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10 HIGH ST - BUILDING INSPECTION 11 The Commonwealth of Massachusetts ` t ' `1 W De artment of Public Safety Massachusetts State Budding Code(780CMR) Building Permit Application for any Building other than aOne-or Two-Family Dwelling 0 (This Section For Official Use Ord ) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and L t#for locations for which a street address is not available) 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 ❑ AdditionO 'Demolition ❑ (Pleasefill outand submit Appendix I) Change of Use ❑ Change of Occupiincy „❑ Y., .Other ❑ Specify:.Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ Now Is an Independent Structural Engineering Peer Review required? Yes ❑ No13-' Brief Description of Proposed Work: BW SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigati and Evaluations enclosed(See 780 CMR 34) ❑ _ Existing Use Croup(s): u - 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 ❑ 12❑ H: Hf h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5 11 L• Institutional I-1 ❑ I-2❑- 1-3❑ I-1❑ M: Mercantile❑ R: Residential R-t❑ R-2❑ R- Rd❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: . SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill ❑ ,'; I_IA ❑ f18 ❑ ❑!A ❑ IIIB O 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: PP Y Public Check if outside Flood Zone❑ In municipal(, A trench will not be Licensed Disposal Site❑ Private❑ or inden[ify Zone: or on site system❑ ' required❑or trench or specify:. .permit is enclosed❑ _ Railroad right-of-way: Hazards to Air Navigation: .MA I I' t n_c. mivu si n I _view Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes O or No❑ ` Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code Use Group(s): Type of Construction: Occupant Load per Floor: Dues the building contain an Sprinkler System?: - Speci,d Stipulations: r SECTION 9: PROPERTY OWNER AUTHORIZATION Name:Ind:\yfress of Property Vila �D s Name(Print) No.and Street City/Town P 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 aufforized'b this bufldui ermifil . lication. X. . SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendixl) If building is less than 35,000 cm.0.of enclosed s ace and or not under Constmction Control then check here O and ski Section l0a i .1 Re istered Professional Res onsible for Construction Control Nagegi t�ram) / T�`p tuz N a-mail add ess 2( Registration No _ 15 Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor 42 -ram ,fie Cc� rre��,-o r� p Cormpany [�'iaipS 7AppIcZb1e yName of Person Responsible for Construction License No. and Typ Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address ,-�" '4CON I PEN6AI'ION INSUItaNCP.AFTIU;\VI'f M.G.L.c152. 25C6 SECTION 11:\\1.61.E1... from the MA De mtment of industrial Accidents must be completed and Workers'Compensation Insurance Affidavitp . A P ' submitted with this application. Failure to provide this affidavit will result ui 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 Item and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=$ - Note:Minimum fee=$ ontact muma ility) d Mechanical (HVAC) $ r ��/� 5. Mechanical Other $ Enclose check payable to ;/a 6.Total Cost $ 7�'C] (contact n..... ality)and write ch c number here SECTION IGNA URE OF BUILDING PERMIT APPLICANT By entering my name below, [hereby❑ est under the sins and penalties of perjury that all of the information contained in this applicat'n r true rand accurate to the be. t of my knur dge and understand ng. Please print and sign name Title Telephone No. Date Street Address City/Town State Zip Nlunicipal Inspector to fill out this section upon application approval: 711' / a Name Date CITY OFS.UZi N y ,r, L,L. sS&lCHLSETTS �� 1 tLOLYC 0 C11.I3HC4rTO,Y 5rtfisT, 31O FtOOtt v` lt?L-(973) 7 i5-9595 j.%(3HALHY ORISCOLL FVt(973) 7•t0-934.S „UYOR 111C1 UST.PIER" DIRECTOR UP PCOLiC PRCPEQTY/BE:MDLyG COSL�(JSSIO.V EQ Construction Debris Disposal Afttdavit (required toc all demolition and renovation work) In accordanca with this sixth edition of the State Building Coda, 730 04R Section 111,5 Debris, and the provisions of b(GL a 40, 3 54; ©wilding permit N this week shall is issued with the condition that this debris resulting from I 11, s l sn,�. be disposed of in a properly licensed waste disposal fnoility as datined by NIGL a 1'he ifebris will be transported by: (ndn,a ul hawk ) t•ha debris will be disposed oOn ; -- (name of r,allily) I ----(IdJress u(ra:ilny) it Il Wlq fe p'1 .II,P Ik:.III( l CITY OF SALEm, NLikSSACHUSETTS BUILDLNG DEPARTIM&NT i l?O 1'f/.1SH0VGTON STREET,3"FLOOR TFL (979) 745-9595 FAX(978) 740-9846 KIJ[BERLEY DRISCOLL THOMASST.PTEM MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLL<IiSStONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly �1ai11e(Uusintss.Organixation/Individual): �4'�e �T�'C.(-�%l�`�� '"r� Address: City/Statc/Zip: w Atxcizl Phone hl: G it=F-7 Are you an employer?Check the appropriate box: Type of project(required): I am a emp loyer to er with .S 4, am a general contractor and 1 P Y 6. ❑Now construction employees(full and/or part-alma).• have hired the subcontractors 2.El am a sole proprietor or partner- listed on the attached sheet t �• ❑Remodeling ship and have no employees These subcontractors have S. ❑Demolition working.for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workcrs'coinp.insurance 5.'❑ We area corporation and its officers have exercised their 10.❑Electrical repairs or additions required.) - 3.❑ I 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 I�Roof repairs insurance required.)t employees.[No workers' comp:insurance required.). 13.❑Other •Any appilaue that chmits box II Mail alga ell out the action below showing their waken'= MINation Palmy inrurmatiora '1lnmeuwmrn who submit this affidavit indicting they am doing all work and then hiio outside conuacton mull submit a near a(adavit indicting such. lConuactors that chcsk this box must atlachod an addiiiund ghost showing the name of the subcontractors and their workers'romp.policy information. l urn an employer that/s pravlding worker'compearadon hiss raneejor my employeex Below/y the po/fey and fob site ins t4 / C Insuranceurance Company Name: Policy 4 or Self-ins.Lie. d::� / Expiration Date: Jab Site Address: �✓ / �/l �� City/State/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 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 unilfor one-year imprisonincnt,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to S250.00 a day against the violator. Be advl,,ed that a copy of this statement may be forwarded to the Office of Investigations of the DIA for' cmxe overage verification. /do hereby certify and rd p-enuhfer ojperyury that doe infurarallon provided above is true cord correct. � �1 1 1 5� / )eta: i'lionc,i: OJrcial use only. Do not write in thew area,to be completed by city ar fawn oJj&lat City or Town: Pernolul'icemue# Issuing Authority(circle one): I. Uourd of Health 2. Building Mpurtmant 3.Cityfrown Clerk 4. Electrical Lupector 5. Plumbing Inspector 6.Other Contact Person: .., Phone#: [ nr s ........... !Isar ur, tsn dlohBLdllfir : .. fu,hufl'pk+fl/fit ` Co �:.tUn " �fltlnr ns fBr t rr ruction Su rMicensenu Wes' 71149 sup License k,ud�;- JEFFREY 156 SAREHILL RRDNE SOXFORD, MA 01921 -r Qiumnlss{"rum ._ Silii'aribm; 5@7/2013 16170 �� o mNlacieP.J�1 ' Vlze aennnairu� Bus'�e's Regulation Office of Consumer Affairs&Bus' OME IMPROVEMENT CONTRA Type: egistrotion 173642 Corporation n 11120/2014 xpiratio HORNE CONSTRUCTION JEFFREY HORNE r yr 156 BARE HILL RD _,^Maen rrary