54 FORRESTER ST - BUILDING INSPECTION c* l-7
- ISol
The Commonwealth of Massachusetts
W Department of Public Safety
Massachusetts State Building Code(780CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Onl )
Budding Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a skeet address is not available)
aR&'S;�M 42r s � , vyy d' Wr z
Nu.and Street City/Town Zip Code Name of Building(if applicable)
SECTION2•PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply I it, the two rows below
Existing Building❑ Repair❑ Alteration ❑ Additimr❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ - Change of Occupancy ❑ Other ❑ Specify
P fr
Are building plans and/or construction documents being supplied as part of this permit application? Yes Nu ❑
Is an IndependentStructunl Engineerin eer Review requireJ? Yes ❑ No ❑
Brief Description of Proposed Work: Q•}3/-L �(7 j'p ,� �A.�l r
SECTION 3:COMPLETE TFIIS 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 Cruup(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 a licable)
A: Assembly A-1❑ A-2 Cl - Nightclub ❑ A-3 ❑ A--1 ElA-5❑ B: Business ❑
F: Facto F-1❑ F2 E: Educational ❑
❑ fi: Hi It Hazard H-1❑ H-2❑ H-3 ❑ Ff-4❑ H-5❑
1: Institutional 1-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3 O R-4❑
S: Storage Sl❑ S-2❑ I — Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ III ❑ IIA ❑ 1111 ❑ IIL1 ❑ IIIH ❑ IV ❑ VA ❑ VB O
SECTION 7:SITE INFORMATION(refer to 78U 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❑ Iadicdte municipal❑ 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: V._\I liaa rrt innnii.ci m It airy,1'r��.hs:
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:
Dues the building cnnldin an Sprinkler System?: Special Stipulations: —
SECTION 9: PROPERTY OWNER AUTHORIZATION
a
Name,am Property Owner
"fEQ S� rd RR6.4T��— 4% /l�I� _4L�Zl
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
' I��CNfFG�I � ala/� CoH
Title Telephone No.(business) Telephone No. (cell) e-mail addr s
If applicable,the property owner hereby authorizes
N:une - Street Address City/Town State Zip to act on the property owner's 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.R.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(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
11cf�y 7r ;r &i (,
Company Name
41,
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address
- City/Town State Ziip�
7� ��L.- - fY//'/n//C/JyD.G/if'iy QlldAb/L
Telephone No. business Telephone No. cell mail addr ss
SECTION 11:%VONKERS'COMPENSA iION WSUItANCE AFFIUAVII M.G.L.c.152.S 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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$�S
1. Building "+ Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing S
d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ n Enclose check payable to
6.Total Cost $ 3/ �SQt (contact municipality)and write check number here
SECTION l3: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 acc . to the best of my knowle I a and understanding.
PI pr'ut mud si n wu a i l///!7 Telephone
Date
Street Address City/Town - State Zip
11 Municipal Inspector to fill out this section upon application approval: L
Name Date
i CITY OF SiUEIN4 N'LkSSACHLSEM
BUILDING DEPART C&NT
j 120 WASHiNGTON STREET,3"FLOOR
TEL. (978)745-9595
FAx(978)740-9846
KIMBF_RLEY DRISCOLL
;MAYOR T HOMAS ST.PTERRE
DIRECTOR OF PL•BLIC PROPERTY/BI:ILDLVG CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name teusinessOrganiratiotvindividuaq:
Address: 6<- 0 fFSrXA-A,/
City/State/Zip: S[a/�60, 0,4 a 61W Phone#:
Are/you an employer?Check the appropriate box: Type of project(required):
1.tfd l am a employer with 42�- 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractars
2.0 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These subdconttactom have g. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9, 0 Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs"additions
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers'
COMP.insurance required.] 13.0 Other
•Any applicant that checks box#1 most also fill out the section below showing their workgs'compensation policy inti m,olom
t I fomeowners who submit this affidavit indicating they are doing all work and then hire omside contractors must submit a new affidavit iadimli g such.
'Commetors that check this box most anached an additional sheet showing the name of the sub<omnaelors and their workers'comp,policy information.
I um an employer that is providing lvarkers'compensatlan insurance far my employees. Below Is the policy and fob site
information. /�
Insurance Company Name: #qe— l9'IZDI/L3
Policy#or Self-ins.Lic.#: OL 1/16 _`(V 7 /.f SRO 5 ] ,;L Expiration Date:
Job Site Address: Sff �nRl�F�Tt 4 n, ///1/ - City/State/Zip: /9zlm?
Attach a copy of the workers'compensation policy declaration page(showing the polity 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,is 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 of the DiA for insurance coverage verification.
I do here tertijy)Under the pains and penahfes of perjury that the information provided above is true and correct
Si+rat are /^ Date. j 7
Po #
Ofjtci use only. Donor write in this area to be completed by city at-town oflitfaL
City or Town: PermidLicense#
Issuing Authority(circle one):
1.Board of Ilealth 2.Building Department 3.CilyfFown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other,
Contact Person: Phone#:
CERTIFICATE OF LIABILITY I-hISURANCE bATEtMNv°°"�"'
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONIPRIS NO RIGHT5 UPON THE CERTIFICATE HOLDER,THIS
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BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTFEACT BETWEEN THE ISSUING INSURER(SI, AUTHORIZED
REPIRQSHNTATIVE,OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT; 11 the certifcate holder is an ADDITIONAL INSURED,the policy(ios)rliit he endorsed, I7 SUBROGATION Iff WAIVED,Sutyeet to
the terms and conditions of the policy,certain policies may require an andor
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' BUILDIU tG DEPARTSIONT
120 WASHNGTON STREET,Ya FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KIJIBERLEY DRISCOLL
MAYOR T HOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BU TMLNG CONMUSSIONER
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.
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sii a of permit applicant
permit applicant
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