0390 HIGHLAND AVENUE - BPA-18-864 T e Commonwealth of Massachusetts
® Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(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)
N Oi d
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❑ 1 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 ❑ No.9
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work: S-e c-T( P 7 e Te 14 L a)
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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: Hi It Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Insfitutional I-1❑ I-2❑ I-3[1 1-4❑ 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 ❑ 111 ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑.. IV ❑ 1 VA El VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
-Public Check if outside Flood Zone Indicate municipal N A trench will not be P
Private❑ or indentify Zone: or on site system❑ required�,Ed or trench or specify:
permit is enclosed❑
r Railroad right-of-way: Hazards u to A 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❑ Yes❑ No ❑
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:
N AI L'En -M P"M ba')% I S l�
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
� Ut Ra44rFf —�yL5T �56 uvrr/liq,.� ,,e SYI e,
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
ToK n,�n�rtt Y11 � � } Tow nfG s
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 authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O 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
9St hN
Company Name
O( t_ 5_9 /47G /o,04& C 5 0o I qls,
Name of Person Responsible for Construction License No. and Type if Applicable
/are c.edAr S S_ U�P/�f?SIPIf aA (141V
Street Address City/ n State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.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)_$
1.Building $ Building Permit Fee=Total Construction Cost x (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 $ � contact municipality)and write check number here
SECTION 13:SIGNA -RE BUILDING PERMIT APPLICANT
By entering my name below,I er the rns 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.
,bAU Ld ,.V -yofj Pres(dely -as- vo8c
Please print and sLign nam Title Telephone No. Date
Jao r
Street Address City/To� State Zip L
.Municipal Inspector to fill out this section upon application approval: , 575
Name Date
CITY OF SiU. M, IN'LAiSSACHUSEM
BUILDING DEPARTMENT
• 120 WASHINGTON STREET,r FLOOR
TEL. (978)745-9595
FAX(978)740-9W
K'INEBERLEY DRISCOLL
MAYOR THows ST.PIERR&
DIRECTOR OF PUBLIC PROPERTY/BL'10MING CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information L �q Please Print Le ihiv
Name(Busi,xss.Organization/Individual):'Si
Address: A20 Ce&y� f ---S F _
City/State/Zip:G1���0_5_ _t Wit&I Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.91 am a employer with -T 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. g. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[No workers'
comp.insurance required.] 13•❑Other
•Any appliam that chucks box itl must also fill out the section below showing their worker'wmMiutian policy information
I rnmeowner who submit this affidavit indicting they are doing all work and then him oulsidc contractors must submit a new aMdavit indicting such.
=Contmclor that cheek this box most aaachod an additional sheet showing the name of the subcontractor and their workers'comp.policy information.
waCaat
I am an employer that is providing workers'compensation insurance for my employeex Below Is the pollty and fob site
information. /t /
Insurance Company Nzme:t ,,"AI eN 4, I
Policy k or Self ins.Lie.H:�& ^L3 9g93 —D/- o f Expiration Date:S�o�7/.20/Y_
Job Site Address. 6 /dIvir/ Aie City/State/Zip:,�A IP/ri M-q 0-/910
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 S 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 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 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sian irtire, Date
Phonq& g,
Official use only. Do not write in this area,to be coarplered by city or town of iciaL
City or Town: Permit/License q
Issuing Authority(circle one):
1. Board of Heallh 2.Building Department 3.City/Town Cterk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone M
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
License: CS-001915
DAVID G STJOHN. '
8 SHERIDAN CIR _
WELLESLEY MA 02481
J12..
Commissioner 10/29/2016
&Xe �pt��ve�a o�zcr�eco�� dC>G�tzr1�-�e�z�r� -
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 102465
Type: Private Corporation
Expiration: 7/2/2014 Tr# 227530
ST. JOHN CORP. -
David St. John
120 Cedar Street
Wellesley, MA 02481
Update Address and return card.Mark reason for,change.
'- O Address 0 Renewal E] Employment 0 Lost Card
SCA 1 0 20M-0911
r/!n.//rrLrrr'kejell.l
office of Consumer Affairs&Business Regulation License or registration'valid for-individul use only
13 _ I}OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration 102465 Type: Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
,N xpiration: 7/2i2614 Private Corporation Boston,MA 02116
ST.JOHN CORP.
David St.John ,
120 Cedar Street ' Q ,�
Wellesley,MA 02481 Under4ecretary Not valid without signature -
r
CITY OF S.-u.F.M, NL-�SSACHUSETI'S
' Bua.DD;G DEPARTMENT
120 WASHINGTON STREET, Yo FLOOR
TFj— (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THoNw ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDCVG CONMUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# 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 MGL c
111, S 150A.
The debris will be transported by:
(name of hauler The debris willbe pdisposed of in
(name of facility) �J
LSk] f4 w p, ._Sn 90
(address of facility)
signature permit applicant
date
a�ed,arrdu<