435 HIGHLAND AVE - BUILDING INSPECTION (3) , The Commonwealth of MassackMVW
Department of Public s"(gECtloN'AL SERVICES
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than O of w atnkpwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
fi 01 UIfGt.E Q p`h 4 (�E
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 N7�- Repair 91 Alteration ❑ 1 Addition❑ 1 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 ❑ No —/
Is an Independent Structural Engineering Peer Review requirAed•,? Yes ❑ No IN
Brief Description of Proposed Work: 4Ft hGtNlo Tv'+ 'F`AI/YCIN(, �X-T 0r: E,crr oF= !77 M0.
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 ❑ A-4❑ A-5❑ 1 B: Business Er E: Educational ❑
F. Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ 1-2❑ 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 ❑ HA ❑ HB ❑ ILIA ❑ 111110 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supp : Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Zone EfIndicate municipal
A trench w' not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required permit is enccll Yl trench or specify:
osed❑
Railroad fight-of-wa 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 01� Yes❑ No 11I'�
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
' { h y� /,T �LttF , NY 'El 221
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
g9036GT W46IL -IJi-640- ep05c JWWbA lam
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
J114TIA Wr" owt llt2 (
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 fill out Appendix 2) ✓
If buildingis less than 35,000 cu.ft.of enclosed space p and/or not under Construction Control then check here IH and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
6"i4im- L;zyg
Company Name -
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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❑ No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor _
and Materials) Total Construction Cost(from Item 6) m
1.Building $ Q N'00 � A
Building Permit Fee=Total Construction Cost x µ1 (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 $ Q ,40,^ (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 knowledge and understanding.
4V--Sx-_1_-1 3 1
Please print and sign name �7 Title Telephone No. ate
7r W"lT hTmyr iEkt y AAA 01 w
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
The Commonwealth of Massachusetts
U1VDepartment of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le2ibly
Name (Business/Organization/Individual): (.W (tact„ k( JW,
Address: -7-7 WAWVT 2�
City/State/Zip: A 01400 Phone#: Q-1
Are you an employer?Check the appropriate box:
general contractor and I Type of project(required):
1.�I am a employer with '✓ 4. ❑ I am a B
employees(full and/or part-time).* have hired the sub-contractors 6. El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. HIRemodeling
ship and have no employees These sub-contractors have g_ ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P tl' $ 9. ❑Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.❑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
employees. [No workers' 13.❑Other
comp. insurance required.]
*Any applicant that checks box H I must also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then him outside contractors must submit a new affidavit indicating such.
;Contractors that check this box most 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 most provide thew workers'comp.policy number. e
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Riiim W!ffl Z✓CAMPAIY
Policy#or Self-ins. Lie. #: yl G 277 47 qs Expiration Date: $ $ 1S
Job Site Address: __ ,r -City/State/Zip:_6LfAA AM 0410
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 certify under the pains and penahies of perjury that the information provided above is true and correct
Si tare: Date: �!
Phone 1A N
Offcial 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.CityiTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF siu2 j tiL-1S&kCHUsETTS
? t ) EIL=LYG DEPAR-11 NT
` 120 WA3HLYGTON STiEST, V FLOOR
wti. ,s'4 Tal. (978) 745-9595
F.ALX(978) 7-W-9845
KIJtBEl2LEY DRlSCOLL
&LAY0I1 THomAs ST.Pi£RM
DIZECTOlt OF PUBLIC PROPE1kTY/81:1MLYG CONNISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 0,111 section l t 1.5
Debris, and the provisions of VIOL c 40, S 54;
Building Permit k 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 r%vICL c
l 11, S 150A.
The debris will be transported by:
� Got_ow+�Ac.. �tto•a `hloat�S • i
(nama at-hauler)
'fhe debris will be disposed or in :
--� —�%4cbme
(name offacdity)
(address ottitcility)
signature of permit• icant
_— I ``ate - —