41 FEDERAL ST - BUILDING INSPECTION 00
1� L INSPECTIONAL SERVICES
The Commonwealth of gs h se is
� �;l 41 I' k 4 06
➢U - Department of Public
y'Q 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 Onl )..
Building Permit Number: Date Applied: -Building Official: 0.
SECTION 1: LOCATION(Please indicate Block#and Lot#for locations for which a street address rs of available)
W feJerlr.-I `ii- 4c--\eon O%q a3
No.and Street City/Town Zip Code Narne of Building(if applicable)
SECTION 2:PROPOSED.WORK
Edition of MA State Code used If New Construction cluck here❑or check all that apply in the two rows below
Existing Building Repair el Alteration ❑ I Addition❑ Demolition O (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 0�
Is an Independent Structural Engineer in Pcer Review required? Yes ❑ No f _
Brief Description of Proposed Work: I,eew.:r Cubbe:r foot- cAir\A Ae OcS
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=f❑ A-5❑ I B: Business ❑ E. Educational ❑
F: Facto F-1 ❑ F2❑ EI: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4 Cl H-5❑
t: Institutional I-t ❑ 1- CI I- ❑ l-1❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ [IA ❑ IIB ❑ IIIA ❑ IIIB ❑ I IV ❑ 1 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❑
required CI or trench or specify:
Private❑ or indentify Zone: - or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: 41,A II i i 4 C'm"m w n re w' I'm,
,
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No Cl
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:
S�.►�p- L{ 13
A 3'VI3Sff,.rION9: PROPERTY OWNER AUTHORIZATION
Name and r\ddru�yfj4s4bpg'rty Qstii�er(�;}�y24{)
P'nMk1 , Mello Ptnboc��
Name(Print) d0 l A P !Nblandl Sffeet City/Town Zip
tu';t e,ea
Property Owner Contact Information:
own CC 93 531
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 2roperty owner's behalf, in it[matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendiii 2).
If Wilding is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
Rio4�acc� �c�5� "r-LIO6- 1-+11 Cc�sSCc� cac cn1'1@GHdi I UqS�
Nanne(Registrant) TeDlephone No. e-mail address Registration Number
3�R Cflto�tcn�c:5 MMc.5 6c4 f ��3116
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
C C6Y13TCl3CaG
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
NlR I-tliokt si Oe.nuecs Ma 0111-1-3
Street Address City/Town State Zip i
�'ir_40b_ 1}}I tc�sScc,:•skcoc�aHWDGM�.�l.cc>rry
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:1V0RKERS'C 0%N1P13NSA I10N INSURANCE MFIUAVEI M.G.C.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 $ 6,150G. Od
Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$
3. Plumbing $
1. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable nble to
6.Total Cost S (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.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
01,91
CITY OF SU-E1d, �1AsSACHUSETTS
BUILDING DEPARTMEINT
120 WASHINIGTON STREET, 3aa FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
ICIJ(BERLEY DRISCOLL THOhtrS ST.PtFAAH
4iYOR
DIRECTOR OF PUBLIC PROPERTY/BC1TD[tiG CO\CfflSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
V 81nC (13usinesiOrganizariun,9ndividual): �.Lh�fG� L'o S.S _ —_
Address: 339- rII 'oAr't 5+
City/State/Zip: Vc^L:ae S View Phone 4: CA-IV L10(- -k-111
:1re you an employer?Check the appropriate box: Type of project(required):
I.❑ lam a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.y�j-+ 1I , sosole proprietor or partner- listed on the attached sheet, t 7• ❑ Remodeling
.,[tip and have no r:mployces These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. Building addition
[No workers'comp. insurance 5. ❑ We are a corporation mid its
officers;have exercised their l0.❑ Electrical repairs or additions
required.) of
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself.(No workers' cutup. c. 152, 91(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 13.❑ Other
comp. insurance required.) -
-Any applicant that checks lux 91 most also f II out the section below showing their worker'compensation Policy inlbanatium
'1 homeowners who submit this a@Irbavit indicating thcy am doing all work and then him outside contractors must submit a new afrdavit indicating such.
K?mtrwtors that check this box most attache!an additional Klima showing the name orthe subtonlncton and their workers'comp.policy infurmmion.
1 ails an employer that is praviding workers'comprasaton insurance for my employees. Below is the policy turd job site
infonaation. ii •�- /
Insurance Company Name: C-1 e' r
Policy N or Self-ins. Lie.4: 6'ri, F i tk e Expiration Date:
Job Site Address: LI 1 Feder",,_, S City/State/Zip: <,c,\-M
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to sceure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and it fine
of up to S230.00 a day against the violator. Ile advised that a copy of this.slatement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ida hereby certify radar ar pal s and pen allies of perjury that the infuriation provided above is rrue and correct.
Si,toatttrr /n _ �,6�- � Date. 3/1°t
Phunel: el-jb�
FF.,
only. Do not write in rhis area, to be completed by city or town official
n: _.._._.. .__ Permit(IJccnsc t1______.
hority(circle one):
Health 2. Building Depurtutent .1.Citylruwu Clerk 4. Electrical Inspector 5. Plumbing lnspeclor
....—Person:
_. . ._ Phone B: _ ------___ --
1
CITY OF S:�Lzm) iti L1SS:ICH US ETTS
BCILONG DEPAR-MErT
120 WASHLNGTON STREET, Jw FLOOR
TF-L (978) 745-9595
S
KiJ®ERLEY DRISCOLL FAA(978) 740-984
itiL�YO',L T�tOJL�S ST.PiERItB
Di.UCTOR OF P"LIC PROPERTY/8Ur1-DLNG CONOnSSIO.NER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL a 40, S 54;
Building Permit 9 is issued with the condition that the debris resulting fmm
this work shall be d
l 11, S I SOA. isposed of in a properly licensed waste disposal facility as defined by tN4GL c
The debris will be transported by:
ti
y
(namc of hauler)
The debris will be disposed of in ;
(narncoffacility)
------(address of tacility)
�y
signature of permit applicant
. 3 /iffy
date