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84 HIGHLAND AVE - BUILDING INSPECTION (4) =` The Commonwealth of Iitassachusetts Department of Public Safety S '•• �' \le,+,Irhusrtls Stalr flu ddin;Co 1.dv 1%411 \II( - 1 ) Building Perm it Appllcahun I for any Building other than a One_or I\v ', r t ly Dwelling (Iltis S*vt(ion Fly Off dal Use Deily) 1111 l,linl;l'cnnit Nunda•r DaleApplied: Z_J.L_ Building Official: SECTION I:LOCH IION(Please indicate If luck 9 and I.ut 11 fur locations fur which a street address is available) 8Y /CCH_L.Q �rQ 4✓E _sf}L,4_'p_o/.97d N/�i4GA�o_ Gec - Nu. .nIJ Strrct lily:Town lip Qale Name tit IfitilJinl;(it applicable) .- SECPION 2:1'ROPOSF'U WORK Petition of \I:\Stile Cade uxvl If New Ci nslntclion check here❑or check ell that appl in the Ion row, li xislin); RuilJin};❑ Rvpmr :Weraliun ❑ :\Jthtion❑ Demolition ❑ (I'lease fill out and sul+mit.\ppvnJix I) Ch,ury;c nt Use ❑ Change of Uccupanry ❑ Other ❑ Are building plans and/or construction dtkunlculs being supithed,Is l,arh)l this per application? 1'es Nu ❑ _--� _ is an Independent Structural Engineering Peer Review required? Yes ❑ Nit B� Briet Description of Proposed Work:__.13. = 0 C I/I lO R /ii'E` SECTION J:COMPLETE I'HIS sEcr10N IF EXISTING BUILDING UNDERGOING RENOVATIpN, AUUI'flpN,Oit CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation And Evaluation is enclosed(See 7W)CNIR.N) ❑ Existing Use Group(s): - - CI.SL�E,3'ss Proposed Use SECTION 4:BUILDING IIEIGIIT AND AREA Existing Proposed No.of Flull"/Stories(include basement levels)4:\raEPer or(sy.(tJ S r. fatal.\rva(sq. ft.)•md rotai Iicight(ft.) SF-C 1•ION is USE GROUP(Check As a liable): A; Assembly:\-I ❑ A-_20 Ni);hlclub ❑ A-1 ❑ :\-I❑ A-i❑ B: Business"011-5 onal ❑ F: Pxdi F-i ❑ F2❑ 11: !li h Hu.vJ FI-I ❑ H-2❑ II -i❑ititutional 1-1 ❑ 1-2❑ 1-1❑ 1-a❑ �,V I: Jtercantile❑ li: Residential R- -� ❑S: Storage S-1 ❑ S'_❑ U: Ctility❑ SpeciAl(1sn O and p Special Uss• -SEC[ION li:CONS"I-Rucr10N IYPF- (Check as applicable) IA ❑ IB ❑ (IA (3 IIB ❑ Inn ❑ IIIB ❑ IV ❑ 1 ll 0 V�11 -___- SEC"r1(1N7:SIIEINFORMATION(refer to 74B CMR 111.n fur details on each item) \V,ucr Supply: Tlnua Lune Information: Sew•tga UipposAd: E Trench PemtiF. Oehris Renun'al: —._ 1'uUhc C hvl k d,nl hlJc FIanJ Lnnr❑ Indit;Uc muuicipA❑ em h ,.III not be I I.rn+ad hi+po+ai yin•❑ ❑ ,r iudrnGly Gnn• irod ❑nr tr,itch ,,r. nhm+ne+t+Ifni ❑ pr,flynn hen,lo+t'd 0 1(ailroad right-of-way: 11-3/ards W Air Nat igatiun: \• t \plh,.ILIrO I A<Inn tort urtlun.urpl•rt appn•.It It.In•J' j I+Ihrrr rn lrw lrnlPl,rI'd, jr ru.rnt hl lfudJ,n,L +,.1 ❑ 1r+0 ••r \o0 - lr+❑ \ 0 ♦I1-11(LN4:I. ON I UN r(IF l I.It I'IFIC\IE O1:(1_77_ \.V('Y I IJIWm.a l- •Jc l .r t.nIlpl+l It I•r•q l' •n.hmtl,m t`„npaul l •.L1I,,,r I1,.1•r___._._._._.___. . _� i :I , . th•• I•.nl,lin7;Inruu."I`J-Iulbl,rti,+l,rlit -In,i.d�lil•uldlion+ I (� ��l a ���9/z� S...Zzfi�?V'9`iRRDiERT1(OWALOTtT2AI ©Tis� w.M"�' Name and Address of Property Owner ,5AL F!.f Al 16 NL eW(D 63 X7_LENT/(_ 4✓�— 0-'7-27 /`7µ Name(Print) /?C-<L/>y T/7v--5/No.and Street City/Town zip Property Owner Contact Information: ExTS R IGI{ 0.EN 04 >s o%/ _- aR 9.1 5_ae_-5Z 3- /v 93 $/1l3 e .OF Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes PariL L6 f&A/R/&A e 63 47--",y7-1G dv 13osTO v. r114 D2'//!� Name Street Address City/Town State Zip to act on the ro owner's behalf,in all matters relative to work authorized by this buildingPermit' annlirAtion. SEC'1�UriY]A}�bNS't1Rl;ICTIO2�CON71'BOG ea�ef?l�"out�l ea'rlrx""`�$= .. .'�f.. ' 1NITilAn >s{esst§an�5©UO en:#r.'of�o e� � or�ioc w�id�e�Cox strue�vn,�'ontraEtit�c eYieckli� s. �erep'�nfls?n -� 11L1 .. �111 IRe" t�edYrofes"sionSl;RA '9nsritie�or`;Canstriction_�oa`fro'], -." -. �. ` ,�'� jHE �RGif/TECT(//(AL TEd 7 ,A Rc i4~L7!a4 Al c Name(Registrant) Telephone No. e-mail address Registration Number SO rAr9/4d://�f�/-/7S khe/ G!/EG SFA � o ,9 i d R Gf/. . Street Address City/Town State Zip Discipline Expiration Date '°-1ft 2)Ct'eileralx4'nrrtraetpa _ ` " _5616A Company Name - P1/GhAEG P St/% i4vE 6f39 �9 CIS Name of Person Responsible for Construction License No. and Type if Applicable 7Z /�',zl/P A/- JC,17-,�.�1,d 7-;6 lqz- 02c957 Street Address City/Town State Zip C11 1l�7 3aZj07_ / - 9/7.3 �1Fa-r e. _Si lF' irI nrF�ox/tai o Tele hone No, usiness Tele hone No. cell e-mail address 'SRC'1'ION I.i N RKERS',Zbt' ' ATIOM,LN "' : cL; • �v1Y G:i,.:s:152. ^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 is5oance of the building permit. Is a si Affidavit submitted with this application? Yes No ❑ : ""--`. Y `^. _ _.SECTIt7T�T,12_CONS'FRi�CT3©IaiICQSTS�ND�PEItI� fT.EEE�` "Y�,�"' Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 4 C,O .00 " 1.Building $ . :0 -O.. _""' Building Permit Fee=Total Construction Cost x LL•(1(insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ -_. Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ O cj0O - (contact municipality)and write check number here s, SECT�QNf3 GNAljii gPBtu DTLVGYPik11 [� AP>?ISCAIVYF 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 mykn 1 ge an derstanding. - 191GN<EL A° ,S l /4/ F ' OiF's/,DtF 7 Al Please print and sign name "`f Title �j Telephone No. - Date 7Z HG CTFOiCQ �K--� /V. .S [;/TCi.a 7.E RE :7?Q5-7 Street Address City/Town State Zip § gi'._wnrt8 it _ M`umctpaigector3a,. r1I ut thi=s' ectroq ,pou appluatign, g ��.., CITY OF 5,UElI, Akss,1CHl;SE'1TS 13L'IL-DING DEP.%armE.NT ��,� •f, '� 11'/�;� 120 1V."HLNGTON STREET, 3'a FLOOR TFL (979) 115-9595 F.,a(979) l W844 KI IOERIEY 0RISCOLL LA Y0.1 T310SL13 ST.PIsaRa DIRECTCR OF MLIC PROPERTY/Sun-DING CO\ISIISSIO.iER Workers' Compensation Insurance.\ITldavit: Builders/Contractorv/Electr(clans/Plumbers lnplleant Infthrmatinn Pt are Prlut Lcnihty Nlllnd Illuuiu•�Urgani»fion lndividudl): S C/G /t' (/.E - .4.S.S0 G /iVG Address: 7Z 1/ dATFc1 Q I't /t E OZ BJ 7 City/StMOZip: n< SciTy4TC /RT Phone N: Vo/-GY7- 3890 _ ,1re you an employer!Check the appropriates tests Type of project(required): 1.❑ lam a employer with 4• ��general contra]nIr nd 1 employees(flall and/or part-time).• have hired the subcors 6• ❑Now construction 1.❑ I am a sole proprietor or parinur. listed oil the attached I 1• ❑Remodelins .hip and have no employees These sub•conlmctor g. 0 Demolition )v)rking for me in any capacity. workers'comp,insur9• Building addition 1. o workers'comp. insurance 5• ❑ We are a cnrporotion snyuircJ.J orfleers have azareise I0•❑Electrical mpain or additions J.❑ I mn a homeowner doingall work right of exemption pe 11.0 Plumbing repairs oraddidons myself.(so workers'sump, e. 152,11(4),and we o 12.Q Roof repairs insurancerequiied.1i umployees.INoworkII.�IuthetRET- t.UtlLL_sump.insurance requi i nny.Wilkins dW dhavtia boa 01 mwr aloe nll uul rho 4vliuo below.hawing their.akin'comlwnmiun pulley ma)nnatlan. I fl nvurrcn-ho.olunil thin nndavil indieuing they ire doing all Overt and then hire uuaide mainebra mtul 114111111113 Pane anrda.it indlealing cw)L t'.,mc+dtun lhll Owl,this hex muai inach.a)an.Wtbllutad.har.hawing ib nwrta atiha.ub.aomn<gae and lha4 wmktrs,comp pulley Iniornultaa. /urn un nnpluyer that 11 pruv/dlnX ivorktn'cumpturadon lnsurenee for my employees, Below/s the polley undue Ills, in/ornutlnrry In>urnce Company Name: I-/Diffv 7 V...f?'(/ TU,iQ,t: I'alicy Jer Salf-ins. Lic.it: )6/C -/- 3/ -".3�/�/�9^ OG'/ Erpiralian Date:—aQ///, )ub Slid A.IJresic e9 CilyiSlaletZip: S,4 L E 114, A-f,* 0/9Td Aitacb a copy of the workers'compensation pulley declaration page(showing the polity number and espintloes data). F liluru lu sccuru cuvaraga as required under.Section 11i\of MGL c. 152 can lead to Ohs imposition of criminal penalties of s Ar.c rep Oa i I.M.00 dnd/ur one-year imprisonment,ds well as civil penalties in the form or a STOP WORK ORDER and a tins .:(I'll to S_'iQCO a Jay lgaillst file violamr. Ile advi..ed chat a copy or this aatcmcnl may W iurwar&d to ilia OI'tica of Iav C.ligalimlit,irihe OfA G)r imurince coverage vcrilleatiun. /du lrtrrby eerti jr wil, /u is mrd pun .ni/parjury.huff the iujunrrorlun previdaJ ubuvt it true arrd comet rr�e.r /IlJrcr�!rot Andy. /Lr na/nvirt in rhr:c urea, ra�r cunrpltrdd 5y rity ur ror.n,i//Iriaj Cily nr rave: . . _ i'crmit/Llcenre 1 L :;nnrJ al Ilcalih !. ❑u;Lling ❑rp.icbn col !. ( ily�"f,mn Clerk 1. Ffzctric tl til.pcsl,lr i, 1'Ionillin. In.pactar 5. thh:r