48 HOWARD STREET - BUILDING INSPECTION I
The Commonwealth of Massachusetts
Department of Public Safety
i NlassathusrllsStatcliuilding Code(781)CNIR)
Building Permit Application for any Building other than a One-or I-wo-Family Dwelling
(This Section For Official Use Only)
Building Permit Nuntbee Date Applied: Building Official:
SECTION 1: LO 'ATION(Irlease indicate Block It and Lot#for locations for which a street address is not available)
70
No. and Street City/Town Zip Code Name of Building(it applicable)
SECTION 2:PROPOSED WORK _
Edition of NIA State C+wle used" If New Construction Check here❑or check all that apply in the ttvu rows below
F mstiog Building Repa Alteration ❑ 1 Addition❑ 1 Demolition (Ploase till out and submit Appendix 1)
Chatq,c kit Use ❑ ChaogeofOccilpancy ❑ Other ❑ Specify:
---- _
Are building plans and/or construction LkWil men is being Su pplicd as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review re r fired? ,,nn � � � Yes ❑ No ❑
Brief/ .Scriptioo of Propose 1 Work: P_ (.; I(L �ZJ �_ Q V/)SU ru. !V/Y
ZJ[� -(— —I I �l 7 S �/JOti eL
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 CNIR.N) ❑
Existing Use Group(s): _. Proposed Use Gruup(s):
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(Sy. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-1 ❑ A-I❑ A-3❑ 1 B: Business ❑ G [iduwtional ❑
Ft Facto F-I ❑ F2❑ fl: High Hazard 11-1 ❑ H 2❑ H-t ❑ 1I-4❑ li-5❑ -
1: Institutional 1-1 ❑ 1-2❑ I-3❑ 14❑ NC Mercantile❑ R: Residential R-10 R-2 R-1❑ R-4❑
S: Storage S-1 ❑ 5.2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 1111 O IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VBx
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Lone Information: Sewage Disposal: -french Permit: Debris Removal:
:1 trench will nut be I.IteIISCd Disposal Silo
Public❑ Cheek if outside Iluod Jane❑ Indicate municipal❑ , 'v
required❑or trench or specify:_--.:.
Private❑ or indenlil}'Lunen Oran Sac sysu•ot ❑ permit is enclosed ❑
Railroad right-of-way: !lizards to Air Navigation: \I + i A ��.
Not Applicable❑ Is}truttore within airport approdc It area' IS their I,-% ew completed'or C+m,ent It,Budd cot losed ❑ 1 1 ON❑ or.No❑ I 11•s❑ No Cl
SI:CIION 3:CON'I I:N'F OF C'ER111 ICA'I'L•'OF OCCUPANCY
idilion+d lade: _ _.. l'ae Gnnlpls): - . I\prollnil,trurnon: !tit upmtt l mad per Iloar.
Doe,the huildmIl, mtam,m Sprinkler Sy,tom' '�potial Stipulations: _
-ti
SECTION 9: PROPh:R'I'Y OWNFIt AU'I'IIORIZAIION
N,ma•,uul :\JJrrss ut Pniprrly Uwncr
3-0Jaf2l _i{ fie Howard SF. - -Sa ( - ---- - -- -- olVIa
Name(Print) Nu.and Street City/Town Zip
Property Owner Contact Information:
-- -- 60�43/3 — -- -- —
I'itle telephone No. (business) 'rcleplione No. (cell) c-mail address
If applicable, the property owner hereby authorizes
Nance Street Address _— City/Town --- Slate Zip
to act on file property owner's behalf, in all matters relative to work authorized b• this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if building is less than{i.t"I cu.ft.of enclosed space and/or not under Construction Control then check here D and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
I..su� �r�e55auly 770- 2l0- 196O _ Qil� tcu�arc�i iCo�/ �76?
Name(Registrant) Telephone No. a-mail adt ress Registration Number
lQ n� 5 f Urvl�Z ( D.rrr v Q/QED �_ 9 20/�
Street Address City/Town State Zip is spline Expiration Date
10.2 General Contractor
A'Yn 0 5 g/` o
Comp any N:ume
Name of erson Responsibl for Construction License No. and Type if Ap liatble
5 rrrerro tlQy-Ir, '3U'("'&6t01 5C0# A
Street Address City/ own State Zip
Tole+hone No. business Telephone No. cell �-a-mail address
SECTION 31:au n: .b.ts a t aw 1,v5.:\ru+\LN:ant\Na'r.v tI; AVI I M.G.L.c.152.9 25C 6
A Workers'Compensation Insurance Affidavit from the NIA 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 a lication? Yes❑ No
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Itcm Estimated Costs:(Libor
and Materials) Total Construction Cost(from Item 6)_$_
I. Building S Building Permit Fee=Total Construction Cost x_(htsert here
'_. Electrical S appropriate municipal factor) =5
{. Plumbing S
I. Mcchanical (FIVAQ ; Nate: \lininnun fee=S__(contact municipality)
A ..Mcchaniad Other) S Fndose check payable to _
6. Gdal Gast` S O (Contact municipality)and write chock number here
SECr10N II:SIGNATURE OF BUILDING PERMIT APPLICANT
Be entering nil'name below, I hereby allest under the pains and penal tics of perjury That ell of the information containod in this
application is true and accurate it)the best of my knot Icdge and undcrstuuling.
aflI � L255�G�'c( — -- _� ��1 1-re ' ��7Y/�2/D /96D rt/iz/rr
Please print.m I 'I Ill.ram• - title L It phone No. ILoc
/�-�e�vr -- tr , Z - _sue _- -
j Stroel Address City/row❑ State /ip
I
Municipal Inspector to fill out this section upon application approval:
-------- — N,mie Ica/tc- ---
zi
CITY OF S,�LEti(
_l/ PUBLIC 1'RUPRERTY
=` DEPART
MENT
� 111'. M'1 Y'talw all
\I 11.w
i I!:�Vnon.\1;u,A icrctl' a i•u l•u.M.1wat.rn u 1 LJpq�
11,1. )7Ntyri'IS .P 1.r v7aarC•''xM
Workers' Cumpenfatlon (nsuru
► 1 lllcan ncn U(lduvit: BulldervCuntrac torsi Clectrlclynyplumbers
In nnn�ffo Nome I aanlrunlminJlrntul : � Q s sQ.rCJr � e�A in
a hl
u _ LIR, .
► drvsm: L\ 1 re IL )o l G�
Cl(y,s(amZip- 8) Zlo-- IQ60
Phoneik q 7
I .Iry toju as v,nployor'!Chuck the appruprluu boa;
1.❑ 1 am a cmpluyur with 0. 0 I am a general come3clor and I I)IN,arproJuet(mimired),
cntpluycea(lull,nd/ur partwiote).• huvd hire)IMr.vuh•cunauwrs (t' ❑Now cunsirucfiun
1.on a sold jimprichlr or punnet• listed on the anachcd.lheut t )• ❑Relnalaiing
Mlip and yw
have no ulnpluuo These sub•contracton haw �(
Irurkind file Ind in any cipacky. workers'Camp. Insurance. tl'/(nemaliiion
I NO workers'cutup, insurance J. Cl we are a cnlparation and its 9• ❑allowing addition
reyuircd.J olilcers have vwmia.yl their 10.0 Etactrieal repairs or additions
i.❑ 1 ant l hnmeuwner Joing all work fight ore.rcmptton per MOL I I.C]Plumbing repairs ur additions
myself.(iaa garters'comp• C. 1 s2,¢I(1),aml wr hnvd no nrurunev reyuired.J t anpluyuea. (NO workers.
orkers 1= ❑Ruul'repuirs
cnir invuran I].C]U11wr
h nr •,I dice ilia A w nyuind.J
1 w chrcb eua el mlyt.Ilw all uw IM wrhwt Lvhtr Jwrm r
'I illMowmn-he tuallnit this 0171Javit itwtlulin I r Wweu••�mnlraatYlfMt Ilulivy Inhua1111ita►
i-•nllrwlun Ihw vhvice this Ipa nllw,IlaAad.ie rails +u Juina all wY, .we IM•e hors uWdds rpMrnalen mul•Yfwt1Y a nF URJsva 1nJivia
irttsl.hwtt ulnein Ihlt nraN er Ills Iu►vannnye aM Ihse wwkM• 'nr ww'h.
/urn Ulfcruplayer thus It pruvlJ/nr tverfnr'rumprnrndoa lumrnnre/w lay ern /u, Iatllay 101 int mug,
ill/ururwGrrs P J ra.R Bdalr/r'Air puryay and jut.u1s,
Insurance C•umpuny,VIlnc: ..
Policy As-jr$veins. tic.trt _
—�—',- Eapiruoon Date.
Jub Silo 4ddresa;
lillach a copy of fhd workers'eumpulnatloa po111:) duc
Failure laratlun pogo(Showing the Policynumber and erplratlun dap),
w lecaro cureruye as reQwred uudur Suction:!r► ul'tIOL c. 132 Cau lead to the fmpdsition ofcrilninal penallies Of
line ut nt SI GO,,
y Idailuue•year onpri.rimmunr, us Mull,rr civil penuhlu in the term ora STOP►VURK URGER in
a fine
^Ilgt m i'1n 00 a Jay Ifuulat the v ll.unr. tie sdvl*d Ihut a copy urihu rliwinum may be I4rwarduj w the Ullicd ui
Im.�ll,awlnr ul;Iw MA ;or ulvar.u'cc ci,vcru,e lcnlicahun.
t.
/Ju/rs•rrAy rwti/It rur6v the peinr Irnd pate/liver u
_�/ .1 n • �` ��r/nry r r dr /unnat/ew prvri d ouvy it Irmo word 4 is preR
--------------
1)//Iciul rnI un/y /)u anI nvi/r in lAlr an•u, lu Ar cuurp/rlyd ay city or/own.r/114iol
( itr or 1•olrn: _
Pcrmir/Llecnw 1
"'uiny Authority (cirvlo noel;
I M. •i(Rra111f 1. Iludihn� IAp.lrrutrul l. I,it). ruwnC'ICrk !. Uvoric.11 lu+lcvlur :,
I)Ihcr I Plumping Impccrar
�I 1' II Icl I'1 non:
Information and Instructions
wte an s Oipee is d "Nut a every pets 1 m the dery r of another umlcr•+nY cu^react of hire,
>1,+>;aCl+useus l,icneral Law!Chaper t i2 icywres all euytlayen to provide wOa Of other idCr I hsr there Ct O hire,
Pho
Ihtr.u.u+t to uus'ta
:.pre»it IMPhed. Oral or wnuen. ' oralwn ur other legal ennry, or any two or Inure
nice, and uuluJing the legal represeutativcs ut a deceased employer,:v the
+n C,npfupar Is defined as"an individual, ise. InnhicludiucW it le Cory lam employees, However the
,,I the 6rccgumg engaged in a Imm enterprise.
nW m nhtp. +raaelauur or other legal¢nary,cmp Y II ' Of the
ecerver or Itutee of.tn utdivldual, p
uwnat of a dwelling{house having not snore than three aparananu and who resides tl+eretn ur the occupant e
uriithin t'tlreretoshalI for becawt'of such em la Incur be deemed to be m employer.'
uwelh,ig,huus� )f arorhar•.who eMPIaYs persons w do tnaintenunce,Cunvtruc rlpl yt repair week in III b dwelling utw
or on the I oundi'tii but Ing aPV ^
CSC 6 also slues thee'wary ste%i•of local licensing ag+sey ihzaU witlihald'tAe bsuora or
�IGL Chapter 152, 4_ I ) alnd."
rene+vytof rAlvugsq ur partialarawfli
W,uPaf?t�a huslneu or c couiluet buildings lr the`a amtie I subdivilk ision,¢hall
renetwrdf iihu erfiga nog p'rndueed accsptaba wideaa of CumpUara with the IniuranN coverage req
\dditlawlly,SIGL chipper 1 S1, j15C17)alaler 'Neither the conunanwealth not any of its p
Cuter into any centred for the Pertam+an'd us Pit I the co limiting aluthorityy gene OteunrPliaeice with the inwnnee
requirements Of rhis chapter have been p'
;v>
414ppllc211111 e hd boxes that applyto Ylaut situation and'if
" ans+tion alndavit completely.bM checking
¢lung wi A their t:eniAeutals)of
Plea+r 1i11 out the workers' Bump a unalq,aJJtess(es)and P with no em loyoes Other than the
necessary,suDPlY+ub eontraetor(s)
workers' eon+pematian ityuroact. If an LLC or LLP does have
insurance: Limited Liability Companies(LLC)or Limited Liability Pannenhips(LL
memban ur pudn+n,its not required to carry be inou tt id to the Department of industrial
an+ployld
gas,r policy is required. 9s advised that the affidavit be ill 1 wasted,nog the g1,+poRmcnl of
mpla . far contlrmatiun of insurar+ee eovaroge also be sure to jigs Ord Juts the ul'pdd.00 lie otyl06 shoo
he reuimed to the city or town that the application for the ponnit o licarw is being req
ou haw soy queattooa regarding ehs law Or if you ate umd required go obtain is workers'should linter their
Industrial Accidents. Should y ent at the number listed below. Self•ineureJ comp
cotnperuation policy,platoon call the Deptrm+
sail insurance license number
an the a ro slate lino.
ory or Tows Offlalals
the a licant
rtciha aifidavir tier you to rill affid coMilletti ;Ind avit
the avant the ODIe lutflnvastiu+iDepartment
an�has to contact t you regardinprovided 4 g at lhpp clam
applications c any given year, need only submit Ong affidavit indicating current
it(It e t jars to rill in the puout in
nut Char which will be used,ir a re, number. In addition,an app scant
hat must submit inuhiPle panniu'lindura dr ' ' be provided w the
Policy iuformarion 1 if necessary) and under"lob Site ,stamped
Iha applicant jhnutJ write"ell Inay be s o levy ur
uswnl•" cuPY of the uffldavit that has been officially jumped ur marked by d+e city or town nay P
ennit not related to any business or comn+aroial venture
applicant as proof that a valid a1'fldavit is tin file for Hrtarc Patmits or licenses. A now a111dtivit ntwt he tilted out each
y our. Whcre a home owner or citizen is obtaining a license ar P
tie. a dug Iicetisa nr permit Its burn leaves ate.)said Person is NOT required to complete 4 this uIJ Y uthavu.tn ueshans,
I he ) 11Ce A love;tigaliuns would Itee w thank you in advance 1'ut your coupuuiun and••+huu1J y Y y
pka.e Ju nut hesuata to glvc us a call.
fair number
fhc UCp.uunent'j address, tcicphunelap}I 0�MtLilatAls3att! ' 1.,•
• . .•• . 1°)1¢COtnmOnwee•1d1 r
Department of Industrial Accidents
Oftics of lsvesdgadons
500 Wi+sI'+n8ton Street
Boston, MA 02111
fe1. q 617.727-4900 ext 406 or 1.877•MASSAFE
Fax M 617.727.7749
_j ]i,.iis vww.mass.jov/diA
J' J
CiTYOFS,V-&%f, AkssACHL'SETTS
BCILDLNG OEP-MT-NONT
120 WA,it4ILNGTON STAEHT, ya FZOOla
I-EL (978) 745.9595
KIJ®ERLEY DRLSOOLL FAX(978) 740.9&M
MAYOR n(O-%W ST.PMUX
DtnFCTaaO►PCBUC PIIOPElt7Y/8La,DC'JG CO\pItSSIO.VEJt
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 I 11.S
Debris, and the provisions of MGL a 40, S 54;
11 Building Permit M is issued with the condition that the debris resulting from
work shall be disposed of in a property
1 11, S I SOA. licensed waste disposal facility as defined by NIGL c
The debris will be transported by:
t�rINC, Z
(name ut hauler)
The debris will be disposed of in
(name of
,ty)
lildreaa orl3cdpy)
"dn'n'fe o(permrt Jppliunt
lZJ/zZol/
Lta ��
011,