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1 EAST INDIA SQARE MALL - BUILDING JACKET � l;� . � • � <"w`� ``\ � ���.�17" �_�l' �.,[1�,1.'.��'I � s � �. r ,,; ��� ,,� P���r.�rc r�x���i���:�z�r�� ��� . '>:��,�:J,��%� D F]':1RT\I}�::v"1' � I:���Itl-.lil.l!Y Dliltit;Ul.�. �', �ulAP01: 1?tl`V'.A.I IINc:II�V$'IAi:I l'�i.AI.IIl.L'.LAx.'u i:i T.-f�y C 1'�'t� � . Ilit:V7H-?-45-95%$ V I��.AR:9?S-i i�i 0.41G � r�PPLICATION FOR PLAN rXAiV1INA1'lON AND 13UII..1)lNG 1'rRMI"f 1 ALL STRUCT[IRF.S EYCE�'T.I AND 2 FAMlLY DWELI.INGS J . . � ` . * IAIYOR'I�:�N7'.A licanls must com�ictc ull i[cros on[his �n e � � ��,�._..,,.,..,, Sl7'E INFORMATI04V ` � `�� I -..... C.ocationName C +� as�l�•-. - 6ui;dln�--- ------ — � -- Property Address f9 h He t i J.��� S� ( . � Map# � Locuted in: Conservation Aren YiN u Historic district YrN_ � � I - Usc Groups � (chcc;k one) , Residen[ial(3 or more Units) RZ 'Type oF improvement Residential(hotelhnotzl Rl �(checkone)• Assembly(churohes) A1 . New Bi�iltling_ Assembly(nightclubs etc) A2 Addition �� . Assembly(restaurants, rccrcation) A3� � Altcration_� .� Ciusiness B_ � Repuid Replacement_ E�ucational E , Uemoiition �j � - Fac[ory(modcrate hnzard) FI _ . MuveiRelocate � � •� � �-• y Factory Qow hazard) . F2_ �� '. ^Poundation Only.__-- � � I-figh Haztird '� � • � � '.�I�I � Accessury F3uilding= Ins[itucional (residential care) ' CI O[hcr(describc) Institutional (incapacitated) 12 Institutional (restraincd) 13 Nlcrcanti le :h � Storage(inoderatehaazard) S1 � Storagc(low hazard) S2_ , . O�V\6RSFIIP 1\'POIiRtA"IION(Please t}'���r Ih�iN Clcurly) . OWNE.R Name Trv,,l V�n�6�S Ad�re�5 ''l G�a l:- t�ll'� I�c.ie l �'V� o l�r lS Telephone �' � . �, �z o 0 ur;scH�r'r�o�ot�voax'ro u���h:eroantr:u/�,,� �G �C. •��P,m'}lS^�c.—�'^�� W �k� � J �AiC•.- Oh�� r+nd �►tl�� Go�-t_ G��'l�ce ` 'IO QclA�w.3�ec� f� ' � . 0.ti ttWicSS.� MC.c� \�tr t' �1�.�n�IM��S�al,��.'ri+n �Ui C i�.� ES'1'I,�1:�"ItiD COYSTRU(`CIUti COtiT _____ �S 00. .__._.. __ . _ — . _. _ J CONTRACTOR INFORMA'T'ION Name 11P.i-m M <�hr coN Address 10 lzk4nr. %. C: Telephone T-Ik' WF 1- 1(.C.-C,- Construction Supervisor's Lic # C S ©-L%$iSQ Home Improvement Contractor # _ ARCHITECT/ENGINEER'INFORNIATION Name Telephone Mass. Registration # PERMIT FEE CALCULATION Residential est. cost x $7/$1,000+$5.00= w Commercial est. cost x $11/$1,000+$5.00=� COMMFNTS '�� �✓� / The undersigned does hereby attest that all information stated above is true to the best of my knowledge under the penalties of perjury j Signed �G�r. L_ V �� ✓`c.—, Date Y C — asr_ (Ok- CITS' OI-. 1'um,lCDEPARTNILNT PROPI:K'1'l' ..71.18 N i ..COH K! 1.1'IHL� J I I. I_'U\\ +.iuM i IN�riu a.i • VIII y ria nlQ'ii APPLICATION FOR PLAN EXAMINATION AND BUILDING PERMIT ALL BUILDINGS EXCEPT ONE AND 2 FANCILY DWELLINGS IMPORTAN'r: :kpplicants must complete all items on this page SITE INFORNiATION Location Name L' LInP�hk �L°Y'1 """°'Building - -PVlil Sel4tVg ?��L[_ 4L� Property Address C�IJ� L-/CST y�pi4 SQk 4 iLT_ Sd�L_ kq,4, Located in: Conservation AreaHistoric district -- APPLICATION DATE Use Groups `Q (check one) U Group Homes R3_RJ_ ry ✓ Residential (3 or more Units) R2_ Type of improvement Residential (hotel/motel) Rt (check one) Assembly(Theaters) Al New Building_ Assembly(restaurants & clubs) A2r_A2ne_ Addition Assembly (churches) Al _ 0 Alteration Business B_ Repair/ Replacement_ Educational E_ Demolition Factory (moderate hazard) Fl _ Move/Relocate Factory(low hazard) F2 Foundation Only High Hazard H_ Accessory Building Institutional (residential care) 11 Institutional (incapacitated) 12_ Institutional (restrained) '13'x--` Mercantile M _ Storage SI _Moderate Hazard Storage S2_Lock Hazard OWN'ERSI1111 INFORMATION(Please type or Print Clearly) OWNER Name nl A V0-- VA u U=SS Address °I CL An A-v F— iQ\ J 2 M ! 1 4 Telephone n o o r Signature _____ - _------ DESCRIPTION OF. )YORK TO BE PERFORMED ��/JJ>±-'Fg p���f� GZ„ .S Nn a t.L S cr Get1 t�) r-o o w\ l✓ t 4— L\ C- PrP At G l+E 04- .,-O SIO If ESTIMATED C \STRU "170 CUS'1' 2k 26 i CONTRACTOR INFORMATION Name _ a✓,o McPAC rie-. Address fle> Pe'P-I CIEC(C Glo�ce)ler- Telephone 97 d 017- 1 6 e f Construction Supervisor's Lic # C S 7 C 88 ro Home Improvement Contractor# A4cni'1 EUVENGINEHR INFORMATION Name SA- v-u .I Ltva, V"rc- 14,tt. t'la.c . F � Address 2'ik S+- S4LcK Telephone 4'Ik 1I(y , s3sy Mass. Registration # f!Sri 2LSCS� aicl..��-E y.0 oo ea�r�.x, 1'1?RNII'I'FIs F.CAI.CULA'rION -j obi Estimated Cost x $11/$1,000 + $5.00= $2 CONI M ENTS The undersigned applicant does hereby attest that all information stated above is trite to the best of my knowledge under the penalties of perjury Signed C� t✓L- (owner) (aocnt) APPROVED BY : DATE APPROVED: w V CITY OF SALEM 1r 571 PUBLIC PROPRERTY srr DEPARTMENT \I\"xt ILC W,\\HI\s;IU�SI:t LL l' • S.\tl'\t,M.\\s.\' In G 11%3197- I-IA 778.71195'15 0 h\s 978-74".1846 Workers' Compensation Insurance %lridiiI Builders/Contracturs/Electricians/Plumbers i ucant Informalion Please Print Leeibly N:11T1C t Ot"utessitIrl ;amratinNlndn oluul): :Vid fess: City.Slate,zip. Phone rf: 'Type of project (required): 1 .\rr}au an employer:' Check the Appropriate bur. f 1.❑ I 31114 e� tTycr wish 4. ❑ I am a general contractor and 1 6. ❑ New c lxtruction et p ogees(full and;Or part-butt).• have hired the sub-contractors 7. a modeling 2 I Jlll o sole prnpfil'tllr or paflnef• hired oil the:Inachcd sheet. t ,hip and have pr clnployccs These sub-contractors have N. ❑ Demolition working rix me in any capacity. We arra' comp. tion nca q, ❑ Building addition 1No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions I required.] officers have exercised their riSght of examPon per er MGL 11.0 Plumbing repairs or additions 3.El am a homeowner doing ail work ' myself. (No workers' comp. c. 152, g 1(4),and we have no 12.(3RuoCrepairs insurance required.) t anpluyces. INo workers' 13.❑ Other comp. insurance required.) •4n. .g111Lcunt amt checks box pl must:dao fill wn the secbms Inlow showing thsar wurkui eunspens:aiws Iluli y mliurtulium ' I lumcuwmn who submit this affidavif indicauny she)are doing all work arW then him Wlflde eWltf.'Ietnri mutt.uhmit Anew afrdav:l indi"ank;.och. -Comrxrr,n that check this box insist anxiled.m additional.dmet showing the uanta of the subCorruwtora and their ssurlmrs'Bump.policy mfurmar tin. /,list an employer drat i.s pruvidi,gg workers'compensation insurance jar uty employe s. 8elary is rhe pulicy and job site infunnurion. Insurance Company Name:___ - Policv it lir Sclf-ins. Lie. K: __. .. . _ Expirauon Date: Job Site Address: CityStatuZlp: .\uach a copy of the workers' cornpensution policy declaration page (showing the policy number and expiration date). failure ,).secure coverage as required under Section 25A ul'.%IGL c. 152 can lead to the imposition of criminal penalties of a rine up to 51.500.00 jn&ur one-year inlprisanmcnt, Js well as civil penalties in the florin of a STOP WORK ORDER and a fine Of up to S250.00 it d,ly dgaioAl lilt volatlr. lie advised that a copy of this sialcment Inay be lar\\arded to the 0111cc ut . III\�>II:;J I411U ul dic DIA :or tomwi'ce a,\craye \crilicauon. I du hereby a c rrijy under the Painv and/enaBics upper(%�µ, that she n1/arinurlon provided above a true uud correct. ?S' - / bed CS 7C88Cb O/jicial rive wily. Do not rs'rite in this arca, to be cuaupleted by city,w town of itiol City lir town: Pl'1'InitilAccrise 0_ Issuing.itulhority (circle one): I. Id.ard of Ilc:dth 2. Building Department 1.cil1.•faRll Clerk 4. Electrical Inspector i, Plumbing Inspector 6. Other Coulacl ,'coon: .. .. phoned: i 9 Information and Instructions >fassachuseits Gcncral Laws chapter I i2 requires all emplo)ers to provide workers' compensation for their emplgtiees._ _ Punu:nt to rnis statute, an emplgrre is defined as "...every person in the service of another under any contract of hire, clprees or Implied, oral or written." An employer is defined as "an individual,partnership. .usocimiou, corporation or other legal entity,or any two or more .q the foreeoing engaged in aloint enterprise. and including the legal representatives of deceased empluycr, or the receiver or trubtee of'.ut individual,piuumerahip,auoclanon or other legal cnnty,employing employees. However the owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant of the .Iwclling house of another who employs persons W do maintenance, construction or repair work on such dwelling house or on the.rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." \IGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal ofa 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. 4, 25C(7)states "Neither the conunonwealth nor any of its political subdivisions shall enter into any contract for the performance uf-puhlie work until acceptable evidence ofcompliance 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), addresses)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 Laurance. If an LLC or LLP docs have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The allidavit should lie 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 if workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number un the appropriate line. City or Town Omclals Please be sure that the affidavit is complete and printed legibly. The Department has provided u space at the buiturn of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. I'laase be sure to fill in the pernit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pennio'license applications in any given year, need only submit one affidavit indicating current policy information(ifnecessary) 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 permits or licenses. A new affidavit must be filled out each year. Where a Koine owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e, it Jug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he ()Illcc of love5rgations %%uuld line to thank )'ou in advance fur your cooperation and should you have any questions, Please do not hesitate to give us a call. The Departinent's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax 0 617-727-7749 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT Construction Debris Disposal .affidavit (required fur all demolition and rcnu\':Iliun xwrk) In accordance \%ill, the sixth edition of the State Building Code, 7SO Cb1R section 111.5 Dcbris, and the provisions of MGL c 41), S 54:- Building Hermit if Is ISSlled with the condition that the debris resulting from a properly licensed waste disposal lacility as defined by MGL c this work shall be disposed of in I 11. S 150A. The`d^ebris will be transported by: manic of hauler) I he debris will be disposed of in tnamr of laultly) Iuhln�. of I]ciluvl v/-' HL'Ilal Ul l- nf p:iluit .lpphcaN dale fL11elIB1Ml6�i�Ef APPRQVEO BY T44E =pZC=PWQR TD A.PEI3WT SMIG GRANTED CITY OF SALEM No. f0 /46 \ owe Is PmWty LOG"in Location of aw MWwlo ow"? Yew No_ as ""% L t `h 2.kK4 S4 is PMPrny Locem in s Gw KA- ft Cawmron Am? Ya NO BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool, Repair/Repiace, Other: cor gck { u PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The underaigned hereby applies for a permit to build according to the following specifications: Owner's Name (2 ;«ncS4ccw LLC lA�.�a.< ocsz 4 Address & Phone WE ' ZYY^ Architect's Name Address & Phone ( 1 Mechanics Name P"j �1 Address & Phone i Its) Pr2-N c l Lc.Ce 0=')141 y $S 7 - rb e d What Is ttr vWvo••a WOft? MW"of kddhy? klF LCV-. n a awWq,for how m.ny Wams? WN b kk%Q wrd to haw? \l 5 MbW=? EatMWed ooat lS S XD Cay Uw w r N p` Stare Llorrwa r C S 0 7G d'o //� \ aaaa 7apro�eiant Lie. / iqa4sk S' re of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE _ t'Z`el� ea��rk t P�►� t.utid.ls I �e�lG�� ��.�aoK-, —r MAIL PERMIT TO: C,'Ltsi<S4dr ., , o faal- T�J:� NO. APPLICATION FOR PERMIT TO LOCATION PERMIT GRANTED Tc)ae I31) 2dD (� APP OV D :V P"ICTOR OF BU NGS i i� ' CITY OF $ALMN9 MASSACHultTTS PUBLIC PROP[RTV 0XpARTMtMT tab W""'NaMMl ftn69T. 300 Puma SALEM, MASSACHUSETTS 61970 TELEP"Gkl b 970.745-969e W. 300 FAX: 678.746•Ee4e 3alels 8uiid�®tr D�z��.,�._ Debris Dlsowd Fa[w Yn accordance with the provisions of MQ,c40 3 54. a condition of your Hu�Tding Permit is that the debda rmddng from this wark SW be disposed Of in a pt+opedy licensed solid waste"disposal facility,as defined by M(ML Chapter UL 3150 A. The debris will be disposed of in: -►'��Sc�„` Qac, 1'4�a� �`"r°�' (Lo cation of Facility) Nth Signature of Applicant S Data 7Ars CofftasoafacoltAt o M " u► Dcparffuearf ohm aidatb Cffla afl WUIAWVM met ' Beafoay MA CIII WOMMagpWAN Workers'Compenudoa Insurance AmdAMM 209&& 4ContradorsMecdidamyplamben ADDNeaut In% matiovPlnae trtet :olh1.. Name Addmm- CA ce-N + ' - � � Or�P?o AM 3-74 Are you an C10et tlli pest' _ Type of pvjm*"gree 1.0 I an a employer vvitL Q I am a DMara1 eoatractar and I qftm(lYBee&Wpnt-dee}e havepiedAariteeataeeoes d• 13 New 2 oma sora ptnpatpor or PWOW6 Hoed an an at" d sheat i 113 Remtdeffog ship and have no eatpiwjm Tbese ab-convacen bave L ❑DemoMi n brnMi� aorop,' (M wororkaa'comp&� S. owe oorIa .' , 9, Q ragaited t-� ,: o8 hers*v ` ioU Firstar rwoke or addmoar 3.0 Iamabomeowmad0*28wat Tworg U, lLQPlembingtepa�aradditioms myself IN*V '.comp a 152,1i(. ;!�;�eb,v,m 12.13 •Aqav&addrdrrbbeael awe dooalataguWaaedo.ronhae,#. , aoaon.Me. Inom�ova.� dmMeY.®aw aetox.oddoa4.at.ear� a.H`oo.aiad.d..w�6mi .t6madneso* tCo.roebataotdtooaellrtraa'�mtreodr0roddllkaotdoorSoriaar�artMaYaiooae oa/tboiwe�ra'coup Po"i I as aY t+ePkD'/tAaf b�►er�rt rar#aa'e�a�oda�r�y�a4��rla'ddw►b tA1/ali�as�fol arks br�iraser6a Imarance CoaopanYNams Foft 0 or Self-ins.Lia. M.- Job kJob Side Address: MY&M7*. Attach a copy of the wwkwle eom Omgfm pofky dedvadw pap Okwfay the part samba and eaphMdoa date} Fame b sacro oavMjP s req"Under Section 21A ofbl(x a 152 an lead b the inVosidoa oferimiod penatttea of a fisc op In f I'SWOO Anwar oasyear fiWiNDOMM as wel as dvtl pmeNes in spa form of a STOP WORM ORDER and a fine ofup a$250.00 a day against dte viobmc Be advised that a COPY ofth statement maybe ibswasded b&g0j&@ of Iavesdgatioaa of the DIA far fide rance coverage vaifiadoa. 1 M Am4P ew0 a Ave Aa paha an dpoxdd s o� et uie lvf naaloaorov!/r/above b Ursa aaJeen+ee�t "—��diDoer Phone $S7- 1(.Si Offle/d ass oa► Di oaf wr*la dib aaq to dv eawpfelahY edoobms OlLid Clly ar Toww l ermW1leesse 0 Issafal Audwtty(drde oae)t I.Board of Heahb 2.Bufldfng Department 3.ChYfrows Clerk 1.Eleeb isecatiih ela inspector 6Other mb Contact Faust Those A Infrmation and Instructions o . .. .... �. . �,���• wda,w wM,"at'h,* V"atimtied,drat ar written" ert ,,,,�,faro or=mots moeldfog4 �abab�l ®piayet4ortbe �,rt mditriBstL w est abo reridet tbeteia,ar me oarpac . Ywuec of a b�y,�aoc mora tbsa tbta� at rryeit'tvm#as meb da�eWsi boaao �boWdmot4ae ®P1dYapcows Scmumil�a>t •becow mem mertl°a°a"°°41°ee:mrPloYea' at as the sMlft a<ba � da wttbba as butte or ,Lo sates drat"e r+7 orad w um ti and bd tba d*for aq UM ebapte:l3�.4�� a bb-ar a anrtraet eildaV eeveriM regdrel �bm art P""W me* armor Dol�a1 rhaY ,ttdd dow** 15%PM saft-NeAff IM otpoblieardorm*aoc�cVidC °o[am+vt&6armmeiararaoc. ottlfr cbav�baraeearp��o�raoskas ApV WM �IMwy coup" �byclMfttbeboawthat2P**7wsi Of phare aout the s)sddtaa(d)nt4P�0° p�ptlms>dpa �°;dwk o 0.m. secarsrg mPyb' ,0=a Lio»aed Y.iabdigt bi as U.0 ar t.iP door bow bwams mambas ar vamar�.0 not mvw to day�w o�a DrVacaumt pouey>s reg Be advitted �M Abe bto dp u+date the amdavlR !b°'Sfd"'rt'LoDqpxrunct�otit AccidenS���w"to�'�"°°,� �rmepao�tam law of � wolken be IcuuDdlndOWW�wo�' SDyaldyoabttvetmy q,pedbdoa. Sc*iararatt gbonlddatatbei: dL.XCA ,ilarasruea Car or Town Ol chdo ,sp,c,at the botbm Ptcma be mrn dot the a�is complete dad P�le�b1Y• � wnW youn�,be aWplll rr. 110 of the af9days tat Yom to®oat m the eve�w9l be used w a refawee=mbar. lua an apP� pleats be tme to�in the P is a ear,need only submit one of ldwd tedicaft auratt P '° " •the appueant tboald arils"aII loatfe°°'is (e�'°f dist=a subm ( ed the aty ar tows w"be provided to d w towel"A M..Griealb6abrrbudaMeidlFrteaLalieeot�ea Adewa�dmitmabet'JlledoutesCh ,v,.s y�dat a valid atffidavii o u file tares�mtt rebned, MW p bmtiow ar commaei�venom ar d*M i obtahtt (�s�e or y��a bon leaves eta)Lard Faroe it NOT required b complete thir afHdagit The O@ior otlavatiiadom�aid bre 0 tbaot yes► io advance fog your wopaadoa and sbosbt you bave any 4�0� pleads do mtbeai"a�us a ca9. 1be pcparmrent't addreab talep w dad fns nmobQ The Commonwealth of Massachusetts Dgm=cot of Indust W AceWenri OWN dTnvesdpdous 600 Washington street Boston,MA 02111 TeL d 617-7274900 ext 406 of 1-877-MASSAFE Fax 0 617-727-7749 Revised 5-26-05 wwwmm.gov/dia v e ✓lieC.'~..v a' o� as uaeCG _ Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 142452 Board of Building Regulations and Standards Expiration: 4/512008 One Ashburton Place Run 1301 _ Type: Individual Boston,Ma.02108 DAVID M.MCPHERSON DAVIDSON i 10 HESPERUS ERUS CIRCLEGLOUCESTER,MA 01930 tM Administrator Not valid without signature - 4 I �e ii�omman«rvall� o�✓�auealla ! BOARD OF BUILDING REGULATIONS 11 License: CONSTRUCTION SUPERVISOR Number: CS 076880 Birthdate:08117/1963 Expires: 08/17/2007 Tr.no: 2657.0 Restricted: 1G` DAVID M MCPHERSON. 10 HESPERUS CIRCLE- C GLOUCESTER, MA 0193,, Commissioner 1 �.��___.. -�a-�� ���-���� � ,� . �h� � The Commonw�ith of M assac�usetts , A Department of PubiicSafety Massadius�ts8ffie Building Code(780 CMR) Building Pem�it Appiicatia�fw any Building other than a Ono-or Two-Fami ly Dwetling (ThisS�dion For Offi6ai UaeOnly) BuildingPermitNumba: DateApplied: �ildingOffidal: SECTI ON 1:LOCATI ON(Rsaee i�dirate Bladc#and lot#for lo�tions far whieh a atreet�drees is not available) / t �AD.`A ���fe MHI/ , �/t,r�i9 oi97o y�jdtcu.t.� Ql�ce, M�4� No.and Sreet City/Town Zip Code N�ameof Building(if�plic�le) SECTION 2PROPOSED WORK Editio�of MA 3ateCodeused_ If New Construction d�edc hereO or diedc all that apply in thetwo rowsbelow Euisting Building O Repair❑ Alteration O Addition❑ Demolition O (Pl�sefill out and submit Appe�dix 1) Ch�geofUse ❑ Changeof0aupanq ❑ Other ❑ S�edfy: Arebuilding plans�d/or oonstruction docvmentsbeing supplied aspart of thispermit application? Yes ❑ No ❑ • Isan Ind�endert 8ruriural Engineai�P�a I�view required? /Yes O No ❑ &i�DesQiption of F'oposed Work: ` - /' O�) l�✓ � �",Z�rs a ( i ivr/-1// �� L L�� i SECTION 3:COM PIEfE THIS SECTION IF EXISTINCa BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY ChedchereifanE�datlngBuildinglnvestiga�lonandEvaluadonisendosed(See780CMR34) 0 ExiSing Use Group(s): Roposed Use Group(s): SECTION 4:�JILDING H9GHTAND AREA - Existing Roposed No.of Floorsl 3ories(indudebasemert levels)&Ar�Per Floor(sq.ft.) Total Ar�(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Chedc as applkable) A: A�emblyA-1❑ A-2O Nightdub ❑ A-3 ❑ A-0❑ A-5❑ & Busineffi ❑ E: Edutatlanal ❑ F: FtO F20 H: Hi H�ad H-1O H-2O H-3 � H�O HS❑ I: Inetitutlonal I-1❑ I-2❑ 13❑ I�� M: Mercantile❑ R: ReddeMial R1❑ R-2❑ R-3❑ R-4❑ S: Storage S1❑ S2❑ U: Utilily❑ Spedal Uae�and please desQibe bdow: �edel Use: SECTION &CONSTRUCTION TYPE�Chedcasappliable) IA ❑ IB O IIA � 116 O IIIA � IIIB O IV O VA O VB � �CTION 7:SITE I N FORM ATION(refer to 780 CAA R 111.0 fa defalls on�ch ltem) Water3upply: � FloadZonelnformation: SearageDiaposal: � Trend�Pertnit D�risRemoval: Public❑ Chedc if outsdeFlood Zone� Indicatemunidpal❑ A trendi will not be Lioensed Disposal Slta❑ � Rivale O or indentify Zone or on sitesystem❑ required O or trendi or spedfy: permit isendosed ❑ � Rail►oad►Ight�ONx18y: H�a�dstOAf�NeVig8H0�: MAHisloricCommissonRe�iewProoess: NotAppli�le0 Is9trudurewithin�rporta�proachar�? Istharre✓iavmmpleted? orConsenttoBuildendosedO Yes� orNo� Yes❑ No ❑ SECTION&CONTENT OF CERTIFlCATE OF OCCUPAN CY Edition of Code: UseGroup(s): Typeof Consiruction: Omrpant Load per Floor: Dcesthebuilding mntain an�rinkler 9�sten2 �edal 3ipulations `� 7g- �f�� - 2��- (j�-[� INc���-�'`�����' ��' �� .. , SECTION 9 PROPERTYOWNERAUTHORIZATION N ame and Address of Roperty Owna � N�ne(Rint) No.and8re� � City/Town Zip property Owna Contact Information: Title�� TdephoneNo.@usiness) TdephoneNo. (aell) e-mail address If applicable,theprop�ty owna hereby authorizes Name 3rcetAddress City/Town 3ate Zip to ad on the r ert awnerabehalf,i�all mattersrdffiiveto work authorized b thisbuildin ermit liq[ion. SECTION 10:CON STRUCTI ON CONTROL(Pl�se fill aR Appendix 2 Ifbuildin Islessthen35,000a.ft.olendosetl aae�d/andundaConslructionControlthen O ski io 70.1 10.7 R a6ered Profe�ional R ble for Canatrudian Contrd Gabe Gabrielli 617 584 1453 gabeg86�gmail.com 39794 Name( istrant) TAephoneNo. �mail address Registration Number . 14 Elm�treet Acton MA 720 Civil /30/2012 StredAddress City/Town State ip Disdpline pirationDate 10.2General Cantraclw Compan Name �(°,P� 0 oC� e NameofPasonResponsblefar nsiudion Licen�No. andTypeifAppli�able �S� ,�o,�i�� �i�9c �o �-��.r�';�-r � ,uA o/9�3 8reet Address City/Town State Zip ���� f - 1 ?6� - - Tel honeNo. busines Tel honeNo. aell e-m�laddress SECTIONII:WORKERS�COMPENSATIONINSIR4NCEAFFIDAVIT M.G.L.G15L %C8 A WorkefsCompensation InsuranceAffidavit from theMA Department of Industrial Aotidentsmust beoomplet¢d and submittedwiththisapplication. Failuretoprovidethisaffidavitwillresultinthedenialoftheissuanceofthebuildingpermit. Isas ned Affidavit submitted with this IicationT YesO No O SECTION 72CONSTRUCTION C09TSAND PERMITF� Estimated Costs(Labor p �t� and Materials) Total Construdion Cost(from Item 6)_$ 7�� 1.Building � $ � Qo o ' Building P�rmit Fce=Total Construdion Cost x_(Insert here 2 Electrical $ appropriatemunidpal fador)_$ 3.Plumbing $ Note:Minimum fee=$ (mnt�t munidpality) 4.Mechanital (HVAC) $ 5.Mech�ical Other) $ Endose chedc payable to 6.Tot�Cost $ QO U (contad muniapality)and writechedc number here SECTION 13:SIGNATURE OF BUILDING PBtM IT APPLI CANT By entering my namebelow,I hereby�test under thepainsand penaltiesof pajury that all of the informatiom m�tained in this application istrueand aowratetothebest of my knowledge and understanding. � ��9�/���Cc=" !c� -6w,�e 'C �7�_y1���� _,- e Po�seprint and sgn name Title Tdq>honeNo. Dffie �v Mt��/e S ��n��i s✓I I� _ O �. Street Addres City/Town - 3ate ip Munidpatlnspedortofilloutthisae�ionuponappU�adonappro�ral: � � l N�ne Date ��j /� // � . . . . ,.. _ . { . . . . _`\�\ . . . : '� O W /! � � �l� .. � v.�� �r�eWS _ ��g ��° ' � 5 a,� r , ��i� � ..�.,- _ _ _ _ `'` : ' I'x!'� ? ���w. . ' � � � '���x1� 1 'Xj� I�X �� a t 53" ' !' _�,� + �.-�� --� . —�'��z.������ �aL� .� �( �R� zo�rTt��- . , r r ` � .__- � • � . � �,--' �` ` �.� a � � ;� r� t . � ' ' � � t -:.('► Y ) � � ,. . � .- // . . � ` - F` , �� � � ,��.. v� ��.� ��� �� � � � � , � �, . � ,µ . , C� v,. � �� y " �_� ��•� I � � � \ � , . ��� � ��! v� � �--. ; ►� � � ,�� � � � � I ,; ' �I - �� . ! ,� � `� - � � ' �.' �� �i . } 1 .;. � �o ` \ ` '� � - . � ., ��. Q� "../ �bl�" �(ORiZON'rRi-- �la *� � , -,--�F' �_.,�R R�e K-�l ,� �:. � -�:...�_..---� `�,y � /4`� Gb'� , _ �� ' � � �j *d J � `'^�. � , 5 L F / I � X i 7 �� n I — -- ` ' . y�' "____.""""""=. ' — , _ � 7 � g�' -i . �d l ' ► o'!�" --_ JOB t K'vk Dodge - I � SHEETNO. OF � �347 Rowley Bridge d . 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