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18 GARDNER ST - BUILDING INSPECTION L( - 1 p 12 RECEIVE©INSF . SERVICES The Commonwealth of Massachusetts �UU Department of Public Sjj -n'N I b P - �f Massachusetts State Building Code 0�`1R) Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) 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) 18 6A P,D1xj E.lz ST o l 9 -� 0 F u 5' l NJ L-) t�j c C L) No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Append Lx 1) Change of Use ❑ Change of Occupancy _ ❑ Other ❑ Specify: Are building plans anti/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is att fndependent Structural Engineertn Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: E hn u✓E fir) L.F_PL Al C'C /V'c rJ 2oe76T' 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 CNfR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flours/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 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: Hi h Haz ed H-1 ClH-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ ❑A ❑ 1180 IIIA ❑ !!IB ❑ IV ❑ VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 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❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ required CI or trench or specify: or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: {A I I i n, c,,ngni,ti n R",w hoc"': c"': 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: e�2,0 et aes�,a SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Addy s,of Propertyy Jwner i�.3v'a6r,y� JAiiul""V�2M! u.1 A L T r 12 S ro LA L Z ]8 LO to NEB S7 SffGsia r M f�- D/9 7 O Name(Print) f � ^ No.and eeStreet City/Town Zip Property Owner Contact Informatti+n UL ��U� uU h l T C fZ S`T c) a1�178-!^O l_?7S-6-- 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 budding permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) - If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control ff CIST! o l�IJFIo`� C��avc-tt2to - '_S3[�DRII -usTin/60VaQ2i• A,Qk le,78 Dame(Registrant) Telephone No. e-mail address Registration Number Y �Fv iy�s %Z z�Ls9LA,7aZ-~ 4 B/96o (J 9- 28-/y Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor /YJEG05 CDrLsTiZUG`�'i0i✓LLC— Company Name )9USTir/✓D 0 OH0. 3!q3 y Name of Person Responsible for Construction License No. and Type if Applicable AW I'2e4 o/945570 Street Address City/Tut State Zip 9u-531,0-&� Cow Telephone No.(business) Telephone No. cell e-mail address SECTION 11:IVORKF29'C)MPFNSA'IION INSURANCE AFFIDAVI'I' M.G.C.c.152.§25C 6 A Workers'Compensation Insurance Affidavit from the NIA Department of Industriad 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 0 No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ L Budding $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical S appropriate municipal factor)=S 3. Plumbing $ 1. Mechanical (HVAC) $ Note:Minimum fee=$ (/coon%ntta�ccttt inunfci rlity) 5. Mechanical Other $ Enclose check payable to ��—G=d p P•Y• 6.Total Cost S O Q U('� (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. F AL)57e, 0"t CLD - a81I G-is' Please print and sign name Title Telephone No. Date 5 r'ZL`N y i ✓GS Cr`Z Pf/B/3D�7� ✓�/t /9'6 v Street Address City/Tows—,,ma�y--� ,^,State Zip �blunicipal Inspector to fill out this section upon application approval: 44-1-4 Name Date 1 r = CITY OF S:1LEl t LYl.1SS:1C HLSE TTS EIL:ILDLNG DEPAR-MLENT 1r.Yifr, 120 V11ASHLNGTON STREfiT, 310 FLOOR TaL (973) 745-9595 Kl1L➢ERLF,Y DRISCOLL FAX(973) 7.10-934,5 Lltwo a I;-tasc�Sr.Pta.Rng DIRECTOR OF PUBLIC PROPERTy/BL•ILDLNG CO\L\(IsSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Coda, 730 Cb1R section 111.5 Debris, vtd the provisions of tb1CL e 40, S 54; Building permit 1t is issued with the condition that the debris resulting from this work shall be disposed ot'in a properly licensed waste disposal facility as defined by ,b1CL c 111, S 150A. The debris will be transported by: ti y f M P (11Jptl•U('heUNO The debris will be disposed of in ; (name of I'acdtty) (iJlttss Ur ra�ilir�) 11 f IJ RI(C Ut � C//7C S j,crrni(Jppfianit CITY OF Scu.EM, NL\SSACHUSETB BUi DING DEPARTMEINT 4 al' r<fl 120 WASHLNGTON STREET, 3r°FLOOR TEL (978) 745-9595 F.Sr(978) 740-9846 w\IBERf FY DRISCOLL a, T w•IOM ERB As ST.PIs `:tiL'IYOR DIRECTOR OF PUBLIC PROPERTY/BIaiDI11G COMMISSIONER Worlcers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers Applicant Information_ Please Print t e ibly _ V;1tnC r/1�/(nueinessOrgmbati--o/m'Individu:J): �Lf) � �fJ/✓STiZUG�rrD I.e.. C. Address: Cl /1/rVi S 6�, e City/State/Zip: Phone ll: 7g 53/ — 8 g f / Are yyu an employer?Check the appropriate box: 'type of project(required): 1.02 i am a employer wilt 4. ❑ I am a general contractor and 1 6. ❑New construction mnpinyees(full and/or part-time).* have hired the sub-contractors 1 2.0 I ani a sole proprietor or partner- listed on the atlached.rhect. t 7. Remodeling ,hip and have no employees These sub-contractors have S. E] Demolition working litr mein any capacity. workers'comp. insurance. 9. Building addition [No workers' comp, insurance 5. ❑ We are a corporation mid its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I IT-1 Plumbing repairs or additions myself.(No workers' cunip. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) r employees. l\o workers' cunip.insurance required.] 13.❑ Other 'Any upPhigni dial aheckS bur ri marl also nil oar the sactiun below showing their workers'corrpenvriun Policy il,A)"ation. m'I lueuwnars who uhnol this allidnvis indicating they um doing all work and then hire outride eantractors most Submit a new aftldavil indical ina Such. ('nnrnuwrs thin chick this boa most anachul an addaiuwl opal.hawing the mane of she subaantncton and their workers'camp.policy infannmion. I ant an euspluyer that Is providing workers'conspensarloa in.raralsce for my eurpluyees. Qe%Iv is the policy and fob site inf,nnuffnn. Insurance Company Na n e: G fZ05 .... �/ ) SII PZ./-� A I Policy #or Self-ins. Lie. 0: �R I ti M Lf Expiration Dote: Job Site Address: 10 GARnAX 57— City/State/Zip:_ Lr/�M l_l¢-r9/9Q10 Attach a copy of the ivorlten'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A arMGL c. 152 can lead to the imposition of criminal penaltiea of line up to S 1,50 00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine nr up ro S230.00 a day against the violator. Ile advised that a copy of this statement may be funvarded to the Office of Investigaiiun.s of the OIA ror insurance coverage verification. /do hereby end later the pains and pawllies of Petiury that die injuratadon provided above is true and correct. rr , •,y: 8- S31 ��J - Official use may. Do nor write ill this area,rn be completed by city or hit'"offiriu2 t City or ruwn: ,___ Pcrmit/LkcnscN Issuing Aulhorily (circle one): 1. Board of health 2. Buildlm, Dupartntcul I.Cilyffnavn Clerk I. F:Icetriul (uapeetur 7. 1'Inwbing Inspector 0. Other Contact Person: Phone lt: