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55,57,&59 FEDERAL ST - BUILDING INSPECTION The Commonwealth of Massachusetts Department of Public Safety W 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) R ALEK M A- Cx q 1 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 I Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix"1) Change of Use 91�_ Change of Occupancy ❑ 1 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 Q' Brief Description of Proposes{Work: C©aV a� M S— vt N P—> StDEflJT7A� t9tii It,) fl�o A't7�t��lt~D R�Vi�IrJZr\ UtJtiS Its) S � I1J 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-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Factor F-1 ❑ F2❑ I H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ 1-I-5❑ 1: Institutional 1-1 ❑ 1-2❑ I-3 ❑ I-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ 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 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV 1 VA VB ❑ SECTION 7: SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Public Licensed Disposal Site E3' P Check if outside Flood ZoneA Indicate municipal A trench will not be required El or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic lPn1t:,_ss: Not Applicable O� Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes ❑ or No¢Y 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: lL� iL�r'a tN 0C=(=tC6 CR t_t_- y • t) 4 .1 1 ?e72a-A SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner RENEL'AL yarueen �SAtAE*A r1A oil" R Name (Print) No.and Street City/Town Zip Property fO�wner Contact Information: T)ftb A& e- ���- IT/- l dPal�tch�S�tlewt �trte y t c h Title Telephone No. (business) Telephone No. (cell) I e-mail address If applicable, the property owner hereby authorizes I Name Street Address City/Town State Zip to act on the pro2erty owner's behalf,in all matters relative to work authorized by this building permit ap2lication. 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 O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registr nt Telephone No. e-mail address R�istration Number P o RBY e � O_11 lo IIGG s Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor StNLFK V2 Nj wAL- LLc! Company Name b P�[t'.►4 cs �01345 Name f Person Responsible for License No. and Type if Applicable A�n Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:LCORKERS'C0\1PENSr\"LION 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❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor Item and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ 40MBuilding Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ 760DO appropriate municipal factor)=$ 3. Plumbing $ WC00 1. Mechanical (FIVAC) $ 0co0 Note:Minimum fee=$ (contact municipality) 5. Mechanical (Other) $ Enclose check payable to 6.Total Cost $ 8,20� (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name belo attest under the pains and penalties of perjury that all of the information contained in this application is true and accr ate to th best of my knowledge and understanding. Please print and sign name Title Telephone No. Date To ss a� 6 MA- -Q1-1-77i2 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: V 2rY�✓ �z1 /�lJ�� Name Date y - O1 1 lam'SAL FJ MASSA MI IkL 74r#.M.. Ka"I J PAX 74"M MAIMDMumx ilr�SASS1sP�te crRaucmowr/smtwaOMwMja Construction Debris.Dispose►/Affldh* (required loran demolition and.renova'don work) in aoaord w whir the"Oftb a of the State Bulldhg Code, 78Da^Sectlon 113S Deb! and the prn*bw of M6L M,S 54;SIB pern*p bis:uedwiMr the oornfitlon thetthe debris reaultha from this Waicshe6 be of Ina propedly Awnsed waste dePM*lac 4 as defined by M6L c 111,S 15K The debris wIN be transported by: (name of hauler) The debris will be disposed of!n: (name of fadrity) (address of facility) Sl ature off applicant iD to ,per \ The Commonwealth ofMassaehusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 ' www mass.gov/dia Workers' Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information oo Please Print Legibly Business/OrganizationName: C,�laMn Address: 611 GbN&pr5� `aT City/State/Zip: SP�,EK AA- 01970 Phone#: Are y an employer?Check the ppropriate box: Business Type(required): 1.�am a employer with�employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/EatingEstablishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(me].real estate,auto,etc.) employees working for me in any capacity. [No workers' comp.insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4),and we have I0.❑ Manufacturing no employees. [No workers' comp. insurance required]** 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, l with no employees. [No workers' comp. insurance req.] 12.ErOther G.bNS'i-2t..C.Ctc>rJ *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box NI. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: SA)G'`e N SJ.E.e4A1C/°T Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as require a tion 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/jo:rmsurance ear imprison ent,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day age violator. e advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA verage verification. I do hereby certify, under the p and penalties of perjury that the information provided abo a Yoe and correct. Si nature: Date: i� h Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more - of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a 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,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance 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 your insurance company's name,address and phone number along with a certificate 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 insurance. If an LLC or LLP does 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 date the affidavit. The affidavit should be 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 a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary). 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 pennits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE Fax#617-727-7749 www.mass.gov/dia Form Revised 02-23-15