18 GARDNER ST - BUILDING INSPECTION (2) `t ` "3 5 c K 3oo�y
The Commonwealth of Massachusetts
Department of Publ}, e� � CtE�t�V 'D.
Massachusetts State Buildin eC� TK!Mt!) SERVtCE.e>
Building Permit Application for any Building other than a One-or Two-Family Dwelling
Q L
(� An electronic copy of the ^
TWO(2)SETS OF PLANS ARE TO�EXPEDITE THE APPLICATION,EMAIL
NEEDED WITH THIS APPLICATION plans is also needed-email ADDRESSES ARE REQUIRED
n ksaunders®ci.readin ma.us
V SECTION 1:LOCATION.(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of B pld�ul�g(Qapplicab,
SECTION 2:PROPOSED WORK
Edition of MA State Code used-,ZO ' If New Construction check here❑or check.,b:..that appl in the two rows below
Existing Building El Repair❑ Alteration ❑ Addition❑ Demolitior�,❑ Please � gut and�Bmit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other to Specify (<t Y`
,.I
Are building plans and/or construction documents being supplied as part of tins permit applic lion. �Yes ❑ No Mf
Is an Independent Structural Engineering eer a 'ew required? ,,, Yes ❑ No
Brief Description of Proposed Work: ` -'
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation EvaluaHon�is a cclosed(See 780 CMR 34) ❑
Existing UseGroup(s): `i�.�"'`+I'\. 4`tI' Proposed UseGroup(s):
SECTION 4:BUILDING HEIGHT AND AREA
�Y N'" 13` Existing Proposed
No.of Floors/Stories(include baseH�rmtent levels&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Heigh{ft c
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A 2❑ `1Vigfitclub ❑" A-3 ❑ A-4❑ A-5❑ B: Business ❑ E. Educational ❑
F: Factory 4174.0,--. 172`17,. H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 O�1 11 I-3Tp,d-4❑ M: Mercantile❑ R: Residential R-15r R-2❑ R-3❑ R-4❑
S: Storage f, 1 ❑ S-2`Oa .^' U: Utility❑ Special Use❑and please describe below:
Spec_ial'Use:i., }€
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
'lA ❑ IB l7- � IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
B
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
Wafer Supply: Flood Zone Information: Sewage Disposal: Trench Permit:
- A trench will not be Licensed Disposal Site❑
Public§d Check if outside Flood Zone[IIndicate municipal❑
Private❑ or indentify Zone: - or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
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:
Does the building contain an Sprinkler System?: Special Stipulations:
Ky\aa 01b Cot-4rrq�
SECTION 9: PROPERTY OWNER AUTHORIZATION
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Name an Ad ress of Property Owner
S�0 Vavz bJ&I+tv- 18 Gnff 5�
Owner-Print&Sign No.and Street City/Town &Zip
Property Owner Contact Infomiatiori:tSl'; -V J.
Olt 661
Title tJ :?. A 'relepfione�No(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
{ xs 1 4c o Sf a � 0(9 1
Name I_J Street Address City/y6wn State Zip.
to act on the property owner's behalf,in all matters relative to work authorized by this building permit applicatiorr?�
SECTION 10:CONSTRUCTION CONTROL(Please'1111 out,Appendix 2)
building is less than 35,000 cu.ft.of enclosed space and/or not tinder Constniction'Control:then check here O and skip Section 10.1
10.1 Registered Professional Res onsible.fonConstructionControl
W.973-30
TTRe ant) &Signatu e L^ Qr lep one No. Re ' tration 9�mbero
Street Address City/Toci State�j Zip e- ail ad41 es vsc plu�te` E ira on Date
-10:2'General'Contract'o? -. ...... . . . `�.
Company Name Contractor N me \
C ctor rgn re CSLicens m e °art xpira 'on ate
I r 000
Street Address Ci Town. y Stat Zi
Telephone No.(business) Tele hone 1) e-mail addr,4s CJ
SECTION 11i WORKEW COMPENSATIO1V:iNSURANCE-AFFIDAVIT.,M.G.L c 152., -25C 6
A Workers'Compensation Insurance rd vit from"the i\�I'i� epartment of Industrial Accidents must be completed and
submitted with this application. Failuge`t-o'gr� dat. is affid ill result in the denial of the issuance of the building permit
Is a si ed _.:;davits Jul wt__ application? Yes❑ No ❑
SECTION 12:CON$TRUCTiONrCO$TS;AND:PERMTr FEE
EstiAted�Costs:(L. .,r... ., _.
Item and Ma�'ials Total Construction Cost(from Item 6)
1.Building "`..,,,
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $r appropriate municipal factor)_$
3.Plumbing 40f, $
4.Mechanical (AV � �$ ,�'� Note:Minimum fee=$ - (contact m cipahty)
5.Mechanical Other '..;$
„ Enclose check payable to
6.Total%Costom"- Z)O0 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By erite sing my namq",r ec1 I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is trued accurate to the best of my knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip e-mail address
Municipal Inspector to fill out this section upon application approval: �""� -•� ��/
Name Date
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The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Orgmization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).• 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in g, ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I a a homeowner doing all work myself[No workers'comp.insurance required.]t
m
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions
proprietors with no employees. 12.E]Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.�ROof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box 41 most also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the time of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance jar my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/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 MGL c. 152, §25A is a criminal violation punishable by a fine 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 fine 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 and penalties ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town offrcial.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: 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,partnership,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 apartments 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 construct 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
members 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 appropriate line.
City or Town Officials
Please be sure that the affidavit is complete 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 permit/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 02114-2017
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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Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application. A\
Checklist for Construction Documents*
Marlc"x"wher,gapplicable
No. Item Submitted Incomplete Not Re u
1 Architectural
2 Foundation
3 Structural Aga. V
4 Fire Suppression IL. NON VA
5 Fire Alarm(may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections) 'i
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan(Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation Insurance
19 Hazardous Material Miti atiom Documenta'on
20 Other(Specify) _
21 Other(Specify)
22 - Other(Specify)
*Areas of Design or Construction for lans of complete at the time of application submittal must be identified herein.Work
so identified must not be commenced appl on has been amended and the proposed construction document amendment
has been approved by the ority ha . g 1 i n.Work started prior to approval may be subjected to triple the original permit
fee.
( egs a Professional Contact Information
Na °(1?yegi'S adapt) Telephone No. e-mail address Registration Number
eet Address l� City/Town State Zip Discipline Expiration Date
Nam'en(lt`& nt) Telephone.No. e-mail address Registrat on Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Discipline Expiration Date
Street Address City/Town State Zip
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SECTION R105.7 -
PLACEMENT OF PERMIT
The building permit or copy thereof shall be kept on the site of the work and
be posted conspicuously until the completion of the project.
This means that work shall not start
until the permit is issued and posted at the site.
SECTION R105.3.1 -
ACTION ON APPLICATION
The building official shall examine or cause to be examined applications for
permits and amendments, and take action, within 30 days of filing.
SECTION R105.5 - EXPIRATION
Every permit issued shall become invalid unless the work authorized by such
permit is commenced within 180 days after its issuance, or if the work
authorized by such permit is suspended or abandoned for a period of 180
days after the time work is commenced. The building official is authorized
to grant, in writing, one or more extensions of time, for periods not more
than 180 days each. The extension shall be requested in writing and
justifiable cause demonstrated.
SECTION R110.1 - USE OF OCCUPANCY
No building or structure shall be used or occupied, and no change in the
existing occupancy classification of a building or structure or portion thereof
shall be made until the building official has issued a certificate of occupancy,
therefor as provided herein.
780 CMR-EIGHTH EDITION
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i
PLEASE GO TO MASS.GOV - BBRS WEBSITE FOR
THE MOST UPDATED "INITIAL CONSTRUCTION
CONTROL DOCUMENT" AND THE "FINAL
CONSTRUCTION CONTROL DOCUMENT"
These documents are needed with all commercial work
Massachusetts Department of Public Safety
Boa of Building Regulations and Standards
License: CS-032197
Construction Supervisor
LELANDHUSSEY -
490-500 WASHINGTON ST!
LYNN MA 01901, I it
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CA— Expiration:
Commissioner 10/16/2017
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A Ilcant Information
Workers Compensation Insurance AMdavit: Buil rs/E
ders/Contractolectriciana/plumbers
v� Please Print
Name BUEIutioaRndividttal) �-2-� / I• l �,� v t �C
Address•_
ei /state/zi : 'r i-►'� a Phone#:Are you an employer?Checkthe appropriate boa:
I.❑'I am a employer with 4. am a general contractor and I Type'efproject(required):
employees(full and/or patt time).• have hired the nub contractors 6. 0 New construciion
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.
ship and have no employees •These sub-contractors have Remodeling
wMidag for me in say capacity. employees and have workers- S. ❑Demolition
wadears,comp.insurance
required.] Comp.inalrance t 9. ❑Building addition.
3.❑ tlarrrg all work( homeowner S• ❑ We are a corporation sad its
offmcn;have exaccised their 10.❑Electrical nPairs or additions
al
"a too� comp. right of mtemptioa per MCiL 11'�Plumbing repairs or additions
101 Ce required.]t o. IA$1(4),and we have no 12.E Rodf repairs
amPI070ea.(No workes• 13.13 Other
cot insurance )
• o eownem tlhoshecb beetsl mittalm oil out ms notion below showtoa flekwo&..
t Horneowms who submk this affidavit indicatroa ate•am do W work sad 9.hire outside Policy ia5ottnatfon,
=Contractors pit chock mh boa must attached ao addiaood sfia showingam name off must submit anew affidavit mdiofteae&
.mgdoyftL tfYbs im�lo em.ftsmustpmvida9mk v ,l,,e. and state whether or�tihmeectidq have
' comp•pulley mmtber.
1 am as emiP1dYVarlhalls proplang workers'comperrseon manna eefor n�injormodon, employees Below h thepoUcy and jobaite
Insurance Company Name:
Policy#or Self-im.Lle.#:
Job Site Addtes Bapiration Date:
a:
Attach a copy of themorkers•compensationCity/S1ateZzip:
Faflum to sacra m drS policy declaration Page(showing the policy number and
covaaga required wader Section 25A ofM(lL a 152 can iced to the hn eaplrati°n date).
fins UP to$1,500.00 and/or one-your imprisonmem,m well as civil position of criminal ptmnitles of a
Of up to US0.00 a day against the violator. Bo advised that a fanaltim to the form of a STOP WORK ORMI and a fine
lavestigation s of the DIA for insurance coverage verification.
a copy of this statement may be forwarded to the Oi$ce of
1do bzvrby M•"dertbepahn and penaN a ofparjary Oral the Infornratlort
pvvh ed above is arse and coned
b �
Offld t use orn(R Do not writ gn thtr area,ro be ao
n'IPkW tSy dtY ortown oJJlrlo(
City or Town-
Issuing Aatho Permlglttxnae#
rHy(circle one);
1.Board of Health Z Bglidiag Department 3.Ci
6.Other ly/fown Clerk 4.Electrical Inspector S.Plumbinglnspector
Como Person•
Phone#: