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6 HORTON ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts 1 ® Department of Public Safety Massachusetts State Building Code(780 CMR) Building Pennit Application for any Building other than a One or Two Family Dwelling 4 (This Section For Official Use Only) = v- Building Permit Number. _ - 'Date Applied '` -'t" Building Offic al: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which-a stre of v ' le) B /a rA-, N^A- d C7 No.and Street City/Town Zip Code /N g(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 0 Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Pher ❑ Specify: Ibald.L *i54- pest) V iuY( b '. "93-,- Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 0 Is an Independent Structural Engineering Peer Review required? Yes ❑ No��1 Brief Description of Proposed Work: 1 M ( M�k i V G V I S e 'a 14' C2:F= "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.) ' i uSECTION 5:USE GROUP(Check as applicable) 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 ❑ HA ❑ IIB ❑ ILIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: _ Public A Check if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site-K nor on sites stem❑ required❑or trench or specify: Private❑ or indentify Zone: Y permit is enclosed❑ Railroad right-of-Way: Hazards to Air Navigation: MA Historic Cor ssion 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: SECTION 9: 'PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: a ck,rv-e�-- N/-C20 era - Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes IZOC.-00 .3a 2;Ijer 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. � 3 'SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix If building is less than 35,000 cu.ft of enclosed s ace end or not under Construction Control then check here O and ski Secfion 10.1 10.1 Registered Professional.Res onsible for Construction Control ==w' ; " + ` Name(Re strant) Telephone No. e-mail add ss Registration Numb e 3 ��s to , -h,d�d � ,ryt ,C^ 6._-1 Street Address City/To� State Zip Discipline xpiration D to 10.22 General Contractor_ Company Name _ Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip �V-ems.3Q5-3 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.E] No ❑ ` �, SECTION 11-CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ C/®`b 1.Building $ • �� Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ ` Oy) 4.Mechanical. (HVAC) $ /y Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to f2/ ! d 6.Total Cost $ (contact municipality)and write check number here r. SECTION 13.SIGNATURES 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. Please print and sign name Title Telephone No. Date -3�. 12�,t.�r Q Street Address - City/Town State Zip Municipal Inspector to fill out this section upon application approval i . Name Date_ w 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) a 11 Z l0 1-14X-40N a 500401 rnk 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 0 Provider notified and Release obtained? Yes ❑ No IM Gas Shut Off? Yes ❑ No f Provider notified and Release obtained? Yes ❑ No CAI Electricity Shut Off? Yes ❑ No 6 Provider notified and Release obtained? Yes ❑ No 14 Yes ❑ No 1� Provider notified and Release obtained? Yes ❑ No 10 Other(if applicable) Yes ❑ No Cp Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) ,. CITY OF S�UEM, l%'LxSSACHUSETTS • BIuILD ,NG DEPAR'fSIENT 130 W.ksHINGTON STREET, 3'°FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KI\IBERLEY DRISCOLL MAYORTHot�tAs ST.P[ERRB DIRECTOR OF PUBLIC PROPERTY/BUUMLNG COMNUSSIONER 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: Lt p s (name of ha er) The debris will be disposed of in : (nam o facility) t l (address of facility) ©1 G 7 � r 1 I'r1�r./9'�r ✓t'�74 1 U signature of permit applicant date dcbri>ffdoc CITY OF SM E:N4 TUNSSACHUSETTS • BUILDING DEPARTMIUNT 120 WASHINGTON STREET,San FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KIJffiERLEY DRISCOLL T MAYOR HOMAS ST.PIFRRS DIRECTOR OF PUBLIC PROPERTY/BUILDINNG CO%5ffSSI0NER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information f L Please Print Legibly Name(Business/OrganizariorVIndividual): Coew l ���5�� Clya�JFTVG c7 / Address: 3,'� v`e-r t2 A tr I fn P to City/State/2irr [s Phone Are you an employer?Check the appropriate box: Type or project(required): 1.0 1 am a employer with 4. 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the subcontractors 2_)&J am a sole proprietor or partner- listed on the attached sheet.: ?• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity, workers'comp.insurance. 9. 0 Building addition [No workers'camp. insurance 5. We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL I I,0 Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' _n comp. insurance required.] 13.aOther •Any applicant that dawlat box Of most also ell out the section below dewing their workers'compensation policy informarloo t I Imrwownm who submit this affidavit indicating they am doing all work and then him o=Wc contractom must submit a new affidavit indicating web, -Contm fors that cheek ibis has must anachod m additional,beet showing ate name of the sub contactors and their workers,entop,policy intotmatiwr. 1 am an employer that Is providing workers'compensation Insurance for my employees. Below is the polley and job site informatimL Insurance Company dame: Pot icy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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. Ile advised that a copy of this statement may be forwarded to the Office of Invcsligations orlhe DIA for insurance coverage verification. 1 der hereby certify under the pains and penaties ofperjwy that the laformadon provided above Is true and correct Si nakure: _ Data: 2—Y-11 J Phone — ,} Official use only. Do not write in this area,to be completed by city or town ojjlciaL City or Town: Permit/Liceose# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 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 applicable No. Item Submitted Incomplete Not Re uired 1 Architectural 2 Foundation - - 3 Structural 4 Fire Su ression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections) 9 Gas Natural,Propane,Medical or other) 10 Surveyed Site Plan Utilities,Wetland,etc.) 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review(521 CMR) 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22. Other(Specify) *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 Street Address City/Town State zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State —Zip-- Discipline Expiration Date The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code (780 CMR) Building Permit Application to Construct, Repair, Renovate or Demolish any Building other than a One-or Two-Family Dwelling Code and Other Requirements for Building Permits The Department of Public Safety has issued these building permit application forms so that municipalities across the state can move toward use of a single permit form and consistent permit application process. The MA State Building Code specifies the requirements of building permits and the applicant is advised to review and be familiar with these.requirements in order to avoid some of the common permit application problems. Likewise the applicant should be aware that some municipalities require that the owner confirm, even prior to acceptance of the building permit application, that no outstanding property taxes, water fees, etc. exist. Filing Instructions 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be reviewed if construction documents, specifications, fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a check for the Building Permit fee. The fee may be calculated using the information to be supplied in section 12 of the Building Permit Application. The check is to be made payable to the local city or town where the work will be done. tom! Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supenisor .. License: CS-089457 ROCCO J KESTA, 88 BOWDOIN STREET Winthrop MA 02i52 Expiration commissioner 06/16/2014 Office off/c �Orrrrrrnrunea r e - Consumer Atfairs us `-f, . rc%a r/Fs ME ,PROM &Busness Rc r VEMENTCONTRACTOR' ,e.fME anon: 160898 XPfratlon•.. 9/10/2074 $. 'ROCCO D3A r' FESTA CONSTR`'UCTION S. "1r ROCCO FESTA - 94 RICHARDSON RD. a LYNN, fdq 01904 ` - tluQerserre� ' .