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63 - 1-2 JEFFERSON AVE - BUILDING INSPECTION The Commonwealth of Massachusetts \V 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) 6S- - SAUA— - ot9-Iv Fry-,Dtty%u4tc 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 ❑ 1 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 IT No ❑ . Is an Independent Structural Engineering Peer Revi w required? ~ Yes ❑ No ❑ Brief Description of Proposed Work: N'c� :39 fit,....., OF 4�on S/F oF- iN/�4b.ou5� A '}-ham (�k SAS a,lr Int �tl try 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) O 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.) t,,�wt4?L (•j$uo Lpoo 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❑ B: Business E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hf Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2❑ I-3❑ 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: tnjaraf.�nowts q SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA' ❑ IB ❑ IIA ❑ IIB O IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water SuppI Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public ll3 Check if outside Flood Zone Indicate municipal A trench w' rnot be Licensed Disposal Site Private❑ or indentify Zone: or on site system❑ required a or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 0;� 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?:_J_Special Stipulations: i i SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner RTO nNonr,.:I.%. 9,A kyA-NSA 63'/a5JTz-jz Arc- Salt, MA Name(Print) No.and Street City/Town Zip Property Owner Contact Information: (�(�6v� 7W su so 60 839 sosv t706A(ae�fLCQrywg Title `IT"S 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 m.It of enclosed space and/or not under Construction Control then check here 0 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 �--& Oev,,4LL Company Name Ro6w-4 Name of Person Responsible for Construction License No. and Type if Applicable 611/3. A-,,- SA1,-, n--*,+- of o Street Address City/Town State(� Zip Q78 7W Soso bt t_ �3S SoS'o bolo& @ eN.000fSiwA It , Z- ,._. 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 0 No 0 SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 11 S, X.)- Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ I S oe'o appropriate municipal factor)_$ 3.Plumbing $ '7000 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ g000 Enclose check payable to 6.Total Cost $ 910,000 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I h e y attes nder the pains and penalties of perjury that all of the information contained in this application is true and accura to st o my knowledge and understanding. Q„1°cQf p e poa,.� �k 97£i_ ?m JSSo Please prir(t and sign nam Title Telephone No. Date Street Address City/Town State Zip �f Municipal Inspector to fill out this section upon application approval: L` /� Name Date i CITY OF SUE.. 2UNSSACHUSETTS BOIL DING DEPARTMENT • M• 120 WASHIINGTON STREET, Y'FLOOR TEL. (978)745-9595 FAX(978) 740-9846 KIMBERLEY DRISCOLL MAYOR �Ioi`us ST.P>ERRs DIRECTOR OF PUBLIC PROPERTY/BUILDMG CONSUSSIONER NEW CONSTRUCTION CERTIFICATE OF OCCUPANCY LOCATION: DATE APPLICANT: ASSESSORS FRANK KULIK DATE: (93 Washington Street) CITY CLERK CHERYL LAPOINTE DATE: (93 Washington Street) PUBLICE SERVICES BRUCE THIBODEAU DATE: (120 Washington Street)4d'Floor WATER DOTTIE THIBODEAU DATE: (I20 Washington Street)4 h Floor CROSS CONNECT SUPERVISOR BRIAN THIBODEAU DATE: (5 Jefferson Avenue) PLANNING VALERIE GINGRICH DATE: (120 Washington Street)3`d Floor CONSERVATION COMMISSION FRANK TAORMINA -DATE:- (120 Washington Street)Yd Floor ELECTRICAL JOHN GJARDI DATE; (48 Lafayette Street) FIRE PREVENTION ERIN GRIFFIN DATE: (29 Fort Avenue) HEALTH JOANNE SCOTT DATE: (120 Washington Street)4"Floor BUILDING THOMAS ST.PIERRE DATE: (120 Washington Street) Yd Floor At 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) 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 R'� Provider notified and Release obtained? Yes ❑ No 19- Gas Shut Off? Yes ❑ No L9oo' Provider notified and Release obtained? Yes ❑ No D-' Electricity Shut Off? Yes ❑ No Lei Provider notified and Release obtained? Yes ❑ No P— Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) J 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'Y'where applicable No. Item Sub fitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 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 t/ 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 1 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other S ec: 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 Discipline Expiration Date Street Address City/Town State Zip CITY OF S. .E.NI, NbsSACHLSETTS • BUMDLNG DEPARTJIEINT 130 W{SI-INGTON STREET,3r FLOOR . \ TEL (978) 745-9595 FAX(978) 740-9846 KIJIBERLF-Y DRISCOLL MAYORTHoeNs ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/B I DLNG COMMSIONER 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 It 1.5 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: CAsg (i 'q (name of hauler) The debris will be disposed of in : C(z'5C' IIP (name of facility) P66J, ww (address of facility) signature of permit applicant 5����13 date dcbrivfLJce aCITY OF &U.&N4 UNSSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET,Yo FLOOR TEL (978)745-9595 FAx(978)740-9846 KINME t FY DRISCOLL MAYOR TtloMAs S?.P>ERRB DIRECTOR OF PUBLIC PROPERTY/BUILDING COM!\IISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busifms;OrganiiatioNindividual): ANR OrY�"'A Address: 6 /a -:3� Apt, City/State/Zip: Sp i 1"'," . Phone#: 9')8 Are y a employer?Cheek thea propriate box: Type off (required): 1. ` 1 am a employer with 4. ❑ I am a general contractor and 1 • have hired the sub-contractors 6. ew construction employees(full and/orpart-time). 2.0 1 am a sole proprietor or partner- listed on the attached sheet 7• ❑Remodeling ship and have no employees These sub-contractors have S. Q Demolition working for me in any capacity. workers'comp.insurance. 9, Q Building addition [No workers'comp. insurance 5. Q We are a corporation and its 10.❑ Electrical repairs of additions required.] officers have exercised their 3.Q I am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions myself.(No workers'comp. c. 152,§I(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' 13.❑Other comp.insurance required.] •Any applicant that checks box ill mutt also fie out the section below showing their workers'compensation policy informarloa 'I lomeownen who submit this affidavit indicating they ors doing all wolf and then hire outside contraerms must submit a new affidavit indicating seek :Contractors that check this bent must attached an additional sheet showing the name of the subcontractors and their workers'comp,policy iafam sdw, I am an employer that hr providing workers'compensadon insurance for my employees. Below Is the policy and job site information. n Insurance Company Name: rv� f'vg za AM - .`�'A Policy#or Self-ins.Lie.#: IN w C 3 o tf S ?Ocj Expiration Date: f 8 /31 //3 I ^ Job Site Add.: 0 (a ; �W City/State/Zip: SA J b— vvtA 6 t l 0 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 lx forwarded to the Office of Investigations of the 1) Insu a coverage verification. I do hereby certify uiYmWffpai4ns a d penalties of perjury that the information provided above is true and correct t tr [)Ore. 0 / Phone#: 7-7, -2W SoSG Official use artly. Do not write in this area,to he completed by city of town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other, _ Contact Person: _ Phone# i CITY OF &U E,N1, NAXSSACHUSETTS BUIDLNG DEP.kRTNtENT • 130 WASHLIIGTON STREET, 3tO FLOOR 'ILL. (978) 745-9595 FAx(978) 740-9W KIJIBERLEY D91SCOLL "I MAYOR �iOMAS ST.FIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COSWISSIO,iER CONSTRUCTION CONTROL DOCUMENT / Project"title: �"�NSC OrywA \\ Date: Project Location: 6a V\^A olc,70 Scope of Project: Y7'° s/F In accordance with SECTION 116.0-116.4.2 of the 6th edition of the Massachusetts State Building Code: 1 Mass.Registration Number being a registered professional Engineer/Architect hereby CERTIFY that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: ( ] Entire Project [ j Architectural [ ] Structural [ J Mechanical [ J Fire Protection [ j Electrical [ j Other(specify) for the above named project and that to the best of my knowledge,such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code,all acceptable engineering practices and all applicable laws for the proposed project. Furthermore,I understand and AGREE that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved by the building Permit and shall be responsible for the following as specified in section 116.2.2: 1. Review of shop drawings,samples and other submittals of the contractor as required by the construction contract documents as submitted for the building permit,and approval for the conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. I shall submit periodically, in a form acceptable to the building official,a progress report together with pertinent comments. Upon completion of the work, I shall submit to the building official a final report as to the satisfactory completion and readiness of the project for occupancy. Signature and Seal of registered professional: