200 JEFFERSON AVE - BUILDING INSPECTION Lq
t The-CElm'monwealtfi=qf Mar'sii;allusiNsgECTI'ONAL"SERV-ICE';
Department of Public Safety
Massachusetts State Building Code(780 CNIR)
J Application Building Permit A
45
Bui
z (This Section For Official Use Only)
Building Permit Number: Date Applied: — I Building Official:
SECTION VLOCATIONI(Please indicdte,B16ck#andTot#'.for locations for yhl5h p street address is-riot available},!!.(.)
a0o 0 1572 tj
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 0 or check all that apply in the two rows below
Existing Buildiiiii !" RepairEq..Alteration CI ; ,AdditkinjO. Denf,C)Iitiot'i.,O,"(PleaseLfit,['c)ut and submitA'pP'endiX'I).'JI
Chaogepf�Uqc.j Q I Chajlgeofoccupancy „,,o Other 0 SP'Cdy; 'Perdhe
Are building plans and/or construction documents being is part of this permit application? Yes If No
Is an Independent Structural Engineering Peer Review required? Yes 0 No 2'�
pl Brief Description of Proposed Work: e r-o or P1 � ladvL. "n-zxr,,O,A-
Y-;
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,,OR
CHANGE IN USF)TOkUPANCY .7,
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 C?vIR 34) [3
Existing Use Group(s): I Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) q V
Total Area(sq.ft.)and Total Height(ft.) 70 L)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly-A,.)IO IA-213 r: Facto F-1 C3 F2 .Nightclub El A-.I E] A4 0 A-5 0 1 B: Business 0 E: Educational E3
5_ 1 W._—High Hazard H11-1 ❑ H-2 0 H-3 El H-4 0 H-5 0
ry
1: Institutional I-10 1-2 0 1-3 0 14 13 1 M: Mercantile 13 R: Residential R-10 R-2 C3 R-3 rd R4 13
S: Storage S-1 0 5-213 U: utility 0 Special Use Cl and please describe below:
Special Use,
SECTION 6:CONSTRUCTION TYPE(Check as a plicable)
[A 0 111 E3 IIA E3 1113 0 IIIA 0 IIIB 13 IV E3 VA 0 VB 11
SECTION7.SITE INFORMATION(refer to 780 CMR 111.0 for"details on each item)
Debris Removal:
Sewage
Disposal:
at
S"w=—7 1 Trench Permit:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site 0
. load Zone municipal A trench will not be
Public 92,� Check if outside Flood Zone 0 Indicate munici�pa� required 0 or trench or specify:_
Private 0 or indentify Zone:— or on site system 0 permit is enclosed 0
T
Railroal right-of-way:.' Hazar s to Air Navigation: IV
Not Applicable IiIl< Is Structure within airport approach area? Is their review completed?,)
kd
or Consent to Build'-chcfo�, n Yes 0 or No'k Yes--
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
E,,t,,i of Cod":--Use GTr�m s):— Type of Construction — Occupant Load per Floor:
Does the building containan Sprinkler System?:—Special Stipulations:
1�,t LED CZA
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name amly\ddnss of Property Owner
S u rl�J �t t`l Skow� st SAkew Q/Q�
Name(Print) No,and Street City/Town Zip
[&per iQ�vvnefGbnt'�ZNIn✓`frr�rnation:
AN T� 1 — an-450--9 Y�1 1oatlr.�zcww-fef
Title Telephone No.(business) Telephone No. (cell) ee-nui�s
iff�((aa�pplicable, the property owner hereby authorizes
P'Qk.vCIC CI,EaSSP 1`{ CIejcl,& .n $FMet 04A 61 q el
Name Street Address- ; City/Town ;, .,,,,.,Stale, .Zip ,
to act on the property owner's behalf,in all matters relative to work authorized li this buildin ermit a licrtion.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2).
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10a
10.1 Registered Professional Responsible for Construction Control -
PC SimS41 �� g01 yby �G w1 COMSC CS, 0C S4yI
Nuns(Reggistrant)) _Telephone No. e-mail address Registration Number
l�j Clwt le*-o—s f 5'_.\U h4_ 0147 a sww "Se t, he 12et Y
Street Addrds City/Town State Zip Discipline Expiration Date
A
10.2 General Contractor
P4 SAS14 fliSr• �M R Y .u' ai'
Company Namr1ee'
pwi n^.C 11.- pO"e'we"
Name of Person Responsible for Construction License No. and Type if Applicable
lLi Clete(.* , ks4% h1h olq"Ju
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WONKERS'CONIHNSA'I JON INSURANCE APFIDAVI'I M.G.L.c.152. 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with il�s application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12i CONSTRUCTION COSTS AND PERMIT FEE - -
Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 2-01 a Ao U
I. Building �' $ Building Permit Fee=Total Construction Cost x (insert here
2.Electrical $ appropriate municipal factor)=$
3. Plumbing $
T.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other S Enclose check payable to
6.Total Cost Z� Oo0 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 hereby attest under the pain Iand penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding. '
PA�KlC-%L C4A55e OWNIEv1
Please print and sign name Title Telephone No. Date
L 4 Cleuel,a..o3 St sakke . a.A o141 �
Street Address City/Town State Zip
,11
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF SM-EM, NLUSACHUSETTS
l
BUIMLNG DEP.\RT I&NT
). , t` 120 WASHLYGTON STREET, 3'0 FLOOR
TEL (978) 745-9595
F.ux(978) 7-W-9844
KIN IBF12LEY D[iISCOLL
&LAYo:t Tt-tOaus ST.PIExns
DIRECTOR OF puBUC PROPERTY/3L:mDLN<;CON
BIISSIONER
Construction Debris Disposal Af idavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of tb1QL c 40, S 54;
Building Permit fk this work shall be is issued with the condition that the debris resulting from
lll, S ISOA. disposed of in a properly licensed waste disposal facility as defined by IVIGL c
The debris will be transported by:
ti p
(name ut-hauler)
The debris will be disposed of in
-'- (narr e of facility)
-----(ad�rassoftacility)
signature of permit applicant
thle
CITY OF SM-EM, NL�SSACHUSETTS
' BUILDING DEPARTJtENT
120 WASHIINJGTON STREET, 3w FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR. THoitus ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONDAISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Nanic (BusinesvOrgan izatiom'Individual):
Address:
City/State/Zip: Phone It:
:�rS ynu,un employer?Check the appropriate box: 'type of project(required):
i.r�tXaam a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ lama sole proprietor or partner- listed on the attached sheet. T ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp. insurance. y. ElBuilding addition
INo workers'camp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions '.
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. [No workers'sump. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' 13,0 Other
cutup.insurance required.)
•Any applicant That chucks box AI near also fill out the section below showing their wodca eumpensaiun puli y inllmoatiun.
I huneuwM"who submit this affidavit indicating they arc doing all work and then hire outside contneton most suhmil a new arrldavit indicating such.
t* $lmrmewrs thus chuck this box nret anachai on additional abet showing the mmrlo of the sub-canincton and their workers'comp.policy information.
I ant on employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site
information.
Insurance Company Name:'---�?� --�—Y
Policy 8 or Self-ins, Lic.H: Expiration Date:
Job Site Address: ac9 d 1�l10 City/State/Zip:
Attach a copy of the w$rleers'compensation policy declaration page(showing the pollcy,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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in(he form of a STOP WORK ORDER and aline
oFup m S250.00 a day against the violator. Re advised that a copy of this statement may be forwarded to the Ol'lice of
Investigations of the DIA for insurance coverage verification.
I do hereby cerrify a der It al and penalties of perjury that the information provider!above Lv true art correct.
iim I ter' Daw: �3 /
Phone 1:
Official use 6n1y. Do nat write in this area, to be completed by city or town off ciuL
City or Tuwn: Permit/Llcense All ,
Issuing AulhurRy(circle one):
I. Board of Ileallh 2. Building Depurtutent 3.C'iiyfruwo Clerk 4. Electrical lospectur 5. Plumbing inspector
6. Other
Contact Person:_ _--- Phalle Y:_----_----- ----
I