10 JEFFERSON AVE - BUILDING INSPECTION (3) flit33 - L
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The Commonwealth of Massat
tts
Department of Public Safety
Massachusetts State Building Code(780
Building Permit Application for any Building other than a OTwo-Family Dwelling
(This Section For fficie )Use Ord )
Building Permit Number: Date Applied: Q ` / Building Offici
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which address is not a able)
No.and Street CityTown
/ Zip Code Nailding(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If Nov Construction check here❑or check all ply in the two rows below
Existing Building 6� Repair❑ Alteration ❑ Ailalition❑ ' Demolition ❑ (Please and submit Appendix 1) '
Change of Use. O Change of Occupancy - ❑ Other ❑ Specify:Are building plans and/or construction documents being supplied as part of this permit app ? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 2(
Brief Description of Proposed Work:
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.) aM o�
Sq'Pr
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-S❑ B: Business E: Educational ❑
F: Facto F-1 ❑ F2❑ FL• Hi h Hazard H-1 ❑ H-2❑ .H-3 ❑ FI-4❑ HS❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage Sl❑ S2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a plicable)
IA ❑ IB ❑ HA ❑ fIB ❑ IfG1 ❑ 11I8 ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood ZoA
Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if out ❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentifyor on site system❑ required❑or trench or specify:
rpermit is enclosed❑Railroad right-of-way: azards to Air Navigation: \li\llitil rrt i on,l tj, It j,:r��I r h,ss:
Not Applicable❑ re within airport approacharea? Is their'review completed?or Consent to Build enclosed Yes❑ or No❑ Yes❑ No ❑
ON'TENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the buildiagcontainan Sprinkler System?: Special Slipu la tions
i
� � GL � 3/�
SECTION 9: PROPERTY OWNER AUTHORIZATION ,
Name and Address of Property Owner 0
Name(Print) No.and S cut City/Town Zip
Property Owner Contact information:
Title Telephone No. (business) Telephone No. (cell) e-nail 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 b•this building ermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed s ace and or not under Construction Control then check here O and skip Section 10.1
10.11(Registered Professional Responsible for Construction Control
\LFJ \ �ii1 1�3b �—
tm•( CO rant) Tel• hone No. e-mail address M Registration Number b 1 Y
o�'01�$lA 'ja1-�-t"1
Street Address City/Town State zip Discipline xpvation Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. buness Tele hone No. cell e-mail address
si
SECTION 11:FVORKER9 COMPfiNSAi'u�� NmJRAVT ALPn)AVPI' 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 C3 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from(tent 6)=5
1. Building S r Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $ contact municipality)
Note: Minimum fee=$ ( tlit P' Y)
d. Mechanical (HVAC) $
y. \Mechanical Of $ p Enclose check payable to
6.Total Cost S p (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,nd penalties Of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
fW-. 1H
Please riot and sign u "title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to ill out this section upon application approval:
Name Date
ALI CITY OF SAI.EM, 2ANSSACHUSETTS
• BUILDING DEP t RTIIENIT
120 WASHINGTON STREET, 3AO FLOOR
° TEL (978) 745-9595
FA-.x(978) 740-9946
KIJf9F_RI.EY DRdSCOLL
MAYOR THOMAS ST.PIERM
DIRECTOR OF PUBLIC PROPERTY/BUELDL\G CO\L`IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibiv
Name (nusitwss OrganizatioNIndivid �ual): "S"n" - I-r `''{�
Address:
City/State/Zip:k5RVrAA O 4 7t) Phone #: (SLCE) -71)3
Are you an employer?Check the appropriate box: Type of project(required):
I. 1 am a employer with a- 4• ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).° have hired the subcontractors
' 2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet.t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp.insurance. 9- ❑ Building addition
[No workeri 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 t I.[] Plumbing repairs or additions
myself.[No workers'comp. c. 152, 91(4),and we have no 12.ff Roof'repairs
insurance required.l t emp layers. [No workers' 13.❑ Other
comp. insurance required.)
•nnyxpplio:mulutchecksbox Bt most also Cilluut the accuse Wowshowing theirworkers'compensation policy inhumation.
'I bencuwncn who submit this affidavit indicating they are doing all work and then hire outside contractors most submit anew affidavit indicating such
$:nmmcuua that check this box must attached in addiiiurul;heel showing the name of the sub-contractors and their workers'comp.policy information.
l out an employer that is providing workers'compeusallon insurance for my employees. Below is the policy and fob site
information.
Insurance Company Name: _
Policy#or Self-ins. Lic. d: - Expiration Date:`_ ,
fob 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. Be advised that a copy of this statement may b-c forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby certify undde_r the pains and penalties of perfury that the infarmalian provided above is true surd correct
Si�L utrc: �^n �,� � Date: _ (O
Phone#: JlJ7i V lJ�7 _7
Official rise only. Do not write in this area,to be coiuplered by city ur town officiaL
City or'ruwn: Permit/1.1cense#
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.Cityrrown Clerk b. Electrical Inspector 5. Phnubing Inspector
6.Other._,__.. _
Contact Person: _..._..__ Phone#:
1A.
CITY OF SM�EM, NWSACHUSETTS
BUILDL\G DEPARTMENT
130 W ASHNGTON STREET, 3'O FLOOR
T EL (978) 745-9595
F.LK(978) 740-9846
K1JjBERL.EY DRISCOLL
IAVLiYOR THOSGIB ST.PtERR6
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COS12MISSIONER
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 1 l L5
Debris, and the provisions of NiGL 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 will be disposed of in
�-
-_—_-_ (name of facility)
- —(a�cility)
si�ie of permit applicant
1, o` bI
date