281 ESSEX ST - BUILDING INSPECTION (7) a ay 3
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INSPECT0 AL S0RVICES
The Commonwealth of Massachusetts 1614 DEC 2 q q &
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: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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Q3--e- 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 El' Repair❑ 1 Alteration 19' 1 Addition❑ 1 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 Er-
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 0'
Brief Description of Proposed Work:
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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): .9 Proposed Use Group(s): 3
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❑ B: Business Er E: Educational ❑
F: Facto F-1❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R. Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage Sl❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ HA ❑ HB ❑ IIIA ❑ HIB ❑ 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 B' Check if outside Flood Zone❑ Indicate municipal E3- 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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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Name Street Address City/Town State Zip
to act on the property owners 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 0 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 Contractor
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Company Name
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Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
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Tele hone 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 IYNo 0
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
do
6.Total Cost $ 2,ST�c'• (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 the best of my knowledge and understanding.
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Please print and sign name Title Telephone No. Date
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Street Address City/Town AA fate Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
;. CITY OF S�U.EM, .%NL-kSSACHLSETTS
BUILDING DEPARTJwNT
• a• 130 WASHINGTON STREET,3so FLOOR
�f TM (978)745-9595
FAX(978) 740.9846
KIJtBBRIEY DRISCOLL THOMAS ST.PIERRE
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BL'IID1NG CO\M0:SS10NER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Busincs OrganizatioNlndividual): !/O H A-1 /<O3
Address: G,r/uH /!O
City/State/Zip: ���/L�� /7# 6/yk�:- Phone #: 97 k- �161f-- 96 6
Are you an employer?Check the appropriate box: Type of project(required):
l.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
�mployees(full and/or part-time).' have hired the stub-contractors
2. 1 am a sole proprietor or partner- listed on the attached sheet. �• El Remodeling
ship and have no employees 'These sub-contractors have g. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑hoof repairs
insurance required.)t cmployees.[No workers' 13.❑Other
comp.insurance required.]
Any applicator that checks box#1 must also fill rut the section below showing their worktas'compensation policy infurmation.
t I I.srxowrws who submit this affidavit indicating they an:doing all work and then hire outside contractors must submit a ntxv affidavit indicating Hugh.
=Centnavon that heck this box moat attached an additional shmi showing be name of the subtommctots and their woken'comp.policy information.
I am an employer that is providing workers'compensadon insurance for my employees. Below Is the policy and jab site
information.
Insurance Company Name:
Policy#or Scif-ins.Lis M Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'co npeasati oBcy 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
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. Be advised that a copy of this statement may be forwarded to the Office of
investigations or the DIA for insurance coverage verification.
/do hereby certi u der the a! s nor penahlrs ajperjury that the injormadon provided above is true and correct.
"+n:t r : - p Date: IZ /!s 2oih'
Phone#: s-r
O icial use only. Do not write in this area,to be completed by city or town ofrcial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: __ Phone#:
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,< CITY OF S�U_E:Nl, INVLkSSACHUSETTS
BUMDING DEPART% NT
• P• 130 WASHINGTON STREET, 3' FLOOR
, bs TEL. (978) 745-9595
FAx(978) 740-9846
KINtgFRi F.Y DRISCOLL
MAYOR THomm ST.PIERRE
DIRECTOR OF PIBLIC PROPERTY/BUILDING CONMSSIONER
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
4V. j4jj�o
(name of facility)
[ri a�G-l��GwrtJ
(address of facility)
signature of&rrnit applicant
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