203 ESSEX ST - BUILDING INSPECTION (3) ex
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-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Budding Official:
SECTION 1:LOCA1'IO (Pleas 'odic Block#and Lo #four/locations for which a eet address is not available))
. No.and Street City/Town Zip Code Name of Building(if applicable)
11
SECTION 2: PROPOSED WORK
((���; Edition of MA State Code used If New Construction check here r check all that apply in the two rows below
',1 {1� Existing Building❑ Repair Alteration ClAddition❑ Demolition ❑ (Please fill out and submit Appendix 1)
UU 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 Peer Review required? Yes ❑ No 9—'
Brief Descriuljou X10POSed Work:
SECTION 3:CO LETE THIS SECTIO 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-I ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 Cl F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
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 ❑ 1 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 I I. t'rq;( mu,.,�tiu�n.1. ...... PioSGs:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Budd 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:
I, /
oY//�J /G t�
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and)dd ss of Property Owner
`K!!im Print) No end Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the roper owne 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 building is less than 35,000 cu.ft.of enclosed space and/or not.under Construction Control then check here O and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) - - Telephone No. e-mail address Registration Number li
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
Coluipany Nan
ame of Person Responsible for Construction rc n e No. and Type if Applicable
�tr` rceett AGddress itity/To n� S/late / Zip/
—/try /yr—/tfff�j--=�l�L rY/QS ��f'Cfl�sl4 k; cOir-r�C _ , �GLI
Telephone No. (business) Tele hone No. cell e-mail address
SECTION 11:IN0RK1316'( )N1J1FNSAI'1ON INSURANCE AFFIDAVUf 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)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ - appropriate municipal factor)_$
3. Plumbing $
1. Mechanical (HVAC) $ Note: Minimum fee=$ (contact munici ity) v
5. Mechanical Other Enclose check payable to 6C//l.
a p y.
6.Total Cost $ (contact municipality)and write check number here
OSECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
p
ntering n ame below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
icatiot [rue and accurate to he best of my knowledge and urn nnnding.
�wW
se printa nd sign imetle Tele e Date
t 1 ess City/To n /fS�tale Zips
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF SALEII, N ASSACHUSETTS
• BI:umLNG DEPARTMENT
I1 130 WASHIINGTON STREET, 3° FLOOR
T L (978) 745-9595
FAx(978) 740-9846
KINiBERL EY DRTSCO[L
i1�L§YOR THO%tAS ST.PtERRS
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COSL\IISSIONER
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:
(name of hauler)
The debris will be disposed of in
(name of facility)
dress of facility)
gi re of permit applicant
it e
i CITY OF S.U.ENl, 2AxsSACHLSETTS
BUILDING DEPARTSEENT
N 120 WASHINGTON STREET, 3w FLOOR
T EL (978) 745-9595
F.4X(978) 740-9846
(V.,fBFRT EY DRISCOLt
MAYORTHObtAS ST.P3F4RR DIRECTOR OF PUBLIC PROPERTY/BUn=NG C0\12MISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information l- Please Print Legibly
Name (13usinessOrganizatioNlndividual): e e4ad
Address:
City/State/Zip:t Phone
Are you an employer'Check t e appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on attached sheet t 7• ❑Remodeling
ship and have no employees Th sub-contractors have a. ❑ Demolition
working for me in any capacity. rkers'comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. We are a corporation and its
officers have exercised their 10.❑Electrical repairs or additions
required.)
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.[No workers'comp. C. 152, 41(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required.) I3.❑Other
Any applicant that chocks box Al most alw fill out the wctioa below showing their worlmes compensation policy inlurmation.
I fi.eownem he submit this Amdevit indicating they am doing all work and then hire outside connectors must sub,It a new amdavit indicating such.
:Comractoo that check this box muat attached an additional sheet showing the name of the sub<onto eors and their workers'comp.policy infomution.
l um on employer that is pravfd/ng workers'campensadan insurance for my employees. Below is the policy and Job site
informaliam
Insurance Company Name:
Policy k or Self-ins. Lic. H: Expiration Date:
Job Site Address: City/State/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
line up to S 1,500,00 and/or one-year imprisonment,as well civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. 13e advis• a copy of this statement may lx forwarded to the Office of
Investigutiotts of the DIA for insurance covers ed- alion.
l do hereby y ceder rile pains penaltie ojperjury dint then pro vldrd above is true nd correct
Data: /Z
P n Y:
Euse only. Oo not write in fltls area,to be completed by city ur town aff rlaL
n: Permit/Licemethority(circle one):
licallh 2. Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
rson: ... _------. Phone#: