28 GOODHUE ST - BUILDING INSPECTION (5) The Commonwealth of Massachusetts
Department of Public Safety
y1j i Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Famtl - n
(This-Section For Official Use Only) -
Building Permit Number: Date Applied: Building Of(i
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not availa
I Z- in�21fri ' n -&tA,
1 No.and Street City/Town Zip Code Name of Building(if applicable)
4 SECTION 2:PROPOSED WORK
Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 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? Yes ❑ No ❑
Brief Description of Proposed Work: I rA V%-
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.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-f❑ A-5❑ 1 B: Business ❑ E: EJucallonal ❑
F: Facto F-t ❑ F2❑ H. Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ FI-4❑ H-5❑
1: Institutional [-1❑ 1-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage S-I ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ [IB ❑ II[A ❑ 11113 ❑ 1 IV Cl I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Disposal Site Cl
❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p
required ❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA I I k t ' C m n i i.. n 1""' I lv"
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Yes❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: _ Occupant Load per Hooe_
Does the building contain an Sprinkler System?: ._ Special Stipulations:.
L�- g VQ 7d05
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
I0I-A
Name(Print) No.and Street City/Town Zip
PropertyOwner Contact Information:A
Title Telephone No. (business) Telephone No. (cell) a-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 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 O and skip Section 10.1 /
10.1 Registered Professional Responsible for Construction Control
Tr✓1��f PA&Yk1Mr 97sr )AP - /arc �yryg z
Name(Registrant) Telephone No. e-mail address Registrati tuber
�ri� Louc 11 S� PP 19 IS0,2V l�f� , w V �24,
Street Address City/Town' State Zip iscipline Expiration Date
10.2 General Contractor
Q f
C�ft1�. y Name
_t � f (`( S 876 3 : /a 16 -/g—
Vme of Person Responsible for Construction License No. and Type if Applicable
1no- 901ar- M;/ G/21
Street Address City/Town State Zip
Telephone No. business Telephone No. cell a-mail address
SECTION 11:WON rails C.onIPFNSA IION INSURANCE AFFIDAVIT M.G.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 ❑
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ < 3 OO 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 check n nble to
6.Total Cost $ 3 00 . 0 payable
(contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereby attest u a ler/ a p- ij m 1 penalties of perjury that all of the information contained in this
application is true and accurate to the best i y ww a ge d understanding. �j 14
�� /Y ��y1_Z3---
Please print nd sign name p Title Telephone No. Date
Street Address City/Town A, State Zip (((��/qqq
Municipal Inspector to fill out this section upon application approval: /UGor«J _ �
Name Date
T CITY OF S:U EM, ANSSACHUSE`ITS
BuM.DING DEPARTME.\T
120 WASHLNGTON STREET, 3'e FLOOR -
b.n TEL (978) 745-9595
FAx(978) 740-9846
Kj.%tgFRf FY DRISCOLL
`�VLAYOR THo,%Lu ST.P1E UW
` DIRECTOR OF PUBLIC PROPERTY/BU MDr%G COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant lnformatinn Please Print LeeiblY
Valnc (nminesOrganiraliaN'InJividUual): t Il'J! /� r/��/J�I✓�
Address:
Cily/State/Zip: /h 4 Phone a: 22S— 22—o
A
re you an employer'.'Check the appropriate bait: Type
f project(required):
I am a employer with 4, ❑ I am a general contraelor and I 6. ess construction
�lllployees(full and/or pan-time).• have hired the sub-contractorsF lam a sole proprietor or partner- listed on theattached sheet. I 7. emodeling,\ship and have no employees These sub-contractors have U. emolitionworking for me in any capacity. workers'comp. insurance. y, uilding addition
No workers'can insurance 5. We are a corporation and its
1 P officers have exercised their 10.0 Electrical repairs or additions
required.)
3. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.) t employees. [No workers' 13.0 Other
comp. insurance required.)
•Any applivam tlw checks boa rl malt also fill out he wcuou below showing their Weaken'compensation pufi y automation.
'I fomeuwm"who submit this amsbtvit indicating they am doing all work and then hire outside conlmctors must submit anew amdavit indicting such.
$'.nutaemrs thin chmk ibis base must mlachal an addidunal•list showing the name or the sub4VAIMIon and their warken'comp.pulley Infurmalion.
I um an eatpluyer drat is provldlnK workers'cumptnradun insurauee jar my nnp/uyers. Ueluw/s!/�e po/%y and Jub rile
injrrralarinn.
Insurance Company Name:
Policy it or Sclf-its. Lis d: __.— Expiration Dole:
Job Site Address: City/Stag:/Zip:
Attach a copy of the noriters'compensation pulley declaration page(showing the policy number and explranon data).
Failure to secure coverage as required under Section 25A urMGL c. 152 can lead to the imposition oferiminal penalties of a
lino up to SI,500 00 undlor one-year imprismmncnt,as wall as civil penalties in the form of a STOP WORK ORDER and a line
of up to 523o.00 a day against rile violator. Ile advised that a copy of this statement may Ile rurwarded to the Oflico of
lLtvesliyulions ufthe DIA for insurance coverage verification. -
/du hereby ce t y m r1hepain5MUTI,, aM jprrjary that the infuratW/un prurideJ ubuva is star u�u/d correct,
Date.
P , A:
O%/icier/use anfy. Do net,t✓rire in this area,lobe completed by airy err rurvn nJJ/eial
City ne fmvn: _ -- Per mit/IJconse N__,___. ..___-.
Issuing.lulhurity(circle one):
I. Huard of lleallh 2. Building Department 3.C'ilylfimn Clerk J. Electrical luspectur 5. Phtnibing Impeetur
6. Other
i Contact Person: Phonel:__.,