84 HIGHLAND AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
nDepartment ofPublic Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One or Tw '3plyRWOng
(Thus Sectron For O nly);77777777777777777777
fhnal Use O
Build tn' Permtt;Number ;DateA lied ' ` BuildmgOffimal. . e ''
,SECTION 1r,LOCATION:.(Please iricifeate Block#'and L'ot#for Igcat�`o,'ns for which+,a street a s,rs not available)„ `.
64/ /'>GH!_AYOAIIZ- S,liLEPI 01976 /G. . « ? 9`-':' �Ac
No.and Street City/Town Zip Code Name Building(if applicable)
<. „ SECTION
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❑ 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 P No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ®r
Brief Description of Proposed Work: le Ear®V rf Tio / "" f E ' <V.4-7—E
SECTION 3:COMPLETE THIS SECTION IF EX STING BUILDING UNDERGOING RENOVATION ADDITION
+�, CHANGE IN,USE OR OCCUPANCY `rv,:,•
, . ...:, =. . w . ..„W,,. .. .w .�.
Check here if an Existing Building Investigation and Evaluation is enclosed(See-780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s): /f
r`,SECTION 4:--AND AREAS ..
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) _r
Total Area(sq.ft.)and Total Height(ft.)
•-" " '"SECTION 5:USE:A001?(Checle?as;appt}cable)5"
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ - 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:
SECTION 6:CONSTRUCTION-TYPE(Check as applicable) '`'
IA IB ❑ ITA ❑ 1I313 IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SEC7ION:7:SITE,INFORMATION'(refer,to 780 CMR111.0 for d'etails,on`each rtem)�
Water Supply/: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public 0' Check if outside Flood Zone Indicate municipal A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: G or on site system❑ required�trench or specify:7RoT9 a/
permit is enclosed❑ 4 E-C c/G G .E
Railroad right-of-way: Hazards to Air Navigation: MA.Historic Conunicsion Review Prcn:ess:
Not Applicable Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes ❑. or No C9' Yes❑ No 21,'
--'. SECTION 8:CONTENT OF CERTIFICATE:OF OCCUPANCY --
Edition of Code: Use Group(s): 3 IR-2 Type of Construction: 3 A Occupant Load per Floor: 4,L3
Does the building contain an Sprinkler System?: / Special Stipulations:
f
- ? ••'`;: . :. .�SECTION:".9 PROPERTY OWNER AUTHORIZATION ,.
Name and Address of Property Owner
SdLEr7 ///C%Go�rO G3 Q7-4 e9
Name(Print) RE6G./Ty No.and Street City/Town Zip
TRv-s�
Property Owner Contact Information:
/cK 8E,/,0E7'5O?V G/>-e0Z- o693 Sae-5z3- /`/93 RK!_3EJ�F/. GG
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
�or�L 6.,d 1E/E.F__ r:3 dT/_1NTiGd/� / o sT J rT4 (2
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 frll out Rp'pendix 2) r 5
If btuldiii vs less then3S000cu:fk of encloseds ace and/or notunder' Qnstructlon-Controlthen eieckheredand ski Secuon 101 i
-101 Re iste[eif ofessi'onal Res onsible'for Comstitictimr,Controls , - ;'.. .•' *� ?*'? ;` ,
Tf�= 1AG Al/ TEGT(i QL. T.�-li7 c.V•rE a= 6 C eL 7',5 17, co
7- cz-_ QvE r?lZrx ca 3 ��9
Name(Registrant) Telephone No. e-mail address Registration Number
_5'r/ /rs/ >�7,4',c%�O�,v,�s i+/�/ G/'•�<' s.f,4- lTtt Gz/.SC7 ,u�cr{ s /.3
Street Address City/Town State Zip Discipline Expiration Date
h 5
-;102General';ContractorM ...,. ?.. .,., ,.;c, s., .�:.., .�•..r., �. ..a°. ra.� , .. �. -.. ..� �,':; . ...f. , .... , ., .,a.,".:,
S U sC v E � ,dSSO G r�vC
Company Name
/9/Gf-/AEL 66'379 G S
Name of Person Responsible for Construction License No. and Type if Applicable
7z //dV Tf0/'L? //A'E Al ,SG/7y,'d oo�T O2c�,_�
Street Address City/Town State Zip
/a/-w7- 3690 z/o/_?3S 9/7_35 />r =ca scurrs�/a vEcmx r�rL .cO i
Tele hone No. business Telephone No. cell e-mail address
•. '� "" SECTION�11:`.SNORKLRS'c(1MPENSATIC9N3NSLiCANeE`AI'PItiAVIP bf:GiL'.;c'151 25C
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 si ed Affidavit submitted with this application? Yes❑ No 0
" `s� . . ,'•.SECTIl7N.12_ CONSTRUCTION C,OS,TAIV.D PERMITFEEs,a� "
. ,, . . . . . , k .
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
1.Building $ /O P Om. Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ �j m appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$. (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ /Z O 00• o (contact municipality)and write check number here
• j. SECTION 13:SIGNATURE OE BUILDING PEhMIZ'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 knowlec* and derstannding.
>7ic//DEL P SfiG/�/i� mac/ 0/Fsu srT -�- z
Please print and sign name Title Telephone No. Date
7Z if�r?TFo6' O //�� // SG/Tri d) � OZFS7
Street Address City/Town State Zip
Municipal Ihspector to fill out this section upon applicafron approval ,
_ Name j - Date
CITY OF SM.E.M5 N'-LASSACHUSETTS
BUILD4iG DEP ART,,i&NT
i N - 120 WASHINGTON STREET, 3se FLOOR
-CES_ (978) 745-9595
FAX(978)740-9M
KI\IBERLEY DRISCOLL THONW ST.PIERRE
MAYOR
DIRECTOR OF PC81:IC PROPERTY/HCIIDLNG CO3MII55IONF..R
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
ry Nafne(Business�Organizatior!Individual).: 5 r r D C t= it!C-
Address: 72 4/,,fA7_Z06 ,0 d l/<`t
OZdS7
City/State/Zip: �/�S c1 �/ a � , Phone#:
Are you an.employer?Check the appropriate box: Type
l contractor d 1 Type of project(required):
4. t am genera conracor an d.
l.El i am a employer with [B- ❑New construction
employees(full and/or part-time)." have hired the sub-contractors �,...,
listed on the attached sheet. 7. odeling
2.El I am a sole proprietor or partner- _
ship and have no employees These sub-contractors have S. [:]Demolition
working for me in any capacity. workers' comp. insurance, 9. F-1 Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its
required.) officers Have exercised their 10. Electrical repairs or additions
3.❑ i am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp, c. 152,4 1(4) and we have no 12:[] Roof repairs
insurance required.)t employees.[No workera' 13,�Other
comp.insurance rcgpircd:j
'Any aPPltuM Utar chocks box a t must also rill out the section below stowing their wurkets'compermatian Polity infmraminn.
+I h m no,,, he submit this affidavit indicating they am doing all work and then him oraide conimcrom must submit,new,If3&O indicwing such.
'Coal mum that check this box most attached an additional ateet shox'ing the name of the sabkontragom and their'workera'comp.policy information..
!am an employer iliat is pmvidittg workers'compensadon insurance for my employees. Below it the polity annd job site
information. -
Insurance Company Name: /Ia Tp� . 5_
Policy#or Self-ins.Lic.#: we_ � is'�7 I a+ I Dot Expiration pate:
Job Site Address: -9 4/ N/ </L,LI 1V0 d V F - City/State/Zip: Zl FP'[ 1�T,4 d/�17d
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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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 de-hereby certify ands /h/galas and allies ofperjury that the information provided above is true and correct.
signt t and its
Dato• T?
e-1 7— 3�9(�
Ofcial use only. Do lot write in this area,to be completed by city or town ofjiciai
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
b.Other ..--_---
Contact Person: _______ Phone#:
c -y
1
Y CITY OF S"I zm2 iti ks&S CHusFTTS
BLtLONG,DEPAR'IM&NT
I?0 WASHct '°GTON STRE&'F, 3 F�.00R
TEL (978) 745-9595
FAX(978) 740-9345
4 ;<11tt3E4LEY t7215C0[1.
NG%yoII T�10►6AS ST.PIERRS
DrAECTOR OF PLBLIC PROPERTY/BE:MMNG CMNISSIONER
Construction Debris Disposal Affidavit
(required for ail demalition,and renovation work)
In accordance with the sixth edition of the State Building Code, 780 ChfR section l l 1.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit It is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by 1YfGL c
I11, S 150A.
The debris will be transported by;
burna of hauier)
The debriswill be disposed of in ;
(nnmc ut'tuilf+y)
(�dJresa ut t'a�ihty) � '
siynamrr ufperntit applicant
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