12 HAZEL ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
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
.t\ No.and Street 17 F{d.Z- -/ City/Town S z t,..•1 Zip Code Q 1 7 7 rJ Name of Building( pplica let
1 t 'vim CC''rr
Assessors Map# Block#and/or Lot #
l� SECTION 2:PROPOSED WORK N n
Edition of MA State Code used If New Construction check here❑or check all that apply in the o ro below.
t Existing Building Repair Alteration 9�- Addition❑ Demolition ❑ (Please fill out and submi�ppex 2)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: "N
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No J&
Is an Independent Structural Engineering Peer Review required? Yes ❑ No fja
Brief Description of Pro osed Work: L) S i
P1 ' WH oWS MI'J or 21
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 ❑ A4❑ A-5❑ 1 B: Business ❑ E., Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-10 R-2❑ R73 R-4❑
S: Storage Sl❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA El IBO IL4O IIBCl IIIAO IIIBD 1 IV 13 1 VAO VB ❑
.SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Information I Sewage Disposal: Trench Permit: Debris Removal:
Public 6, Check if outside Flood Zone Indicate municipal 93'
A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required k or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
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: IAI c d
Does the building contain an Sprinkler System?: W o Special Stipulations:
Design Occupant Load per Floor and Assembly space:
MA I L_ Tu J-'u r�i I�¢ten la M 12"1 L-->✓ro 3[lEi- j
Z f Wres c tirr� P rZ i
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner /
hA2 � t2S r N -*V VjSe-3 C
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
rq I4-o inc C�S'1�- 3C7 /7 5-
Title I Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes:
Name Street Address City/Town State Zip
to apply for and 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 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0.
Otherwise provide construction control forms see section 107 in the code as required.
10.1 Registered Professional Responsible for Construction Control(the professional coordin ting document submittals)
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
M2 4 izS �� � w viSGJ LLC
Company.Name
Name of Person Responsi le for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
9� �B 7 3 O F7 9 Z 19� Gz/ 4F/a3 t t z t*e", 64— Goy. c.a,a vt 2
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS COMPENSATION INSURANCE AFFIDAVIT 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 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ O o 0 b Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ /� ( p O O appropriate municipal factor)_$
3.Plumbing $ - / 7, OOv
4.Mechanical (HVAC) $ ( S p o L) Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $- /O CD (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 ybe best of my knowledge and understanding.
Wq lnlic t(_ _ r �I , h 4-- 971 Gal 3693
Please,,print and si ame Title Telephone No. Date
Street A dress City Town State Zip!!/ Email Address
C2 ✓c✓ ✓ U— �/t1 /f h -� B CvKyc �-
Municipal Inspector to fill out this section upon application approval: 0 / 5
Name Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
yr
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information h ( I / Please Print Legibly
Name (Business/Organizadon/Individual): /11 )) /Iry r J 2 ' c- lr L,
Address: 6- .-1 7 //C- v c.c� 7 f' (
City/State/Zip: G '« y1't e- t Phone #: 7D' G cJ (7
- 3 G S
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with�� 4. ❑ I am a general contractor and I 6. ❑New construction
employees(fall and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in an capacity. employees and have workers'
y p h' f 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.]
5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. _
Insurance Company Name:_ A h S so ,r 4— c� r-u'r!��°cl'a✓r` � � �
Policy#or Self-ins. Lie.#: /[till 12 l O t4 3 O4 2— c) / Expiration Date:
Job Site Address: / ��H -2- � City/State/Zip: S /lam 17
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 of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce(rt r de -ihe pgitrs�and peyylties of perjury that the information provided above is true and correct.
Sivnature / ( �' JJ�' G% s Date? - Z 6
Phone#
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
1.Other
Contact Person: Phone#: