161 FEDERAL ST - BUILDING INSPECTION (6) h� The Commonwealth of Massachuset&�
Department of Public Safety
II� Massachusetts State Budding Code(780 CMR) 161b JUL 22 A H* 23
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:
t� SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address its not available)
J'u`2-w O1 41�0
No.and Street City/Town Zip Code Name of Building(if applicable)
1
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❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No lsr/
Is an Independent Structural Engineering Peer Review required? r , Yes ❑ No C�
Brief Description of Proposed Work: Fti: 3 8�r,ti.;,�-- I S C.r .
of 64 FAR ( S1 �t 0�t4 . W e 4^e �.-o Fe Cale �. cell
o Or` r r way
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 ❑ A4❑ A-S❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ 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 ❑ 1 ILIA ❑ I11813 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:i h Pe
rmit:ermt:
Water Supply: Flood Zone Information: Sewage Disposal: Trench
Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
required❑or trench or specify:
Private❑ or inden[ify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: :NI A I Int.,ic
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 -
i"61 0 I.LC z32 Wes•. . --�' g�S�` MA0211{�
Name(Print) No.and Street City/Town Zip
Property Owner Con ticUnformation:
c_a .w
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 property owner's behalf,in a6 matters relative to work authorized by this building permit application.
SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less thin 35,000 cu.ft.of enclosed space and l or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control- !� ,i.o
(' ^- -
AC . S - '•Ial+ n4 F'� 4Q MA - 3o l 6 S
Name(Registrant) TelE ne No. e-mail address O( 'j -7(3 (fie�is�ationcNumber %
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
cc - ( ac -73 -7
Name of Person Responsible for Construction License No. and Type if Applicable
Z_32 \�Si- ea �#-4 Soso MBE- oz1
Street Address City/Town ` State / Zip
Fr I
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COt,4PI NSA I'ION INSURANCE AF'F'IUAVl'1' M.G.C.c.152.9 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 13 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE' -- -
Estimated Costs:(Labor
Item 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 $
d. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
$. Mechanical Other $ Enclose check payable to
6.Total Cost $ ) O 1 O a d (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 Tel phone No. Date
-z-S z 6
Street Address City/Town State Zip -7 /
Municipal Inspector to fill out this section upon application approval:
Name Date
r The Commonwealth ofMassachusetts
Department oflndushWAccddents
I Congress Sttteet,Suite l00
Boston,AM 02114--2017
www.massgov/Ada
Workers'Compensation Jusurance Affidavit:Builders/Contractors/Electricians/Pinmbers,
TO BE F11"WITH THE PERMM MG AUTHORITY.
Applicant lnformatdon PleasePr]M Lenibly
Name(Business/oissai itim✓Iadividual): o A k
.. Address: ?— Z.
City/State/Zip: V> b 5 �D Z(«Phone
Are you ar employer?Check Me appropriate box.
1.❑I am a employer with employees(full codlor . Type of project]dition
tee)' 7. ❑New con2.❑I em a sole pmopaietor or parmerahip and have co empkyees woddng forme in
MY capacity.[No wakens•�comp.inanance required.) 8.�❑Remodel
3.0 I am a homeownerdoing all work Myself.[No wairm.stoup.imaanme requ md.]t 9. ❑Demoliti
4.❑1 am a homeownerand will he hiring contracwn to ccofirct au work on my property. 1 will 10❑Building ease that all rnntractar dtbtohave workers'wmpemanion iasa k e sare sole 11. Electrical
proprietors with no employees. ❑ tions5. am a 12.❑Plumbing tions
❑ general factor and I have hired the sub-rontrectas listed on the amched sheet
Mines sub-conpaeas here employees sat have wodres•comp.imunniml 13.❑Roofrepai
6.�em a corporation and its offices have exercised their tight of exemption pw MGL c. 14.❑Other
152,61(4),and we here no employees.[No waters'comp,insurance required.]
*Any applicant that checlo;bar#1 must also 8n om the section bekrw abowing rhea wakens'ampmseppn polity information.
Homeowner who submit this affidavit"odiwtmg they are doing ON work and then Eire oueide contractors must submit At new affidavit indicating ruck sconractors do check this box muss attacheA sn additiocol them showing the come ofthe ftuh r crrs and site whether a art those entities have
employees. If the subiontracars have employees,Mey mustpmvide tbetr viorkers'comp.poheymm ber.
Jam an employerthaf is providing workers'compensation insurance
injormaBon. for my emphyees. Below is IhepaUcy andM site
insurance Company Name:
Policy#or Self-ins.Lic.M Expiration Dater 1 Job Site Address:__ ( (6 l �e� e-r gl S�� City/State(Zip: Za1s� ✓� O� q -1 O
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penelties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
i ao hereby certify under thepains andpenaktes ofperjury that the mformadon provided above it true d correct
Signature. - ter: 2 .� 6
h e#, � � �( O - � S t g
F
e only. Do not wrtte in this area,to be completed by city or town official
wn: Permit/License#
thority(circle one):Health 2.Building Department 3.City/ own Clerk 4.Electrical Inspector 5.Plumbing Inspector
son Phone#
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 a joint 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 then 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 sub-contractor(s)name(s),address(es)and phone number(s)along with their certificates)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 c 'ate 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 penrvVHcense number which will be used as a reference number. in addition,an applicant
that rrumst submit multiple pemrit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)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 narked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for fume permits 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 burn 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, Suite 100
Boston, MA 02 1 14-201 7
Tel.#617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
OWOFS ALEM, MAS'SAQhIEETP.
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120 W useSnWx-VOROOIt
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Fax 74
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MAYOR 91 AUSST. )MM
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Construction Debris Disposa/Affidavit
(required for all demolition and.renovation work)
in accordance with the sbcth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL coo,S 54; Building Permit R is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c ill, S 1WA.
The debris will be transported by:
(name of hauler) J\
The debris will be disposed of in:
(name of facility)
(address of facility)
Sig at of applicant
�? l 6
Date