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22 GARDNER ST - BUILDING INSPECTION (3) i The Commonwealth`=of'+1fassachiilsetts 60 ^} Dep `it ent of(Public Safety VWWV r Massachusetts State Building Code(780 CMR) Building Permit Application for any r tpnWO119 or Two-Family Dwelling 1 n� (This Section For Official Use Only):. .. U ' it Number: Date.Applied: - Building:Official; -- SECfION 1:LOCATION(Please indicate Block q and Lot N for locations for which a street address is not available) I J 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❑ 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 M— Is an Independent Structural EngineerinAPeer Review requved? Yes ❑ No D-- Brief Description of Proposed Work: J'—pwv, .. .�P r, ) c� dv✓ui� /l A e_e .r •el�h .n v .✓ .i1rw ,;. <i l a ti_� , T 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 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.) SECTIONS:USE GROUP(Check as a Ifcable) - A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E. Educational ❑ R Facto F-1❑ F2❑ - H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑ I: Institutional 1-1❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-113 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 ❑ IIA ❑ 11B ❑ f1IA 0 Hill 0 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 e 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: ;ti I Iistnric Cumnusiun ile...... Not Applicable EIS Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No 6z Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Dues the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION i Name and Address of Property Owner ' C ` 7'2 &ed ,-eerd- sz)e,i A44 ;> /97a Name(Print) No.and Street City/Town Zip Property Owner Contact Information: C.c ur C� Cowin r - c,'76 Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes AA A Y� ' <Qgrt� 7 Z- &,e rr C {— Se< &t c A -4 019;P0 Name - Street Address City/Town State Zip to act on the property owner's behalf,in a6 matters relative to work authorized by this building permit application. SECTION 10.CONSTRUCTION CONTROL(Please fill,out Appendix 2). f building is less than 35,000 cu.ft.of enclosed space and/or/ not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control - �nber �- ✓ 12v ��77 LIO 6L4 fS Li -10fBIG Name(Registrant) V Telephone No. e-mail address Registration Number "7,o 6!.q S ra�yrt M An 7V /Z ;3 0 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor �Gr�SL 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:WORKERS'C'0&1PENSA'I ION INSUI:ANCJi AFFIDAVrf' M.G.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 O 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 $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact n udcipali ) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ 5,V OO (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 y owle lge and uunndeer'standing. !LG'rsfe lP.o^rtt 2� -�� ✓ C�+.-d"'��.�7r - - Please print and sign ame / ''Ti^itleA Telephone No. Date CCYyj' Street Address City/Town State Zip �) Municipal Inspector to fill out this section upon application approval• Name Date The Commonwealth ofMassaehuseits Depay*nent oflndustrial,4ceidents I Congress Street,Suite 100 Boston,MA 02114--2017 www.massgov/dia rWarkers'Compensation Insurance Affidavit:Builders/Contractors/Eleclriciam/Plumbers. TO BE FnXD WITH THE PERMITTING AUTHORITY. ADalicout Information Please Print JAdbly Name(Business/Organuzaeon/Individusl): d ��"-'r'�^ - S/ 4-11 . _ .. . Address: City/state/Zip: C,,i/e= AA A Phone#: y 77 "-(O C q o an ensP Are you yet.Check the appropriate box: .b Type of project(required): l.❑I am a employer wirli employees(full aud/orport-tithe).* 7. New construction ZE]1 am a sole proprietor or partnership end have no employees working forme m 8: 0 Remodeling anY capacity.[No worker'comp.ioetnarice required.) 3.01 son a homeowner doing all work myself.(No workers'cep.insurance required.)1 9. 0 Demolition 4.Q Ism a homeowner and will be biting eonbactors to conduct all work on my property. 1 wrll 10 Q Building addition. - . eoaure that all contractors either have workers'mmpeawOon insurance or are sole 11.0 Electrical repairs or additions popnetcm with no employees. 5.❑I am a general contractor and I haw hired the sub-hone aetms listed on the attached AM. 12.❑Pllmlbing repairs or tldditlolls These sub contr?ctms have employees and have worker's'comp imura ce t 13.0 Roof repairs. 6.E]We are a corporation and its offices have exercised their right of exemption per MGL c. 14.❑Other 15Z§1(4),and we have no employees.INo workers comp:isurance regnmed.) - -Any applicant that cheepbox#1 must also fig om the section below shovnng t6efr workers'compensation policy huhimatron. r Homeowners;who submit this a%davit ihdicatrog they art doing ea work and then but outside contractors must submit anew affidavit indicating such 1Connactors that check this boa must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employces If the sub- err ectms have employees,they mug provide their workaa'comp.polity trumbec, I am an ens to er that is providing workers'co , p y . p g compensation ursurancejor my empJgyees. Below v the polity andjob-site Information. Insurance Company Name: 5T =_�l.\QQ1�1 �"7 Policy#or Self-ins.Lie.#:_ P 3 V 1J 2 G S$ 0 L,2 L.S Expiration Date: `�('"2-0 Job Site Address: Z c:aP4LOTS SIR. 5T City/State/Zip: f- ;-M 00( 9- 0 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' isonment,as well as civil ..umPn penalties in the foam of a STOP WORK ORDER and a fine of up,to$250.()0 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 penabies ofperjury that the information provided above is true and correct SSI afire: v Fit < . Date: /�7 '2 /ice Phone#: Official'use only. Do not write in this area,to be completed by city or town offw l City or Town: Peres tMeense# 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#: Informa tion 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 writtep." 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 to er or the 8 B BaB J erPn B B eP7eS �P Y , 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,§250(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-contractors)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"0 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 burn 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. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia CITY OF SALSA A ASSACHL SE M BaiDDcDEFAjaAe P 120 WA9M4G7MS7RW,3XDpLOOR IkL(978)745-9593. FAY(978)740-9846 BI1vJBF.RI.EYDRiSCOLL MAYOR 7)EMAS ST.PIERRE DIREcrmOFPUBucpxom r/BumDmo ssroi-m Construction Debris Disposa/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, S 54; Building Permit g 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. The debris will be transported by: (name of hauler) The debris will be disposed of in: ✓; Z y; S ,r= r cx/l (name of facility) / !—y "'I 'l (address of facility) Signature of applicant Z2-b Date - �, tT �/.,r)) ePUipgM ST S-'V7nn.. PR -x,g d 5 w aMA 91979-1415 4rsf,� 9 .. 301YSOv0)152109 �f O iee of Consumer Affairs-8i Bnsiaess Regulation MEIMPROVEMENT CONTRACTORT :w"F eglstrabon F:175845 ,. j -� Type:� „' i xpirabon < 6114e2©15 i f R"DBA - BR CONTRAC_TINGtBB"+ x�•'°`"r`,w r. A' s ROBERT'RYAN7 •30 PUTNAMST.+ ciSALEM MA s a undenec7tary O - '- rartment of�PublicSafety Massachusetts R gulans,and Standards ' .Board of Buddih&,v erv5'2 r. t .Cot �ru�bPn�01819',,' . License., ROBERT Y RYfe? r v' 30PtJTN 970at ` ' Salem MA .. r i r>1s. .�ne ?.� Exp11�?n;1 Cp1j1�j115stoner _ ,