1-2-3 GERRISH PL - BUILDING INSPECTION n The Commonwealth of Massachusetts
� M1x!I Department of Public Safety
^J Massachusetts State Building Code(780 CMR)
II`IjCI' 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 It and Lot It for locations for c ss ' t ava le)
/.-9-3 Gfrrr5/t )'g fetyk Ma- 0/g70
No.and Street City/Town Zip Code t ,
SECTION 2.PROPOSED K. -
Edition of MA State Code used If New Construction check here or check all that apply in the two rows below
Existing Building 1r Repair aviAlteration ❑ 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 ❑
Is an Independent Structural Engineering Peer Review required? p Yes ❑ No ❑
Brief Description of Proposed Work: s-/—P, )'j
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.) t -
Total Area(sq, ft.)and Total Height(ft.)
SECTION S:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business Cl E: Educational ❑
F: Facto F-1 ❑ F2❑ It: Hi It Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ Mo Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ I U: Utility❑ Special Use.❑and please describe below:
Special Use:
a
SECTION 6:CO STRUCTION'IYPE(Check as applicable)
IA ❑ r SIB ❑, ' +' IIA ❑ 116 ❑ IIL1 ❑ IfIB ❑ 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 Cl 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: ' -
b �' g .A,LA!h t n�lnnun,si n i vw,, Pr
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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of ro erty Owner
:his f I i-2'3 G CPrr:s� 0- Jatke rw jJ 1 q7U
Name(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 ermit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) _
If building is less than 35,000 cu.R.of enclosed s ace and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Res onsfble for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
S h Gor Co-
C�oo�,m//��pany Name �' // 6` a � �4
t4iy A rr s y Tom /I 5
Name of Person Responsible for Construction License No. and Type if Applicable
a. (; Qvx ti\C-r, AIC, 0Ic.70
City/Town State Zip
Street Address / j r(`/�µ
e
Telephone No. business Telephone No. cell e-mail address
SECTION 11:kv0VKFR13'(Onll'FNSA'I'I01N INSURANCE All 11)AV1I M.G.L.c.152.5 25C6
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 ill 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
Estimated Costs:(Labor o (J (Jd
Item and Materials) Total Construction Cost(from Item 6)_
I. Building $ D � Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $ Contact munici lit
Vote: Minimum fee=$ ( �p Y)
4. Mechanical (FIVAC) $
S. Mechanical Other S Enclose check payable to
6.Total Cost $ 01 C7 (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. ��y G e 7
Al' G{i"11 �W -Irfit!L_—
r T Telephone No. Date
Please riot and si n n rine Ti e
�bp Scsrv�dwu�T L+C 'PifCJDC2 � 0le e
Street Address City/Town State Zip
[imu'llip",
inspector to fill out this section upon application approval: Date
Name
16�
CITY OE Siu.&Nt 2AXSSACHUSETTS
BUI DING DEPAIM1ENT
120 WASHINGTON STREET,3-FLOOR TEL (978)745-9595
F.AX(978)740-9846
KI%CBERt EY DRISCOLL
NL L YOA THO6IASST.PMRRB
D IRECIO R OF PUBLIC PROPERTY/BU I DL`IG COJL%IISSIO:i ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name lBusiii s. Organiratiorvindividuaq: See AC. It r Co?
Address: p 0 ( \A0oZ 7 S
City/State/Zip: If,M MA oIc't70 Phonehl:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(fltll and/or part-time).• have hired the subcontractors
2.❑ ],am a sole proprietor or partner- listed on the attached sheet t ?• ❑Remodeling
ship and have no employees These sub-contractors have Y. ❑Demolition
working.for me in any capacity. workers'camp.insurance. 9. ❑ Building addition
(No workers'comp.insurance 5.'❑ We area corporation and its
officers exercised their 10.❑Electrical repairs or additions
required.)
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(41,and we have no 12.0Roof repairs
insurance required.)t employees.[No workers' l3.❑Other
compi insurance required.)
•Any applicant that chmlts box ill must also fill out the scclim below showing their waken'cc peewlon polidy inf rmmlon
'I bvnuuumers who submit this aNldavit indicting they am doing all work and than hii s eftuidecanuectorn mast submit a new atlldavil indiaina such.
�Comr tors that Omit,this box must attached an additiunul steel showing the name ofthitsub.anntnctun and their workers'comp.policy lnfomution.
/um un eutployet'chat ts provfding workers'compatsadon hlsurance for my employees Below/s the pollcy and job site
h1forurutlotr.Insurance Company Name: "Res St_ +r
A
Policy 4 or Self•ins.Lie. a: 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 Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500,00 and/or one-year imprisonmenk as well as civil penalties in the farm of a STOP WORK ORDER and a fine
of up to S250A0 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Off ice of
Investigations of the DIA for insurance coverage verification.
/du/terrby cur rut dr tl pal s and peuuhles of perjury that the hiforntuden provided above is true and correct
14 )
5L,— lure: T®. Data!
,
Phony;/:
0JJicial use only. Oo not write!it t/tur arrests to be completed by city or town oJJlcluL
citynrTown: ___ Pcrmit/i.lcemeg __
Issniog Authurity(circle one):
I. hoard of health 1. Building Department 3.City/town Clerk 4. Electrical Impuctor 5. Plumbing In.tpector
6.0titer
Contact Person: Phone ih
i
Y
�ij5�ram.,
y CITY OF SALEatr, LbL�Ss:wHUSE,TTS
f1UUXLYC DEPAATNONT
` t, 120 CV.I3HLVGT0N STtt&&T, 3 F2aaR
ILL (979) 731-9595
nfop4LEY ORISCOLL FtC(978) 7•W.934S
,`r UvoR 'CFca�c�Sr.Ft�ts
Dt.ZECrOR UP KaLfc PACHATY/atawma COSLAUSSIG.NER
Construction Debris Disp0331 Aff7davit
(rcyuirid for all demalition and ranuvation work)
to accordance with the sixtlt edition of the State Building Coda, 730 Cjb(R section 111.S
Debris, and thopravisiOns of rb(CL c 40, S 54;
Building permit M
this is issued with the condition that the debris resulting from
tl, sl3o.�.work shall be disposed Orin a properly licensed waste disposal facility as defined by NML e
I
VIC debris will be trinspartcd by:
(Hans lit haulw)
The rlubrii will
be disposed Orin : .
CA
n,r ta�dit�)
i
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;i•tiuurre'�rpermit apptieant