95 CONGRESS ST - BUILDING INSPECTION �1 The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two- 1'
(This Section For Official Use Only)
Building Permit Number:. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street a re
45 L-E o/ 9-7a
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❑ 1 Alteration ❑ 1 Addition❑ I 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 01,
Is an Independent Structural Engineering Peer Review required? Yes ❑ No GY
BW Descri : "ption of Proposed Work �A✓>F f 4-i�(�i'a✓ !� OAI
C.
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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.) - /.Sao
SECTION 5:USE GROUP(Check asapplicable)
A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business Gr E: Educational ❑
F. Facto F-1 ❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional 1-1❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R3❑ 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 El IBO IIA ❑ IIB ❑ IIIAO IIIB ❑ 1 IV 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION.(refer to 780 CMR 111.0 for details on each item) -
Water SuppI . Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Zone❑ Indicate municipal A trench cvijl not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required or trench or specify:
permit is enclosed❑
Railroad right-of-wa 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 lq-� 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 ISprinkler System?: 45 Special Stipulations:
r � `
SECTION 9: PROPERTY OWNER AUTHORIZATION -
Name and Address of Property Owner
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Name(Print) No.and Street -ty/Town Zip
Property Owner Contact Information:
0
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)
f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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Name(Re tstr t) Tele hone No. e-mail addre s Registration Number
Street Address City/Town State Zip Discipline Exp ation Date
10.2 General Contractor
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Company Name
Name of Person Respynsib a fov.Construction License No. and Type if Applicable
Street City/Town State Zip
'V -73$Y — --
Telephone No.(business) Tel hone No (cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ - 0 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ a p appropriate municipal factor)_$
3.Plumbing $ pp 0. r }�
4.Mechanical (HVAC) $ Note:Minimum fee=$ (conta�j y opal )
5.Mechanical Other $ Enclose check payable to
6.Total Cost I $ G - 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 accurst e b in knowledge and understanding.
Please rhu and gn name7 Title 7elephone No. ate
Street Address Gty/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name - Date
9 'Massachusetts -Department of Public Safety
�Board Of Building Regulations.aPd Standards
Con ir,vic ion Supennor
License- CS-091520
FLAVIO ROCHA
503 BROADWAV#oq ' -
MALDEN MA 01148 c�
1
�� 11'1515�
Expiration
Commissioner 01/10/2015 -
i CITY OF S-UENi, iNvasS:XCHLSETTS
BI:R.DLNG DEPmtT\U&-iT
•• p• 130 WASHINGTON STREET,3ae FLOOR
TEI.. (978)745-9595
FAX(978) 740-9M
Kl\tBFRr f{RY DRISCOLL
MAYOR "hio>sus ST.PfERRe
DIRECTOR OF PCBuic PROPERTY/BummmG CO\L\BSSIO.NFR
Workers' Compensation Insurance Affidavit- Builders/Contractors/Eleetricians/Plumbers
Ariplicant Information f� Please Print Legibly
Name(Busintss:OrganizationAndividual): A-47,3.S;0,/
Address: /20 �—�%%.yr� 157 /
City/State/Zip: ��� f1�0 L/S / Phone At: �5-0 fO1 -738f
Are an employer?Check the appropriate box: Ty
pe of project(required):
1.Wi am a employer with -2i 4. ❑ I am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors
6. El Now construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9• ❑ Building addition
No workers'comp. insurance S. ❑ We ate a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ i am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t employees. [No workers' 13 ❑Other
comp.insurance required.]
;Any applirum that cittxka twx 91 mnal also fill out the section below showing their worker'compensation policy infumwtion.
'I hmteownen who submit this affidavit indicating they arc doing all amtk and then hire ou side conimetor mot submit a new amdavit indicating sueb.
:C.mtraclars that check this box must attached an additiormi sheet showing the name of the s sb-eommctor and their workers,comp,policy information,
l am an employer fiat is providing workers'compensation hrsurance for my employees, Below is the polity and Jab site
information. n /�
Insurance Company Name:--H�OKD
Policy N or Self-ins,Liicc..N: / 9.V 0-3 Expiration Data:..
Job Site Address: 7 S eON�;�S�q ` City/Statdzip: :s44 rl
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration state).
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. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perJury that the information provided above is true and correct,
Sil:nature: Date•
Phone x
OJfcial use only. Do not write in tills arcs,to he completed by city or town official
City or Town: Permitil.icense N
Issuing Authority(circle one):
1.Board of Ileatth 2. Building Department 3.City/('own Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone q•
aNc MD" CERTIFICATE OF LIABILITY INSURANCE 2; t""YI
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THIS CERTIFICATE 18 ISSUED AS A NATTER OF INPDRNATWM ONLY AND CONFERS NO RIGHTS UPON THE OMFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRNATWELY OR NEOATWELY AMEIM EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLMU
BELOW. TWG CERTIFICATE OF BISt~C:E DOES NOT COMBTTtUTE A CONTRACT.BETWEEN THE 08UIN0 IN8UR1&4S), AUTNORDND
REPRESENTATIVE OR PRODUCER,AND THE CMWICATE HOLDER,
IMPORTANT: N the INS 11oWer b an ADDITIONAL INSURED,UN P~es)must be m+aassd, N SUBROGATION IS WAIVED.mftoct to
dte terms and IxnCYlMm of U*pofty cataln PONdOs maY an end0fawrA & A shftmwd on Wooef9ftM does not conbrNQ4ds to"
earttfloab holder In Neu of such s
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COVERAGES CERTIFICATE NUMBER: REVIIDON NUMBER:
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