80 FREEDOM HOLW - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety Massachusetts State Building Code R)
\I Building Permit Application for any Building other an a O e-or Two-Family we ling
(Thts.Sectionl,oCOEHcialUse:g ly)
9
Building Permit Number: - ^' Date Applied �' "'` �'v Builduig O( ci r
• ' SECTION 1;:L,bCATIOIV.(Please iiidicate Blocky#•andLot.#for loca irons foiw' ;a street'address '.n`ot available) = ,,,:
No.and Street City/Town Zip Code Name of Building(if applicable)
%-,-'SECTIONON 2:PROPOSED
Edition of MA State Code used_ If New Construction check e❑or check all that apply in the two rows below
Exi.;ting Building Repair❑ Alteration ❑ Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
',Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineerin Peer Review required? Yes ❑ No 9"
Brief Description of Proposed"Fork: 12v_ti r"vt5 o (�v/rl�•�1lcs,� a'yes
AA
SECTION 3;COMPLETE.THIS SECTIONIF EXISTING 13UILDING.UNDERGOING RENOVATION,'ADDITION,.OR- >
` " " ••"<' CHANGE IN USE OR OCCUPANCY~$... ''s• . -
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 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ I-3❑ 14❑ FM. Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑ and please describe below:
Special Use:
TYPE(Check as applicable) "' " _SECTION 6:CONSTRUCTION
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
' SECTION-7:SITE INFORMATION(refer to 780 CMR111:0 for details on'each'item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
A trench will not be Licensed Disposal Site❑
Public Check if outside Flood Zone❑ Indicate municipal required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: ,b1A Historic.Commission Review Pnv: ss:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes ❑ or No❑ Yes ❑ No ❑
•,'k SECTION 8:'CONTEN:T-OF'CERTIFICATEOFOCCUPANCY -
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTIONS-9,PROPERTY OWNER r1UTHORIZATIQI_V
Name and Address of Property Owner
//lenA.ry //4TYl �j 7 L"t c�, ��l/�iw/ r�1 t iM ri/47 G
Naive(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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 building permit application.
"SECTION 10 C U ONSTRCTION CONTROL(Please.fill out Appendix 2)'�' ' ` *:
n
' If buuldin o less than 35,000 cu.fE.of encloseds`ace andjor not under Gonstruction_Control then check here❑and ski Section 10.1 u
-.10:1 Re 'ste ed Professional'Res'onsible foi''Constri'ctioir Control'
124 /3/� S-1
�. am�1e,(Registrant)t Tele hone No. e-mail address Registration Number� /"/fi✓�iy� 'S1 �A�ar�<., �t7� N(44o �'-��—I�'1
Street Address City/Tow& State Zip Discipline Expiration Date
10.2GeneralContractor� -� -�.� � �-- _
Company Name
.Zti�o D?c11-I e =11�3/4I
Name of Person Responsible for Construction Jl License No. and Type if Applicable
Street Address City/T wn State Zip
Telephone No. business Telephone No. cell e-mail address
r SECTION-11:WORKERS:'COMPENSA'TION;NSLiPANCE AFFIDAVIT KG.i::c.152.
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
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)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ - (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 Telephone No. Date
sl— AA4-- rAGG- a
Stre�dress City/T wn State Zip
Municipal Inspector to fill out this,section upon application approval
Name, Date_
CITY OF SiuEmlo ANSSACHUSETTS
BUILDING DEPARTMENT
3 1 ' 120 WASHLINGTON STREET, 3"a FLOOR
TEL (918) 745-9595
FAx(978) 740-9846
KIJfBERLEY DRISCOLL
MAYOR ITiOFtAS ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONL`.ItSSIONER
Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Piumbers
Annlicant information Please Print Leeibiv
Name tBusiruss,Orpniratiorvindivid Jual): A e
Address: L� -S —
City/State/Zip: Pf C N9. 7iY44,y Phone#: GJ�i{'�iat3—�, f ?
Are you an employer?Check the appropriate box: 'Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
,V30oyees(ILII and/or part-time).* have hired the subcontractor
2.ED 1 am a sole proprietor or partner- listed on the attached cheat t 7. ❑Remodeling
ship and have no employees These subcontractor have V. ❑Demolition
working for mein any capacity. workers'camp.Insurance. 9• 0 Building addition
(No workers'comp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised their
10.❑Electrical repairs or additions
3.❑ 1 ran a homeowner doing all work right of exemption per MGL I I.[]Plumbing repairs or additions
myself.(Nat workers'comp. e. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.(No workers'
comp.insurance requircd.1 l3.❑Other
-Any appilcam that chwks box II mutt also all uul the section below showing the,worker'compenwdon policy infurmadon.
'I h"vownem who submit this affidavit indicating they am doing all work and then him outside contmocim most submit a maw aMdavil indicating such,
:Conrracton that chuck this box most ail-ached an additional shact showingthe name of the sub•cdtnrada their nandwurkan'ram . 11 infomuNoq
� p policy
lain on employer that fr providing workers'rompauadan ietsurance for my employees: Below is du polity and Job site
inforarallom
Insurance Company Name:
Policy#or Self-ins. Lic.N: Expiration Date:
Job Site Address: City/Statr/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Seedon 25A of vIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 und/ar one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and it line
of up to$250.00 a Jay against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA tour insurance coverage verification.
Ida hereby certify under the pulps and penaUler afperJury that thdr hrfarrnudon provided above is true and correct
5ii.,naltl C, �rr,, Dard: y7
phmeri•
If7J)is ia!run surly. Da nor ivr/le in thly area,(a be conipleled by city or lawn o/fleial
City or'ruwn' t
Issuing Autltorily(circle one): —
1. Board of health 2.Building Duparintent 3.City/town Clerk 4. Electrical inspector 5. Plumbing Inspector
6.Other
Contact Person: , Phone 4:
i
CITY OF Sa1L.El I, bL15S:1CHUSETTS
�1 ) 1XILDING DEPAIM NT
�1M " 120•.� WASHLYGTON S "O STREET, 3 FLOOA
T L (978) 745-9595
KIJ[3FRI F:.Y DRISCOLL F-v%(973) 7-1O-9346
�bG1YOZ I�10.%& 8ST.PIERAB
DI2ECTOA OF Pt:BLIC PROPEATY/BCILDLYG CO-NaUSSIO.YER
4;
Construction Debris Disposal Affidavit
(required for all demolition grid renovation work)
In accordance with the sixth edition of the State Building Code, 730 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 NIGL c
111, S 150A.
The debris will be transported by:
(name urhauter)
The dobbns will be�diisp�o—sled of in.:
L.
(nantc of facility)
(�ddress of facility)
signature of permit applicant
3 .
date --
!.hii.LIf
i
Page No. of Pages
N° 9265
RESIDENTIAL REPAIR SERVICES
ROOFING
Dump Truck Service•General Contractor
ILIDID VALENTE,JR.
pk 978423-0574 LICH131251
PROPOSAL SUBMITTED TO PHONE DATE
Govy Ri r l') -
STREET JOB NAME
CITY,STATE AND ZIP CODE JOB LOCATION
ARCHITECT DATE OF PLANS JOB PHONE r
We hereby submilopecifications and estimates for: I
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r/f/(/ /�i'MG1/Y' �f17/ ✓�3L �/�'f}�r✓"S�irL� /NIN�tV
�ir�Y s/NSLP 1Z /�vi�� YA111�
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Sri�nGy /v1 v � � vd D/iZ1 /
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AIM
�/✓I n oaui //.yl 7C ) ? 7 �.9 ��r � �a
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We Propose hereby to furnish material and labor-complete in accordance with above specifications, for the sum of:
5J2J2 Tj!o-'2 T� dollars ($
Payment to be madd as toll ws: y
All material is guaranteed to be as specified.All work to,be completed in a workmanlike Authorized
manner according to standard practices.Any alteration or�dvlation,,frormebo;especifications Signature
involving extra costs will be executed only upon wdtten orders,antl will become'an extra
charge over and above the estimate.All agreements contingent upon strikes,accidents or
delays beyond our control.Owner to carry fire,tornado and other necessary insurance.Our Note:This proposal may be
workers are fully covered by Workman's Compensation Insurance. withdrawn by us It not accepted within days
Acceptance of Proposal-The above prices,specifications and
conditions are satisfactory and are hereby accepted.You are authorized to do the
Signature
work as specified. Payment will be made as outlined above. "°✓\�Q v/ ��'�
n f
Date of Acceptance: �J / Signature
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