS o3ga-aC) Name of Person Responsible for Construction License No. and Type if Applicable fncejnP� Ga� Sa 11h L1970 Street Address O�o tJ—� c7� e� City/Town State Zip - -�a-� tin-11-1--� 121` it 6!^Cad • 11 P� 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 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)=$ LO QO•�l-' 1.Building $ q0C10, 00 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact munic/ip�ality) 5.Mechanical Other $ Enclose check payable to / / •6b 6.Total Cost $ t om o (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 application is true and accurate to est of wlednnge and understanding. /+ Ric. 0,14 1--Tlcr\0 a I/ — Ott^nef, 1-n0 V Please print and sign n � Title Telephone No. Date a3 lhhoohe oc Salerh h C/070 _ Street Address City/Town �Sttate Zip / Municipal Inspector to fill out this section upon application approval: krw- "W,. Name Date Massachusetts Department Of Public Safety ®,.r Board Of Building Regulations and Standards License: CS-MB227 Construction Supervisor RICHARD L ARNO,JR r 23 MOONEY RD SALEM MA 01970 { Commissioner Expiration: 02/25'26 ip o Door i 1 few Si ng T�� 3 o ce �o a °a a SCR LE /y'' =1f+ r �� The Commonwealth of Massachusetts Department oflndustrialAccddents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass govldra Workers'Compensation Insurance Affidavit:Builders/ContractorsMectricians/Plumbers. TO BE FH,ED WITH THE PERMMNG AUTH IT ORY. Applicant Information Please Print J&dbly Name(Business/Orgaairation/Individual): g1^yim �0✓1 S�rr,r�i®� ^ r Address: a'lt City/State/Zili: S !e Al- Phone#: TF14.E]Other Are you ao employer?Check the appropriate box: f ro ectUV P i (required):l.EJ I ama employ-with C�empkycea(full and/or part-time).• New construction2.0 Iam a sole proprietor or paMershipand have no employe,working formein any capacity-[No workers'"co emodelingmp.insurance required)3.❑I am a homeowner doing all work myself.[No workers'comp.immsnce required.)temolition4.❑1 s r a homeown-and w'L be hiring connectors to conduct all work c n my property. I wiuilding additioncreme that all conuwm either have workers'compensation mumatte or are solelectrical repairs or additionsproprietors with no-pployces. 5.❑I am a general contractor and f have hied the subcontractors listed on the attached sheet. lumbing repairs or additionsThese sub-contractors have employees and have workers'comp.inam ms oofrepeirs6.0We are a corporation and its officers have-excited then right of exemption per MGL ctter 152,§1(41 and we have no employees.[No workers'comp.insurance requhed.l 'Any applicant that checks box nl must also fill our the section below sit their workers' owing compenseti®polity information. t Homeowners who subrrdt this affidavit indicating they are doing all work and than hue outside contractors must snit a new affidavit indicating such. 1Contracmrs that check this box must anacli m additional shm showing the name oftbe mbconwctors and slate whether or not those entities have employes. Ifthe sub<ontractars have employees,they must provide their workers'comp.policy numb-. I am an employer,that is providing workers'compensation fnsurance for my employees. Below is thepolicy and job site information Al \ Insurance Company Name: A P1 1'/ry1 C460 1 Policy#or Self-ins.Lic.#:W CC -60-2 ) 7 )J —r Lo 1 lull Expiration Date:_ Job Site Address: 7 r�4 S g�e�t1 City/State/Zip: Attach a copy of the workers'cotq ensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebyRaderthep wpd penalties ofperyury that the mformadon provided above is true and correct Si ature, - ate: Phone M � -t Official use only. Do not write in this area,to be completed by city or town officki. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more then three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MOL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the cormnonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmationof insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. in addition,an applicant that must submit multiple pemrittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future pemuts or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia