22 GARDNER ST - BUILDING INSPECTION (2) 1 )
�1 1 The Commonwealth of . ((�� ie`
�O Department of Publ4at `� - ti VICES
el
MassechusettsShtte Building Code(780 CMR)
111 Building Permit Application for any Building other INJ:(0jte.Qr TjAo-6lnjl9 Dwelling
_(rhis Section For Official Use Only)
r2j2-
ilding Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
(-,,,a oav- C,/- S g.le.N AA .91970
No.and Street City/Torun Zip Code Name of Building(if applicable)
SECTION2.PROPOSED WORK
Edition of MA State Code used— If New Construction check here❑or check a8 that apply in the two rows below
Existing Building❑ Repair&fAlleration ❑ 1 Addition❑ 1 Demolition O (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No O
Brief Description of Proposed Work: N-Ie4"o ✓reel c�P�C..� �/� �.! ��,'b.c �✓ awe..
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 CNIR 34) ❑
Existing Use Group(s): IProposed Use Group(s):_
SECTION4.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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F. Facto F-I❑ F2❑ it High Hazard H-1❑. H-2 O H-3 ❑ H-1❑ H-5❑
1: Institutional I-I❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage 5-1❑ - S-2❑ U: Utility❑ Special Use O and please describe below'.
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ III ❑ HA ❑ fill ❑ IRA ❑ IIIB ❑ 1 IV ❑ VA 13 VD ❑
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❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: i-\Ilistgriy G��n�i�is_���;,��i�•,,.,I'�w _e
Not Applicable❑ •Is Structure within airport approach area? Is their review completed?
or Consent to Build enclused❑ 1 Yes O or No❑ Yes❑ NO ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
EJition of Qxlc Use Group(s): - Type of Construction: Occupant Load per Floor:
Dees the btiilJiny,contain an Sprinkler System?:_ Special Stipulations:
St�VT Tl9 �• � . 10 �-7 l (
SECTION 9: PROPERTY GWNER AUTHORIZATION
Name and Address of Property Owner -
l_u ,n e. Guh i 2-2-
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Teleplone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
�}..� T-U..af 72
Mune Street Address City/Town State Zip
to act on the property owners behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less thin 35,000 cu.ft.of enclosed space and/or not under Construction Control then check hen 0 and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control.
i7rr„�ar n 4 �o�z�r f�o� -bz3 1s99 �lna�di�'�Gv,c 70?3d
Name(Re ist ant) Telephone No. c mail address Registration Number
S!�! �� 4m /3.h� GCTrs�Ji+tet�tT /GL, 04rl
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:%VoRKERS'CObO'FNSA LION INSURANCE AFFIUiwIl M.C.L.c.152.9 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 Cl No 0
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 $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose cheek payable to
6.Total Cost $ Q o O (contact municipality)and write check number here
SECTION 1 :SIGNATURE OF BUILDING PERNirr 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
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval• �Q
Name Dale
The Commonwealth of Massachusetts
Department oflndustrialAceidents
I Congress Street, Suite 100
Boston,MA 02114-2017
www.mass gov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE M ED WITH THE PERMITTING AUTHORITY. . .
Applicant Information - ` - Please Print Leltibly
Name(Businms/Organirstion(Individual): vl ra-' ,.1 ..
Address: 72 /� a'W'iy '2_ AX A C71 C/ 70
City/State/Zip: Phone M . Cl 2X
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer witheinployees(full and/or part-time).• 7. El New construction
2.E]I am a.sole proprietor inpartnership and have no employees working forme in 8. E]Remodeling
any capacity.jNo workers'comp:insurance required)
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Q Demolition
4.Fj lain a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10❑Building addition,
ensure that all conhsams eitherhave wmkers'compensation insurance or are sale 1 LEJ Electrical repairs or additions
Proprietors with no employees. 12. Plumbing repairs or additions
5.O I am a general contractor and I have hired the sub-eonuactani limit on the attached about. 13.❑Roofrepairs.
These sub-contractors have employees and have wodcas'comp.insurance.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[1 Other
152,§](4),and we have no employees.[No workers'damp,insurance requred.]
.-Any applicant that checks box#1 must also fig our the section below showing their workers'compensation policy infoimetron.-
t Homeowners who submit this affidavit indicating they are doing all work and ihesi hire outside conhatrors must submit a new affidavit indicating an&
]Contractors that check this box must attached an additional shed showing the name of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their wmkeas'.comp.policy camber_ -
I am an employer that is providing workers'compensation insurancefor my employees.I Below is thepoliey and job site
information.
Insurance Company Name: e7 o-ey—re r2�
Policy#or Self-ins.Lie.#: Expiration Date: A
lob Site Address: 2—?— C ra r c,M c,� S 4 - City/State/Zip:, q 2 f�
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 u�n der
rtthe p/aains and penalties ofpe_rjury that the information provided above is true anddJcorrect
Signature ../d�'"��y Date '��G �/�
Phone V.�O 'Z2 Ci
Ojrcial use only. Do not write in this area,to be completed by city or town offlw&l
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 pemnt not related to any business or commercial venture
(i.e.a dqg 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 02 1 14-20 1 7
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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Unrestricted-Buildings of any use group which
than
contain less 35,000 cubic feet(991m3)of
enclosed space.
Failure to possess a cturent edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DpS ucensinginformation visit: www.Mass.Wv/DPS