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19 FOWLER ST - BUILDING INSPECTION (2) l q O 3rb� RECEIVED The Commonwealth of Massachusetts Department of Public A Massachusetts State Building Cotc 0� A 9)1 11: 2© Building Permit Application for any Building other than a One-or"I'wo-Family Dwelling (This Section For Official Use Onl ) 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) ? Ig Gow/er st 5&_�e, 01970 No.and Street City/Town Zip Code Name Of Building(if applicable) ^ SECTION 2• PROPOSED WORK Edition of bIA State Curie used 2009 If New Construction check here❑or check all that apply in the two rows below \ram Existing Bnildh,g d Repair® I Alteration ❑ 1 Addition❑ 1 Demolition )R (Please fill out and submit Appendix l) \ Change of Use ❑ Change Of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as pan of this permit application? Yes ❑ No Is an Independent Structural Engineering Peer Review required? Yes ❑ No It Brief Description of Proposed Work: 41BPlnce- exa��t..4 ra0oae.. -frxs..+4 -).reb�.cr� r woocQa.. Av.� cIAOP o:.�.-aQ u00A� 7r� 3rRal.gl.}z Utt4 nsw on.)c FArc9lw(� ..e.,,� so[,� pl"4- 900r — 2 " OtR1 t..zks. 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 Grou p(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area(Al. ft.)and Total Height(ft.) 3-foo I W FE SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ rA4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ 11: High Hazard H-1 ❑ H-2❑ H-3 ❑ FI-4❑ FI-5❑ 1: Institutional 1-I ❑ I-2❑ I-3❑ 1-4❑ 1 M: Mercantile❑ sidential R-IX R-2❑ R-3❑ R4❑ S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use ❑and please describe below: Special Use: SECTION 6:CONSTRUCTION 1-YPE(Check as a licable) IA IB ❑ IL\ ❑ 116 ❑ II1A ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Selvage Disposal: "Tench Permit: Debris Removal: Public Qfl Check if outside Flood Zone I Indicate municipal M .\ trench will not be Licensed Disposal Site(� Private❑ or indenlify Zune: or on required Wr trench or specify:site system❑ permit is enclosed❑ c Railroad right-of-way: Ilaz,rds to Air Navigation: \I \ Ili I ,n;_[ n nu.5ion_I:, .. Not:Applicable 0 Cs Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ 1 Yes❑ or NO I Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):_ fvpe of Construction: _ Occupant Load per Flour: Does the building conLtin an Sprinkler System?: _A_P_Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Propc'rty Own 7, fFi2LES 2� /If,;i LE/% J �Z�(�M t Name(Print) No. andp Street City/'Gown Zip Property Owner Cb ta'q n(%nnation17 a 775 -31750�^ 3q�-5g8� Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the prope owner hereby authorizes awe 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 ap2licatioll., SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less thin 35,0W cu.ft.of enclosed space and/or not under Construction Control then check here Kand 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 Kay w NOLA a,� Company Name ( lLa-' pher # Cs IF tdq&1;1 '1 Name of Person Responsible a for C tructiun License No. and Type if Applicable Fc� P Ne Sf 'S�l y A, o/ 5 Street Address City/ own State Zip 978 3zs_ °/ 1�fY C.�tns�ayrws ��1� tict,�we erg Telephone No. business Telephone No. cell e-mail address SECTION 11:I%QRKEKR (:.QMFI N5A'I[ON INS;URAN(T AFFIUAVII' M.C.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 Item Estimated Costs: (Labor 3 SDO Total Materials) utnl Construction Cost(from[ten 6) _$ I. Building Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor) _ 1. Plumbing $ 4. Mechanical (HVAC) $ Note: Nlininuun fee=$ (contact rmuntci llity) 5. Mechanical Other $ Enclose check payable to `J r 6.Total Cust $ $SOO (contact numicipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering lily name below, 1 hereby attest wider the pains and penalties of perjury that all of the information contained in this applicatto is true an, occur.to to the best of my k vledge and understanding. � �,�.� 1. � , ['lease print and sign name Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: /*r-1" �� L Name Date Massachusetts - Department of Public Safety Board of'Building Regulations and Standards - Construction Supen-isor 1 & 2 FamilN ' License: CSFA-108124 CMUSTOPHER 1jAY / 7 verly M E 1913 Beverly 111A 0EE 1913 L - �'�"" �� _• '� "� �s Expiration '.. - Commissioner 05/07/2018 T° CCI'Y OF Sz1LEINI, NWSACHUSETTS BUMDING DEPART\lF—NT .1 3 ) hurl 120 WASHIINGTON STREET, 3w FLOOR TEL (978) 745-9595 F.{x(978) 740-98.36 KINIB Rt FY DRISCOLL `;Vf 1YOR T Hohus ST.PiFRRE DIRECTOR OF PUBLIC PROPERTY/BurLDNG CO\L\IISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Informatints y _ Please Print Le ibl Nalne(Husiners,()rganiraliarvlmlividual): C�r'�S'T�'�l-L e,.— riff h.1-5 Address: Z EC, sA( `O- 5t City/State/Zip: "� MR ©frjlb Phone N: 9 716 375 9 -241Y Are you on employer?Check the appropriate box: [13 project(required): 1.0 I am a employer with 4. ❑ 1 am a general contractor and P ew construction employees(rull and/or part-time).' have hired the sub-contractors 2. I ant a sole proprietor or partner- listed on the attached sheet. tmodelingship and have no employees These sub-contractors have molitionavorkin tin me in an ca sett . workers'comp. insurance,g Y P Y ildirlg addition(No worker•'comp. insurance 5. ❑ Weareacorporationand iUrcquircd.) officers have exercised thelr ctrical repairs or additions3.0 1 nisi a homeowner doing all work right of exemption per M s mbing repairs or additionsmyself. (,No workers'cutup. c. 152, §1(4),and we have no of repairsinsurance required.) t employees. (No workers'comp. insurance nyuimd.J er -Any oppiie:un owl Chucks but Of must also fill gut the section bdowshowing their wwlen'cumpenadun puley inturmalton. 'I h.meowtwis who submit this affidavil indicating they are doing all work and then hire Outside conloCtmf mint sohmtl a new amdavit indicating such. K'wuoewo that ehaak this box must anechal in additiunal Awl showing ilia come of the sub•awnincturs and their woken'comp.pulley fnfumution, l utti un employer!hut 4 providing!porkers'compensailon insuraneefor my employees Ueluly is for pol/ry and/ob site iufamialion. Insurance Company Name: Policy it or Srlf-in.s. Lie. d: Expiration Dale: Job Site Address: City/State/Zip: ,Vlach a copy or the worlten'componsatlon policy declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 2JA or SIGL c. 152 can lead to the imposition ofcrilninal penalties of a tine up to S1,500.00 andlur one-year imprisonmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S25o.00 a day against the violator. Ile advised that a copy orthis statement!nay Lie rurwarded to the 011ice of Investigations offlic DIA for insurance coverage verification. - /do hereby rem 1 r the p Lis mhJ eon/des perju that the infuratudan provided ubuve iv true and correct. )ate: Phone,l: 7 37S 7 `f/V Of/iciul use only. Do nor write in this area, to be completed by city ur town o/fh•lub City nr'1'uwn: — -- -- Permitl 3CQnSe Issuing Authurity (circle one): I. hoard of ileallh 2. ISuilding Departnleut .1.Cily/Turin Clerk J. Electrical Lupectur 5. Plnnibing Inspector 6. Other i Contact 1'enoo: Pho lie:I: I r CITY OF SALEK MASSACHUSEM BUILDING DEPARTMENT ` 5 ' 120 WASHINGTON STREET,3' FLOOR TEL. (978)745-9595 KIMBERLEYDRISCOLL FAX(978)740-9846 MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER 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 c40, 5 54; Building Permit # 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 111, S 150A. l The debris will be transported by: (name of hauler) The debris will be disposed of in: AA e�1 k 0 5 (name of facility) C-,e-I-�� 4m,M (address of facility) Silgd6ture of applicant i0-a 7 t` Date