162 FEDERAL ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Sao JUL 22 A 11* 23
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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No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK.
lN_.Jl Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration Cl 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 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 ❑ ❑ 1
Brief Descri tion of Proposed Work: �_�.. S r..... r S ar r ��-e-r. o r o ,(•'-h
ok6 2—
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): I 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-5❑ 1 B: Business ❑ E. Educational ❑
F: Facto F-1❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional 1-1 ❑ [-2❑ 1-3❑ 14❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 160 IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CIVIR 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❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: %M i Ir t,_ri.;Commi n-si Ro i v I roo-ss:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ or No❑ 1 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:
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,. a . 'SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of.Pfnpeity�Owner
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Name(Print) .p ,y ,�r _' .No,and Street City/Town Zip
Property Owner Contact Information:� 1-703_cno 7S( � 0
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 all matters relative to work authorized by this budding permit application.
SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix 2).
If budding is less than 35,000 cu.ft.of enclosed s ce and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control .ce+- -
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Name(Registrant) Tel�ephpne No. e-mail address Registryttion Number
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Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - - - - - -
Company Name
it L.S - IC> ( 73 ?
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zfp
-703.48 a_ ?51 e:�k b {�, -,k 16 �. C-0 ...
Tele hone No. business Telephone No. cell - e-mail address
SECTION 11: ION INSURANCE AfiflUi\Vfr M.G.L.c.152.§ 25C6 -
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)_$ y_� '�
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4.Mechanical (HVAC) $ Note:Nlininmm fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ 2.o d a (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.
S(8'
Ple3 p�rin[an n nam^ / rl a Sd�....Title MATclep6hon 1 No. v —Dat{e—
Street Address City/Town ""State Zip rJ
Municipal Inspector to fill out this section upon application approval: `° c /
Name Date
The Commonwealth ofMassachnsetts
Department oflndustrWAccfdents
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/ContractorsMeeMdans/plumbers.
TO BE FILED WITH THE PERNIITTING AUTHORITY.
Applicant Information Please Print Lealbly
Name(Busioess/Orponatioa/fndiviauan: a,.-` .�... . .
Address:
City/State/Zip: S pzd
Phone#: 7 � � gb - 7 5-
�
Are you an employer!Check the appropriate box:
1.0 1 am a employer with employees 7(full and/or . ❑Npe of ew
(required).
t:onstruction
2.0 I am a role paoprietur o partnership and have on employees working turns;in
any capacity.[No wcd=' mamaaee 8. []Remodeling comp rearmed] ❑ g
3.0 ram a homeowner doing as work myselL[No workers'comp.insurance required]1 9. ❑Demolition
4.❑I am a homeowner and wdl be hiring e,cuaoms to conduct all work on my property. I will 10❑Building addition
mture that all contractors either have workers'cornpensmfon insurance or are role .
proprietors with m employees. 11 ❑Electrical repairs or additions
5. lama 12.01lumbing repairs or additions
❑ 8e a1eonwctm and!havettw the su"dose,orslistedm theaanched sheet. 13.❑Roofrepairs
These sub-conuactom have employees and have workes'comp.iavmance.r
6.E(We are a corporation and its offlcas have exercised the rright of exemption WM(M c. 14.❑Other
15Z§1(41 and we have no employee.[No wokcts'croup im ram,,required)
*Any applicant the ebech box#1 must also 51l out the section below showing their workkes'onmpousation policy mannation.
'Homeowms who subrmt due affidavit indicating they are doing as work and than hire outside enaaaetms must submit a new affidavit indicating such
'Contractors that check this box must attached an additional about showing the nome of the sub-contractors indicate whetter or not those entities have employee. Ifthe subK lmcmrs have employees,they muss pmvide lbeN workers'comp.policyaamber.
I am an employer,Mat is providing workers'compensation insurancefor my
informandon. employees Below as thepo!!ry andjob site
Insurance Company Name:
Policy#or Self-ins.Lic.M Expiration Date:
Job Site Address: aTy/ ��p
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 line up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains andpenalties ofperjury that the lnformatlon provided she is true d correct
Signature- �— eta -7 7T( 6
OF7��
e only. Do not write in this area,to be completed by cityortownown: Permit/License#
thority(chcle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
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,parmership,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 than three aparmreuts 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 rnnsh d 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 certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited liability Partnerships(LLP)with no employees other than the
numbers 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 N7o 'ate line.
City or Town Officials
Please be sure that the affidavit is corMlete 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 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 marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future 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 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, Suite 100
- Boston,MA 02 1 14-201 7
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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Construction DebrrIs Disposo/Affldovit
(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#I is issued with the
condition that the debris resulting from this work shall be disposed of in a property licensed
waste deposit 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) D 0
(address of facility)
Si nature of applicant
t b
Date