69-71 HARBOR ST - BUILDING INSPECTION (2) r J
The Commonwealth of Massachusetts
I hh Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
... F .. ry ..n ...
(This Section F.or:Offtctal Use Only) -
Building Permit Number. _ .Date Applied `•'' _', =Building Ofhaal r= i
SECTION i::LOCATION(Please indicete�Block#;and Lot-#for,locations fors+ihich'a'street address is:not available) -
b5 -� � SuJg-..., WA 01si-) 0
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❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
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(9I
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 19
Brief Description of Proposed Work:
a, r e e e l Rwa 5
Dave vs1vrn c t� r o
SECTION 3:COMPLETE.THIS-SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR ;
CHANGE IN USE.OR OCCUPANCY.,,.. c
Check here if an Existing Building Investigation and Evaluation is enclosed(See780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION.4i BUILDING'HEIGHT ANDAREA .°.•: *` ' ` "'
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),',.. r
A: Assembly A-1 ❑. A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business. ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential-R-10. R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use: -
SECTIOM&CONSTRUCTION TYPE(CFieck as applicable) 5 " '
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7.STTE INFORMATION(refer to 780 CMR ili.0 for'details on each item) "
. .. -
Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
Private❑ or indentify Zone: or on site system❑. required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission review Prc=cess:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION S: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:
x±" r `" •;-",SECTION9o-PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
QW-� ql%
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 permit a lication.
,,.s < ' SECTION 10 CONSTRUCTION CONTROL(Please_frll out Appendix2).A,;L st ,) m'
If buildin �s less thaii 35,000 cu.fE.of e'nrloseds ace and/or not under C6nstivctionCont'rolthen check here 17"and ski Sechon 30.1 ':
10A Registered Professional Re4onsible for Construct ort Control';? - e .r:;. .'i.....
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 Gerieial.CORfrdCfor 4k.t " _..g =, -7. 7 , ...{ ty ,';ice; t ¢ ;, .t�pg;f.r a. ,s.•+l':r v .t' '4 , 'i'x,'.,.
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
1 � iyrzA �> �M MIA Ol 15
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTIONS 11:, 0RKERSS C0N4PENSATION INSURANCE AFFIDAVIT'M:QL.'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❑ No ❑
SECTION 42:CONSTRUCTION COSTS PERMIT FEE "
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ c' rU' Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4. Mechanical (I-IVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:'SIGNATURE`OF BUItiDING 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.
�r,6.n 3oc 5 ��wyll � late
Please print and sign name e ^� Titl ���� T lephone No.
1�-z-z /11
Street Address City own tate Zi
Municipallnspector to fill out this;section upon application approval."•
Name Date
CITY of 5
; .� .. . .tit, m-us,wxttsErrs
B L:=LNG D EPA%T1 LENT
1?0 CV."HLYGTON STREET, 340 FLOOR
TEL (978) 745-9595
FAX(973) 7-W-9344
1110AU ST.PIMMS
D1: aacrt OF PLUL(C PROPERTY/8t:=LNG COJLv1SSIONEA
Construction Debris Disposal Aft7davit
(required for all demalition and renuvation work)
In accordance with the sixth edition of the State Building Code, 730 C&jR section 111.5
Debris, and the pravisiuns of,MM c 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal
l 11, S I SOA. facility as defined by N1GL c
The debris will be transported by:
�Cw
name ut'haulur)
The,lcbris will be disposed of in :
_-- (nnnta ur t�cdity)
NA
siguamrc u(pamit applicant
s z�l 13
f. . CITY OF S.V�ENl, %,Lkss kCHUSETTS
BL'R.D I.ZNI G.D EPA R'T N'W.NT
120 WASHIINGTON STREET,3so FLOOR
TEL (978)745-9595
F.4C(978) 740-9W
KIJIBERL F-Y DRISCOLL j I;pystAS ST.PIERRB
lbfAYOR . DIRECTOR OF PUBLIC PROPERTY/BUDDING COJLIIISSIONER'
Workers' Compensation Insurance Affidavit: iluilders/Contractors/ElectricIans/piumb'ers
Applieant infirrmation / C Please Printy7Le iib{�ll
Vatnc(t3usiixss OrganiratioNlndividual): VJ IQ 1� �� � b a ` 01 )� )r 6h 5/�U . ` )0y)
9�CZZjq. '
City/Statc/Zip&LAL!1`1 Mfl 01915 Phone ll:
1
Are you an cmptoyerl'Check the appropriate box: Type of project(required):
I.® 1 am a employer with, 4• ❑ 1 am a general contractor and! 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 ama sole proprietor or partrtrs
listed on the attached sheet t ❑Remodeling t
ship and have no employees' ' These subcontractors have g. Demolition _
working,for me in any capacity. workers'comp.insutsnce. : 9, ❑Building addition
[No workers'comp..insurance S. ❑ We are a'corpomtion and its -
required.)
officers have exercised their !0.❑Electrical repairs or additions
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.❑ Roof repairs
w
insurance required.]t, employees. [No orkers"' l3.❑,Other
- _ comp.insurance required.) -
-Any aPP llcsm that chucks bass Of mustal:w'011 out the section laclowshowing their workers'compensation Polity information. _ . . . ;
- t I Lxneuwncn who submit this affidavit indicating they am doing all work and char hire ougidacontraeema most submit a rKw anfJavit.indiating_such.
- !Commims that chwk this box must at1whcd an additional sanest showing the name of the subavntruton and their woritars'mmp.policy information,
l am an employer that is providing workers'compensation insurance for my employees Below is the polka sand Jab site
information. .;: '1 ,.. ,{. . ,...... .t . ). . .. .. S. ..
Insurance Company Name:
Policy 4 or Self-ins.Lic.M: �J J - Expiration Date:— —7 :
job Site Address: - G� ��1 1 tM�71'(' �J City/St atc/Zip: sosaa ,N 3 /O
Attacb 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 of MGL c. 152 can lead to the imposition of criminal penalties of
fine up to SI.500.00 and/or one-year imprisonmen4 as well as civil penalties in the farm of a STOP WORK ORDER and a fine
of up to$250.00 a Jay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigatiuns of the DIA for insurance coverage verification. . _ I 1 1.c . .
l do hereby certify(" wader the pains and penalties of perjury that the information provided above is true and correct :
Sk'nature, \U(� 4 _ .: Data: , 13
I 1
Phoned. --
OJjcial user oaiy. Do not write in this urea,to be completed by city or town efflciab
City or Town: PermidUcense#
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#:
t