16 GRISWOLD DR - BUILDING INSPECTIONI
1 1OZ' 25� EC IVED
The Commonwealth of MA%af@
Department of
Ui dingPublic Safe 6
Massachusetts State Building Code('1�'t1M1W —2 A '1'.44
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(this Section For Official Use Only). 110
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block A and Lot A for locations for which a street address is not available)
/C GCI-'WVQ �•t. Swle,r% , hA• eta?o Prc((M0^ tkrIL
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 r\It ration ❑ Addition❑ 1DDemolition.❑ (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 Engineering Peer Review required? Yes ❑ No Nf
Brief Description of Proposed Work: RW64 1:1CIS{ tA' And-
a bpi xi Ft rer.r dee an ta,
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): I - Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(sq.ft.) 2 Z 2 2
Toted Area(sq.ft.)mid Total Height(ft.)
- SECTION 5:USE GROUP(Check as ap-licable)
A: Assembly A-L 0 A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard - H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1 CV 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 ❑ ❑r\ ❑ IIB ❑ IIIA ❑ IItB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: =on
Trench Permit: Debris Removal:
Public Check if outside Flood Zone Id
A trench will not be Licensed Disposal Site f�
required�r trench or specify: Sw 1t tr`
Private❑ or indentify Zone: permit is enclosed❑ U W C l Z
r
Railroad right-of-way: Hazards to Air Navigation: xl._11 is-to,i lonunnti n R0,w"lits:
Not Applicable 1�„, „its Structure within airport approach area? Is their review completed? `
or Consent to Build enclosed❑ Yes❑ or Nov Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): •l'ype of Construction: Occupant LOad per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
12'AULAE5--p q (g 15brIz F• U .
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name ant Address of Ps "ec"'tyc�".�Yner
30�,. 213���+�32 �Au0rc� 9414Wa�� Dr. S�terk r� till
Name(Print) � No.and Street City/Town Zip
Property Own0ei�CPta'At lifwmaho�n� 019 -
Mr. _ 9il-za/ - 8odo
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 eroperty 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 s ace and/or not tinder Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
8ot.-!> 94a r rt'%4'V0A 9.1
Noun (Re istrant) Te ephone No. e-ma address' Registration Number
y/ �3uiler si. S ,Ip». O/YZO
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor .+ -
Company Name
CS - 103-2 c16
Name orPerson
,Responsible for Construction License No. and Type if Applicable
q/ S�- S"tf- � 'kk 61ti70
Street Address - City/Town State Zip
9r 7- 063 S1Lwtpr�tia Vc}�e J ®rj 4n 4"1•G6�
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKFNR COAIPI:NSA I I0N INSURANC'.F;AIT11MVI'C M.G.L.c.152.§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 in 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
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
L Building $ Z100
o O Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
a. Mechanical (HVAC) $ Nate: Minimum fee=$ (contact ru pmi hty
$. Mechanical Other $ Enclose check payable to
6.Total Cost2110c, al y`$ (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
applicat' is true and accurate to the best of my knowledge and understanding. `
�ixti� e �r 1 Mr. 978 - 8<7 SoG 2 /y
Please print nd sign names Title "Cclephone No. Date
y/ I/er c�. Hf� a4rty
Street Address City/Town
State Zip
Municipal Inspector to fill out this section upon application approval:
Nance Date
CITY OF SzUEM, 2ANSSACHUSETTS
f?a BUILDING DEPARTMENT
120 WASHLNGTON STREET, 3'FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIMBERLFY DRISCOLL
;YLiYOR THontAs Sr.PlFxlts
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO.W.IISSIONER
Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information {T Please Print Legibly
Name(IfusinussUrganiratiom'Individual): 1E1J3e+ A._
Address: e-r C4.
City/State/Zip: r_ 19A . blkZo Phone #: g78-65-7-SO 4.3
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ 1 am a employer with 4, ❑ I an a general contractor and 1 6. ❑New construction
2.rrploym(full and/or part-time).* have hired the sub-contractors
lama a sole proprietor or partner- listed on(he attached sheet.t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity,
workers'comp.insurance. 9• ❑ Building addition
r•[No worke 'comp. insurance 5. ❑ We are a corporation and 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 LCI Plumbing repairs or additions
myself.[No workers' comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] i employees. [No workers'
cump.insurance required.] 13.❑ Other
•Any applitunt Ilan chucks box rl must alau fill out the section blow showing Ihcir workcn'cumpensation policy inlbnnatiun.
'I I.encowm",cho suhn,it this atrldnvit indicating ihry art doing all work and then hire oulside contractors mint submit anewafridavit indicating such.
K>oum ion Ihui check this box must anachid an xddiliumd shwl showing nw:name of the sub-contncton and Ihcir workcn'comp.policy infiamatiun.
l and an employer that is providing workers'cunipenyadon insurance for my entplayees. Below is the policy and job site
information.
Insurance Company Name: COM sate(c.4.._.,�ycSy f7tnr.+C
Policy 4 or Self-iru. Lic. 0: �y D w L- rb Expiration Date:._, 0 5 ,., '
Job Site Address: 14- G R c,J0 [� Dr • City/State/Zip: ���"` J '�� • Ok Q"t O
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 25A ot•MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51,500.00 und/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and aline
of up to S'_SO.00 a day against the violator. Be advised that a copy of this statement may be furwardcd to the Office of
investigations of the DIA for insurance coverage verification.
l do hereby certify under the paLis and peso/ties of perjury drat the infonnarlon provided above is true and correct.
Phonel: �zB -'$57'8Od7 TTT/T—,T
OJjiciul use only. Do not write in this area, to be completed by city or town offieiaL
City or Town: ___._.. . .__ Pcrmitq.lccnsc N
Issuing Authority (circle one):
I. Board of Health 2.Building Department 3.Citylfwvo Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone IY:
[
CITY OF S:1L.Em, ti 15S:1CHUSETTS
t tt ) IXILDLNG DEPAR'i1 &NT
130 WA31iLNGTON STREET, 3'°FLOOR
s,n Tt..L (978) 745-9595
F
KI3[BE12L.EY DRISCOLL .I-x(978) 740-9846
AAYo;2 T'rio.%w ST.Pimus
Df.ZECCOR OF PUBLIC PROP ERTY/81:MnLN(;CONNISSIO:iER
Construction Debris Disposal Aftldavit
(required for all demolition and renovation work)
S-
in accordance with the sixth edition of the State Building Code, 730 0411 Section l 11.5
Debris, cuid the provisions of NIGL c 40, S 54;
Building Permit hi is issued with the condition that the debris resulting from
this work shall be
t 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by tLviGL c
The debris will be transported by:
(Ilan] ufhaulor)
The ticbris will be disposed orin
co.
(name of ractliIttyL)_
-----(aJJraes of tLcilit
. sigrtaturt ufper t app(icmu
i
VIP Office of Consumer Affairs and Business
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Col a,ctor Registration
� ,
Registration: 177161
(,Ll F _ Type: Individual
EUGENE PREYL fPHE= Expiration: 11/6/2015 Tr* 246545
EUGENE PREYL ll;1A
41 BUTLER ST ( _ '
C
SALEM, MA 01970
ate Address and return card.Mark reason for change.
CA 1 O 20M-05/11 ��--�'
Address Renewal Employment Lost Card
C5 lie �Oarmemnureolr�z of'UdJ,QaacLe,roclra - .._ _..� .___. - -
- — Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration. j77161
Type: Office of Consumer Affairs and Business Regulation
xpiratlon ,- 11/6/2015i, Individual. 10 Park Plaza-Suite 5170
0GENE PREYL r� i'yi Boston,MA 02116 -
-- 1 1
1GENE PREYL
BUTLER ST a'>.,LEM, MA 01970 - - E p
Undersecretary Note and wifflolulPsignature
? Massachusetts D partment of Public Safety. ,
Board of�B'uildingyRer}ulations and Standards
Cgnstruclum'Su;py n�iso r,
License CS-103290
EUGENE PREYL
41 BUTLER`ST
Salem MA '01970;-: s `
;
Expiration 4
Commissioner 01129/2015".