62 JEFFERSON AVE - BUILDING INSPECTION (9) �f /0 7�
The Commonwealth of Massachusetts
Department of Public Safety
,Alaps ac
hatsrtls State Building Code(i311 LAIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(Ibis Section For Official Use Only)
Building Permit Number: _ ___ Date Applied: _ _ Building Official:
SEC'HONN�/11: LOCATION (Please indicate Block B and Lot R for locations for which a street address is not available)
No.,md Street City /Town Zip Code Name of Molding(if applicable)
SECTION 2:PROPOSED WORK
Edition of\I:\State Curie used If New Coostruction check here❑or check all that apple in the two rocs below
Exi+tinf; Building❑ 1 Repair❑ 1 Alteration 113,1� 1 Addition❑ Demolition ❑ (Please fill out and Submit Appendix 1)
Change ul Llse ❑ Change of Occupancy ❑ Other ❑ Specify:----- _ _
Are building plans and/or construe lion dth'u amCotS being Supplied as part of Ihis permit application? Yes ❑ No[San hnlependent Structural Engineering Peer Review required? Yes ❑ No e—
Brief Description of Proposed Work:.
e vl -
LL c Vl to r t C2o 2,
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDrriON,OR
CHANGE IN USE OR OCCUPANCY j
Check here if an Existing Building Investigation and Evaluation is encluscd(See 780 CNIR N) ❑
Existing Use Group(s): Proposed Use Gruup(s):
SECTION 4: BUILDING MIGHT AND AREA
Existing Proposed +
No.of Floors/Stories(include basement levels)& Area Per Fluor(sq. it.)
Total Area(sq. ft.)aural Total Height(ft.)
SECTION 3: USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-t ❑ A4 ❑ A-i❑ B. Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ fl: fli h Haz.vd H-1 ❑ H-2❑ 11-1 ❑ FI--4❑ 11-5❑
I: Institutional 1-1 ❑ 1-'_❑ 1-3❑ 1-4❑ NI: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-1 ❑
S: Storage SI ❑ S2❑ U: Utility❑ Special Use❑and please describe below: s
Special Use
SECTION 6:CONSTRUCTION INVE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORNLVI-ION(refer to 780 CNIR 111.0 for details on each item)
- Water Supply: Flood Zone Information: Sewage Disposal: french Permit: Debris Removal:
Public —/ C A trench will not be I.iCensed Disposal Site❑
V� heek if outside FI uaJ luny❑ Indicate municipal❑
Private❑ Or inden n tiiy Zone: -- Or O site system ❑ required ❑or Irettch or specify:,..__
. - permit is enC lased ❑
Railroad right-of-way: I faiards to Air Navigation: \I '• i rd,
NOt Applulible❑ Is Strut ture I,illim mi-porLIll'I" ch ,ve,a? Is their rcriotr 1 Onipleted?
or Cnment to Budd one lased ❑ 1 oS❑ Or No Cl lbs❑ No ❑
SEC"IION 8:CONTENT OF CER I'IFICA IT OF OCCUPANCY
I Stilinn A COLIC. _ Lw Croup(,): I\pe Ol UmslrMI tOo: Oec upaut Lead par I loor.
Po, the building:Ontain .in tiprioklor Sv>temt �pocial >IipulaliOnp: . . ._ _
f SECIION4: PROI'FR I OWNlili AU I'l 10RIZA"1ION
,Neunr.m/il Address of Pn�pertV`U/lvnrr
_IY1lc{�rcl Lh LfR. l, [v C� 2 J¢FF2,Sov fl v_e_
Nance(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone NO. (business) Telephone No. (cell) c-mail address
If applicable, the property owner hercbV authorizes -
__
_-- Name - ---Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized bV this building permit. p pliction.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If build in g is Icss than 33,000 cu.ft,U(enclosed space and/or not under Construction Control then check here O and ski,Section 10,1
10.1 Registered�Professional Responsible for Construction Control
Name(Registrant) Telephone No. c-mail address Registration Number
Street Address City/Town Stale Zip Discipline Expiration 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
Tree phone No. business Telephone No. cell c-mall address
SECTION 11:t(t I MI'l ,:a JON t.NI•1i1 AV I .)rr11"Wn M.G.L.c.152.1 25C 6
A Workers'COolpensation 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 O No ❑
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=5JU00 •O O
I. Building S '60 0 Building Permit Fee=Total Construction Cost x_(Insert here
1. Electrical S appropriate municipal factor)=S
� �. Plumbing S
J. Mechanical (IiVAC) S Note: Nlininnnn fee =$__(contact nuulicip.dity)
5. Mcchanical Other 5 FnclOse chunk payable to ---
t,.Total Gist 5 (anatact municipal it♦•)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Inv entering illy name below, I herebv 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 try- knob ledge and understanding.
Please print and .ign name I"ills Trlcphane No. Date
tilrcrt Address City"Tonvn State Zip
Municipal Inspector to fill out this section upon application approval:
I ,,Nan Da c
i
t
r
< � CCI'Y OF S:1LEa� I, ,\ L1SS:ICH[ SETTS
1, 1 BUILDING DEP.IRT>lEINT
120 WASHINGTON STREET, 31'FLOOK
T EL (978) 735-9595
Rut:(978) 710.9844
i.,:I)ti3E.RLEY DRISCOLL
INLAYO Z T�iOSL\S ST.P1FA p(t
DIKBCTOK OF PUBLIC PROPEKTY/surf-oING CO.NBUSSIONEK
Workers' Compensatlon Insurance,%ITTdavit: Duilders/Contractors/Electrician.VPlumbers
\Lfillcant Infilrmrtlnn Please Print Le!zihly
Nainc IRmituss Urgam/arian Individwdl: �C�s e \P� tlt �C �1�t�
Address:
Cilyi3tatc/Zip: ';�->QV QA ✓1 M\A- b Phune#:e1 rl `iI 3,90 "2 [t 3
Are you am employer.'Check the appropriate boas Type of project(required):
I.❑ lam a employer with 4. 0 I am a gencrai contractor and 1 6. 0 New construction
2. dunpinyea(Rill and/or part-time).• have hired the subcontractors
1 am a Bola proprietor or .partner• listed an the attached'h" t 7• Remodeling
.ship and have no employees These subcontractors have g. E Demolition
working liar me in any capacity. workers'comp. insurance. 9, E Building addition
(No wurkcrs'.comp. insurance 5. 0 We are a corporation and its
reyuircd.J offlcers have exercised their 10.E Electrical Npsirs or additions
3.0 1311112 homeowner doing all work right of exemption per MOC 11.0 Plumbing repairs or additions
myself. (\*workers'sump, c. 152, 11(4),and we have no 12,[] Roofivpairs
insurunce«quired.( t employees. (No workers' 13 Q Other
comp.insurance required.)
•.\ray applLam cur d.wkt but el moor aye rill uul the uction belaw+howing their"hen'compensation puliay inairmuilon.
'I h.neurtwre whu.uhmir this eMdavit inditaing they art doing all work Ind than hire ouside co
, etvcten mmr mhmlr a raw allldaril iodising.rch.
(lntnr•ten Cher cha�k this box moor machud Jn tdtktiumd Aces.hawing the noon*of the rub-eunImfon and their worYan'wmp.policy Information,
f om an rnrplayer that Is pray/ding rvarkera'aumprntaNun Insurance for my emp/ayrra, Hr1uw 1s 11u policy and fobi
inlarara/lan,
In'urmce Company Name.
Policy 4 or Self-ins, Lie, d: Expiration Date-
/eb Site Address: Cityislute/Zip:
.Vlach a copy of the workers'campensatioo pulley declaration page(showing the pulley number and esplradoe data).
F'.tilurd to secure coverage as required under.Suction 25A of,%IGL It. 152 an lead to the imposition of criminal penalties of a
tine up to 11,500.00 and/ur one-year impri.'nnnii it well as civil penalties in the tbrm Via STGP WORK ORDER and d tine
':full,to M0.00 J Jay Jga11151 the violdtar. lie advi.'ed that a copy of this statement may be furwerded to the ollled of
1.l v esli gat iuns,li 111e DIA for i nsunnce coverage veri ticatiun.
/du hereby ratify rmJrr lhr pobu mad penohlex"I perjury rhut floe injurnrullun pruvidrJ above iv true,nrd correct
1� 0 —
F011hiulu.ie,mly.e aoly. Orr,tor writein 11a:r area,tou:_ I'rrmitiLlcenie g
tlrorily (circla uac)a 1lcahh !. Ilulltling Dhli. tmcut 1. (iiyifawnClark J, h:leetrle.ri Gnpccrnr i, Plumbim; Impeehir
rt..U: 1'holle.r:
_—___
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CITY OF S.u.Eai, Aitss,wHUSETI'S
8t. LONG DEP.1R ON-l!
120 W.kSH6VGTON STAFST, 1i0 FLOOR
� ftti. �97i1114�9S9S
FAX(973) 140.9W
Ki1�F_RLfiY DItLSC�LL
MAYOR THG.+uf ST.PtBnns
01mmitOPPCaucPROPffATY/eCmnLYGco1 asslONEit
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CUR section 111.J
Debris, and the provisions of MOL o 40, S 34;
Building Permit As is issued with the condition that the debris resulting from
This work shall be disposed of in a properly licemed waste disposal facility as defined by MG c
l 11. S I JOA.
The debris will be transported by:
ct\\�,k,
(mane ol'haular)
The debris will be disposed of in :
�+- (name of fuili�y)
( ddrefl of f�. hiy)
V�
ynanrra ufpermit rpp6unt