200 FORT AVE - BUILDING INSPECTION (3) .- - '�
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��``88,, The Commonwealth of Massachusetts
,,;� ' h'Ny Department of Public Safety � il
��� bfassachusetts Statc Building Code(780 CMR)
� Building Permit Application for any Building other than a One-or Two-Family Dwelling I
��/ �. - � � . � . . � � � � (This Sectiun For Off�aal Use Only) �'�: - � � i
� Build'uig Permit Numbec� �, Date Appliea: � Bu�ldmg Official: . � ��
- SECTION 1.LOfATION(I'lease indicate Block#and tiot#for locattons for wh�ch a street address is not availatile) - .
Zo0 �Rt` /�V� ,
No.and Street City/Town � Zip Code IVame of Building(if applicable)
� . � � � � � SECTION 2:PROPOSED.WORK��-`� - � � � � �
Edition of MA Sta[e Code used_ If New Construction check here O or check all tha[apply in the two rows below
Existing Buildin� Repair❑ Alteration$ Addition❑ ,qemolition � (Plcase fill out�n1 submit Appenclix 1) '
Change of Use �' Change of Occupancy ❑ Other ❑ Specify:
Are building pl.ms and/or mnstruction documents being supplied as part of[his permit applic�tion? Yes ❑ No ❑
[s an Bidepend�nt Structural Engineering Peec Review required? Yes ❑ No ❑
Brief Description of Propused Work: � � � �
�n r��9r 2 n C(„r� /'t1.�'Fi�✓�a �M•`/
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SECTION 3:COMPLETE THISBECTION IF EXISTING BUILDING�UNDERGOING RENOVATION,ADDITION,.OR
� � � CHANGE IN USE OR OCCUPANCY � " " �� � - �
Check here if an Existing 8uilding Investigation and Evaluation is enclosed(Scc 780 CMR 34) ❑
Existing Use Croup(s): Proposed Use Group(s):
� � SECT[ON 4:BUILDING HEIGHT AND AREA � � �� � �'
- , Existing Proposed
� No.of Floors/S[ories(incluSe basement levels)&Arca Per Floor(sq. ft.) SD $ f� �SQ S F%
Total Area(sy.ft.)and Total Height(ft.) .
� � . � ' .SECTION 5:USE GROUP(Check as�applicable)�� �� � � -
A: Assembly A-1 ❑ A-2❑ Nigh[club ❑ A-3 ❑ . A-4❑ A-5❑ B: Business ❑ � E: Educafional ❑
F: Pacto F-I ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H3 ❑ H-4❑ H-�❑
L InstituHonal 41❑ I-2❑ 1-3❑ I-4❑ M: McrcanHle❑ R: Residential 2-1❑ R-2❑ R-3❑ R=1❑
S: Storage S-1 ❑ S2❑� U: Utility❑ - Special Use O and please describe below:
. Speci�l Use: �
� � SEC'IION 6:CONSTRUCTION TYPE�(Check as applicable)�� , � �� � � � �
IA ❑ B ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ N ❑ VA ❑ VB ❑
� SECTION 7:SITE INF02MATION(refer to 780 CMR 111:0 for de[ailsbn each item)`� �
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit. Debris 2emoval:
Public A trench will not be Licensed Dispos�l Sire
'� Check if ou[side Flood Zone❑ 6idicate municipal❑ required O or trench or specify:
Privare❑ or uidentify Zone: �or on site system❑ �ermit is endosed�
Rail[oad right-of-way: Hazards to Aic Navigation: h(A I hstc nc Cumnu,sron t��v�i�� 1 r i c�ss;
Not Applicable❑ Is Structure within airpor[approach area? Is thcir review complcted?
or Cunsent to Build encbsed❑ Ycs� ar Ni�' � Ycs❑ No ❑
�� �� � � SECTION 8:CONTENT OF CERTIFICATE.OF OCCUPANCY � - � � � � � -
Edition of Code: Usc Gmup(s): Type of Const�uction: Occupent Load per Flooc
Does the building contain an Sprinkler S}'stem?: Spetial Stipulations:
� �
� , �
- � � SECTION 9: L'ROPERTY OWNER AUTF[ORIZATION - � � � � ;.
Nam and Address of Property Owner � � �
_ �a _ n✓� a P ��w7`t�tt� ol q 7
Name(Prin /j`��y v`�l �pci Street Ci[y/Tutvn Zip
. v �,iC�l�,y
Property Owner Contact Infonnation,:�,�p ,��� /� y
r�r� 1 V1 e �' �ZE•8'-fK'i'`7`.�ZGJ�/ _--- S I/0 4/9 '/� t a�ee.r C'tl 41/�
Title Telephone No. (business) Tclephone No. (cell) � e-mail a�
If applicable, the property ownec hereby authorizes
Nvne Strcet Address City/Town State Zip
to act on the ro er owner s behalf,in all matters relative to work audiorized b this build'ui crmit a lication. �
� � � - SECT[ON 10:CONSTRUCTIOMCONTROL(Please�fill out Appendix 2) ; - .
If buildin is less than 35,000 cu.ft.of endused s ace and�or.not under Constniction Control then check here O and ski �Section 101 .
101 Re��iskered Professional Res onsible for Construction Control �� - � � �
N�me(Registrant) Tclephone No. e-mail�ddress Registration Number
Strcet Addcess City/Town State Zip D'vscipline Expieation Date
- 10.2 GeneratContractor - � ; -� ' � � "�" ' � � �
��c c� �2�o I/��2 r un 2.��S
Company N�me —7 �r(�
CS - o ! 70 l 7
Name of Person Responsible f r Construction License Nu. and Type if Applicable I
3o C(��e��� fe Q�,e S�(e� �t c, � 70
Strcet Address City/Tuwn State Zip
�� -�2q yt -_ ��s v o e o � �/'cY Lior� • n a w�,
Tcic hone No. business Tcle hone No. cell �vl ad re�
� � SECTION 11:\VOI I.EItS'CC)nil�I-!VSA'P7C>�.INSUit:�\C7;:4EF�D�>VI'f�M.G.L.c.152�. 25C 6 � .
A Workers'Compensation Insurance Affidavit from[he MA Depaztment of Industrial Accidents must be completed and �
submitted with this�pplica[ion. Failure to provide this affidavi[will result in the denial of[he issuance of the building permit.
Is a si�ned Affidavit submitted with this a lication? Yes❑ No ❑
. . . - � � � -. SECTION 12:.CONSTRUCTION COSTS ANDPERMIT EEE � . ��
Item Estimated Custs:(Labor
and Materials) Total Cons[ruction Cost(from Item 6)_$
� . 1. Building � � � � giii��{�S permit Fee=Total Construction Cost x_(Insert here
� 2. Electric�l � Q O � appropri�te municipal factor)_$ �
, 3. Plumbing $ d Q '
4. btech.�nical (HVAC) $ � � [�7otc:Minimum fee=$ (rontact municipali[y)
5. Mechanical Other � O � Endose check payable to
6.Tot11 Cost � � 8 � 8 � (��ntact municipality)and write check number hem
� � � � SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT� � �
By entering my name below, [hereby attest under the pains and penalties of perjury that all of the infurmation contained in tliis
application is true and accur�,a,teA[o thc best of my knowledge and understanding.
c� e /vlP/w��2�'P�S� r� c,. � � � q7���f`��Z�' �
, Plcase prmt and ' nan Title Tclephone No. Date
Strect Address City/'fown a[e Z'
Q U C/ �
b(uniciPal�Inspector to fill out this section upon.application approval:� � -
� 7/s//
� � � .Name. � � Date
. ,� ,.;,.. ,,:
, . , . . , . , . . .. , .
, . � � , . . . ,. . ., . ., ,
. • � .
P-�°" CITY OF S.1LE;�1, l�'L�SS.ICHUSETTS
HtiII1��4�IGDEP�A'C�(E�iT �
.• } . � '�• l20 WdSHINGTON STREEI', 3'°FI.00R
���� "I'EL (978) 7�5=9595.
F.��c(978}74Q-9846
KI\BERLEY DRISCOLL
�f11YOR THoa�.�s ST.PiExxs
DtRECI'OA OF PCBUG PItOPERTY/BCII.DL�1G CO.1L��ISSIONF1t
_____...__ .
�Yorkers' Cumpensation Insurance Affd•avlt: Duilders�ContractorslElectricians/Plumbero
4pn��cant Intormation Plcase Print Le2ibiv
V�ITiI'(Busiixy.tiOrganiialioNfn�ividual):��.g-�il E7 � Vvl e f WL �Cl � �
Address: 3 � C �tl v P trc� � � C� �r�
Ciry/State/Zip: s�P �...� ovl0�l o [4�?CPhone 1�: /— �1'7 � 76�— �o�eJ �
,lre you aa emptoyer?Check the rppropdate bo:: 'fyps of project(requlred):
1.0 I am�cm lo nc with, 4. ❑ 1;un a genc�at contractot and f
P Y . 6. ❑New consWction
zmployep(fuU andlor part-timc).• have hind�ha subr:onttacWrs
2�I am a sole pmprictor or panncr-
listed on ihe attached rheet t �• �emodeling
� xhip:uid havn no employees � These subwntractors have S. �emolition
working.for mc in any capaciry. workers'comp:insurance. 9. ❑ Duilding addition
[No workcrs'.comp.insurance 5. � We am�a corparntion�pnd ip. �
required]�� . o8ieers hava ezecoised their � 10.�lectrical rzpairs o�additians
� 3.�.I�amahomeownerdoingallwork rigfitofexemptiun�perMGL 11.�Pium6ingrepnirsorndditiona
myxlf..[No workcrn'cump, c. 152,§1(4j,artd we have no 12,� 2oof repeirs
� ��. . , insuranca rcyuired.)t employces.[No worl[en'-. .
comµ inwrnncerequinEd.j. IJ.❑Other
'�ny applic:ua�hu chuck�box 81 mmt alxu fill uui iha uc�iau be�ow showinp theu waken'mmpenwion po8ry infurmatfon.
�I Inmvuu�n�who iu6mit�hii�flidevit indieating ihry aro iloiny all wack a�d theq hiio uubida eonttoetots mutl�u6mit a�xw alf[Jari1 indiotiny such
�Cumracwn iha�ch�sk ihi�6ox muxt ai�xhcd un a�4fiGmmi ehRt ahowiny�ho name of th¢tu6:cuntrMon and ihctr"wurkan'mmy.yulfry infumadoo.
. !um an�unpfoyer rhat Ja provldfng ivorkan'comprnsadon Lirumnce jor my emp/uyeex Beluw t,v t1u pollcy axd Jab sUs
injorinaliom
- lnsurance Company Namr. � � � �
Pnlicy tF ur Sclf-i�u.Lic.q: Fxpimtion Date: `
Jub Site AdJress: Ciry/Statr/Zip:
.utucb a copy of tha worken'compensation policy declarattan page(showing the pollcy numbor and expfnNon date�
Fuilure to sccurc coverngn as requireJ und�r Sation 25A of MGL c. 132 can Itad to ths impoaition of criminal penaltiea of a
fine up ro S1,500.00 uncUor one•year imprisoamenq as wel(ax civil penalfies in thn foan uf a STOP WORK ORDEA anJ n tine
oFup ro S?SO.QO a Jay against rhe viotaror. 13e advised thut a capy uf ihis statcmcnt may be forwardcd m the OYf ice of
Inves�i5mivav uf the DtA for insurance covcroge vcriticalioa .
/du/rerrby cr�rijy m ei d� pulns aiiJ�eim u o ' ry tbat rtie ii�foimuNaa providrJ uBove ia urte uad conrct
Dat : J �/v1 e Z 2 d� �
� �, �,�� � - 4` 7P� 7 g — �2 �1 `�
�OJTci�!use a�fy. Do aot rvrile in 7Gb urru�tn bs cuiiiple(ed by city ur mwn nfJTelat
City or To�rn: Permitlt.lceme#
Gsuing.,\whority(circlo onc):
1. ISwrd uf IfeaOh 2. 13uilJing Ueprrlment 3.Cilylluwn Clerk A.Electrieal Inepector 5. Plumbing In�peeror '
6.O�hcr
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Contact Pcrson: __._____.__ PAone#: �
.. .. . . .. . . . . . . ... . . . .
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:�• , CITY OF S.IL.E.tif, L��L155:1CHUSETTS
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,\� + I_0 \V.1iH6VGT0�V$T12EF-�', 3'�Ft,OOt
`"'~ I�L (97A) Td3-9593
t<itiroE.�it.&Y ��t.ISCOCL F�'�()78) 7•{4.g343
,�,L1YaR TFtasi+.3 Sr.Pt�tns
DtRECTaR UF PCOLlC PRaPEA7y/BC[L.DLVG COJL�(1SSIO,V ER
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Cunstructton Debrls Dtspasal At'tIdavtt •
(rcyuireJ tor all dcmalitiun ;md renuvation wark)
fn accuRlanca tiviHi tha sixtli cditiun oftha Smte Buitding Cada, 794 C�biR sectran l I LS
Dcbcis, :uid tho proviviuns uf�b(GL c d0, 3 54;
�uiiding prrmic M is issucd tivith the candlt(on that tha dcbris resulttng fcorn
thiy wor!<shall be disposc�l uP in a proprrly licensed tivastn dispasa) Facility yy���ncd by�tifGL e
i � t, sisn�.
1'ha il�bris will ba tr,utspaRcd by;
(n�mr uChaulur)
'1'he�Ichcis will bo dispased ot'in :
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