84 HIGHLAND AVE - BUILDING INSPECTION (7) 16 � tI- llcac� �96 uci�szl
RECEIVED
The Commonwealth of Massii�sD' s
Department of Public Safety �f
g Massachusetts State Building Code(780C OCT 30 A I(: 24.
Building Permit Application for any Building other than a One-or Two-Family Dwelling
Mils Section For Official Use Only) -
K_ Building Permit Number: Date Applied: Building Official
r
t SECTION 1:LOCATION(Please indicateBlock#and Lot#for locations for which a street address is not available)
3 y /-1/G HL A Af 4 d iE %SA/ E'Al 0/F70 //i/NG✓vlJ 0�1 >
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No.and Street Cr Town
Y City/ Zip Code Name of Building(if applicable)
-.. .:SECTION 2-PROPOSED WORK
Edition of MA State Code used_7 If New Construction check here❑or check all that apply m the two rows below
Existing Building 2� Repair❑ Alteration I9� 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? ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: R F nr c V,6 Ti C, nr .Pa r�p p/L o.< st r.00 .0 xr")
lift Ti/<�n[7/aCC �f'icr J°.lr .v T. Coif/,c FLnarC TiLF Q �i „r Ti GAL
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SEC
FION 3:COMPLETETHIS 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): �3 - .[3 C/,S r rr' c. r proposed Use Group(s): -
' SECTION 4:BUILDING HEIGHT AND AREA -
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) _ 6
Total Area(sq.ft.)and Total Height(ft.)
' . . SECTION 5:USE GROUP YZ 7.(Check as a plicable) - _
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 ❑ H4 H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R Residential R-10 R-2 R-3❑ R4❑
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 ❑ HA ❑ IIB ❑ IDA HIM ❑ 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:
Public L; Check if outside Flood Zone Indicate municipal A tianc w 1111 t be Licensed Disposal Site❑
Private❑ or indentify Zone: C- or on site system❑ required fd�or trench or specify: T.PO.T,;r y
permit is enclosed❑ ,4
Railroad right-of-way: Hazards to Air Navigatiom MA Historic Commission Review Process:
Not Applicable R' 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:_5 Use Group(s): - Type of Construction:--'3 A Occupant Load per Floor: 5!3
Does the building contain an Sprinkler System?: . 5' Special Stipulations:
0-0 it 115 k4 ,ll ,
SECTION 9: PROPERTY OWNER AUTHORIZATION '
rTitle
ess of Property Owner
C"ZX AN9 G3 4rL..vTiG l/ _ L3�.sT7�� gfZA
E d 4/T V No.and Street City/Town
^0&kj T- Zip
Contact Information:
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Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
P er l- Gals' RRi Pr ._63 �TGexrrsG rr-
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Name Street Address City/Town State to act on the ro owner's behalf,in all matters relative to work authorized b Zip this buildin ennit a li zip
' SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
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s than 35,000 ou ft.of enclosed ace and/or not under Construction Control then check here 0 and s Section 10.1 -
essional Res onsible for Construction ControlTelephone No. a-mail address Registration Number
City/Town State Zip Discipline Expiration Date
10.2 General Contractor
.S U l-,I?uF + f S jj2C /A/e-
Company Name
M/ GFIiIEL SC/ R _ 6®672' G.S
Name of Person Responsible for Construction License No. and Type if Applicable
7Z �-!6/2TfOR® P /tom /✓_ �S G/TuLT tQs �2�L7
Street Address City/Town
State Zip
�--
Tele hone No. usiness Telephone No. cell e-mail address
' _ SECTION 1L-.WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.152.9 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 iss ce of the building permit.
Is a si ed Affidavit submitted with this application? Yes 19'No O
'SEC71ON12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$ .3 6� OOO
1.Building $ ,� 000.
2 Electrical Building Permit Fee=Total Construction Cost x 1L(Insert here
$ o appropriate municipal factor)_$
3.Plumbing $ o0
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $
Enclose check payable to
6.Total Cost $ 3 6 O o0 (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 the best of my knowled/gee andymders thing.
O/�/
Please print and sign name Title Telephone No. Date
_ZZ H,UKTFoit',O 1//-(eF Z ,
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City/Town State Zip Street Address - p
Municipal Inspector to fill out this section upon application approval• �cf'►+v '� /
11
. Name Date
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x'where a licable
No. Item Submitt Incom lete Not Re uired
1 Architectural
2 Foundation
3 Structural
4 Fire Su ression
5 Fire Alarm ma re uire re eaters
6 HVAC
7 Electrical
8 Plumbin include local connections
9 Gas atural,Pro ane,Medical or other
10 Surve ed Site Plan tilities,Wetland,etc.
11 S eclf'cations
12 Structural Peer Review
13 Structural Tests&Ins ections Pro am
14 Fire Protection Native Report
15 Existin Buildin Surve /Investi ation
16 Ener Conservation Re ort
17 Architectural Access Review fqli CMR
18 Workers Com ensation Insurance
19 Hazardous Material Miti lion Documentation
20 Other S ec'
21 Other S ec'
22 Other S
`Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
N
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No.. e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block # and Lot #for locations for which a street address is not
available)
No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
ElectricityShut Off? Ye
s ❑ No ❑
Provider no
tified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supenisor
License: CS-068879
F:II\ I
NHCHAELPSUGOUE "" �.
72ITUATE
N SCITUATE RI%028
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Expiration
Commissioner 02/01f2015
a� CCI•Y OF S.\LL� I, NWSACHI;SE-ITS
1 1l{ (3Lim.NG DEPARTMENT
(20 C!/.VS(iLVGTON $1',tEET 11O FLOUR
tau:
y -rEL (973) 745-9595
FAA(978) 710.9844
"j.\[ Efil EY DRlSCOLL
NL1Y0:t T OSLICSST.PIE-axe
DIRECTOR OF PULIC PROPERTY/0L•R.ONG CO\OIISSIONER
Workers' Cutnpensation Insurance AlVdavit: 13uildara/Cuntraetucv/Electrf&In.qJPlumbers
\)tpllrint lnformutinn Plebe Print Lllibll
V;IIn,:IRmiCx.uUrgamntiaalmlividu.Ill: -SC/G /2 cz•f — ,q..S—SOC /iVG
Address: 7Z , d TFOK6 /'i /< C
OZ r9- 7
City/Statc/Zip: ri/. _Scy7-;-,1,47"C /2= PhoneM: 17o/-GY7- 3c99D
\re you an employer•!Check the appropriates box: 'rype of project(required):
1.❑ (am a employer with 1, Lii't am a.yenural contractor and I 6, Now cunetruction
mupinyees(full aCi part-time).• have hind the sub•conlnctars
2.0 1 airs a sole proprietor or partner• listed on the winched ahccr. t 7• ❑Remodeling
,hip and have no employees These sub-contractors have 9. 0 Demolition
working for me in any capacity, workers'comp,insurance. q, Building addition
(, o workers'.comp. insurance 5. 0 We are a corporation an J its
required.( - officers have exercised their 10.0 Electrical repelling or additions
5.❑ 1 inn a homeowner doing all work right of exmnplion per MOL 11.0 Plumbing repuirs or udditlons
myself. (No warlicrs'sump. c. 152, 11(4),and we have no 12.0 Roof rspain
insurance m required.( t vpluyees. (NA)workers'
comps. iniurancemquircJ.j IS•[�OlheriCETtuxaGL
r.\ill arpll.:ua uW ehuNks boa tt must arse III out Chv wetiuo hvlew hawing Chvir wwYen'Cam penudun pudcy inMrmudoa
I(,miuwmnv who.uhmil We Affidavit indicaing they As*doing All work and that his*",lid,r,,Incror,mtwt mhmll a now anldavit Inditiine.udt
$bmmalan Char.h.vk'hie bust moat aCtauhud An.uldillanal AM thuwiny It*nwna arthe rub¢unlruWn Ind Chair workvn'sump•pulley Intermnaca,
/urn un rurpluya thuNr pruvldluX Ivorkeq'cumprntar/un hunrunce�or my etnp/uyttx Bduw Is!de policy and Job site
in�ururuflnn.
In,unume Company Nmne: L/DEA'T 7 6L74:-,-,yam
1'nlicy is or Sell r•ius. L i u• li:jAZC-n�- 3�.5 — j G--
E>,pirutian Date: f
job Sile Address: A41,✓;//G.W'1:.+`1.xyic dyr'z CilyiStulejt2ip:.,=� q [E 1`t,* d/97d
.mach a copy ur the worktn' compemalfoo pulley dec•aratlon page(showing the policy number and atrplratlon data).
F.liluru to sccuru coverage as required undur.4ection 25.\ u(MCOL c. 152 can feat to the imposition of criminal penalties ors
Ar.v up to i 1,5a0A0 dridlur one-year irripriinninenq as wall as civil penalties in this torm of a STOP WORK ORDER and a tine
ai+q+to 52i0,t10 a day tgainst Ilse violator. Ile advi.;cd that a copy of this+latvinunt Cnay but iurwirdcd to file OI'licu or
LCvvdigaCiuns 01 the fi L\ IOr imurancc coverage vcriticiliurt.
!do/rrrrby orris y au Jr hr/a jru m'd pit" .r 4p.•riary rhur flit inllururuNwr pruviddd u&uvr i/v true'mul c•urrret
U/liaiulmewdy. /Lr rnU .rift in//fir unit, lu 5e aunrpleW 5y'ay or/ut.n lff,iu2
(.try it I'uva: ,
fourr,+,Anilntrily (circlenac); —._. . . ._
I. Ifu Crd ill I[callh '. IhCtldlm; Dcp.0 rt wcut 1. ( ily� ra+.n Clerk 1, lilrctri;II ht,pc.hlr i. I'bCnibim.; fntpaarar