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51 LAFAYETTE ST - BUILDING INSPECTION (4)
The Commonwealth of Massachusetts Department of Public Safety J. IUP 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) �vllnFayErrE Sr SAf.Ew• 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 O or check all that apply in the two rows below Existing Building❑ Repair19' Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineerin Peer Review required? Yes ❑ No ❑ 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.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ I-2❑ I-3❑ 14❑ 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: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ Hill 0 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system ❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: NIA I h,lom C nn nisi..).k n, Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed ❑ Yes O 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 Svstem?: Special Stipulations: l ♦ -S � SECTION 9: PROPERTY OWNER AUTHORIZATION - Name and AddreAof Property Owner - Name(Print) .� ��y N .and Street City/Town p' Zip L` TtAInfoma �/'O�fr-I-.YS LLC - Property Owner Contact Information: Title 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 propertv 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 cu.ft.of enclosed space and/or not under Construction Control then check here 13 and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control 11 1. Name(Registrant) Telephone No. e-mail address Registration Number a Sl Street Address City/Town State Zip Discipline Ex fration Date 10.2 General Contractor any Name /� ar,t� 0� G2(2EA^S 104 gay CSL Name of Person Responsible n�sible for Construction License No. and Type if Anpnplicable 'r� Street Address 602 City/Town II n /r.State � r-7 aZip�t 01Z_-Zt7q '?9 ( , -�!- ! Zu�.wc-qn,A"16J 1anL , [ e v rl,-> i Telephone No. business Tele hone No. cell f � a-n ss SECTION 11:Nl,RK131S'CU611 CNSA'l l(l\=INSURANCE A(F[DAVIC 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 2( No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE - Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical - S. appropriate municipal factor)_$ 3. Plumbing $ 4. Mechanical'(HVAC) $ Note: Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ (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 and penalties of perjury that all of the information contained in t is a lication is true--and accurate to the best of my knowledge and understanding. f �-- fO�SJ3 L &N �G'•+.tX- Oar=-Lri GEA. n' ' -6aZ- !S-S Please print and sign name "Fitle Telepho e No. Date ; L54 /v.Jc.ocaJ Sr. �tah ,.� a13 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval; �� l Name Date The Commonwealth q(Massachusetts PririY Form Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): T�OI`-^��'� -�t`'�`� \&J' Address: Sk `ii City/State/Zip:',�1'i(,i 11 U>i r✓1 A C)IIY5 Phone 4: Are you an employer?Check the appropriate box: Type of project(required): L E31 am a employer with ab 4. ❑ I am a general contractor and 1 employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition workers'h employees and wor working forme in any capacity. 9. ❑ Building addition No workers' coo insurance comp. insurance.- required.] 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its ❑ � 3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp. insurance required.] Any applicant that checks box#] must also fill out the section below showing their workers'compensation-policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hive outside contractors must submit a new affidavit indicating such. 'Contractors that check this box most attached an additional sheet shoving the name of the sub-contractors and state whether or not those entities have employecs. if the sub-contractors have employees,they most provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: i-iAk IS — Policy#or Self-ins. Lic.#: tjt tL 3_N_5 (t/ Expiration Date: Job Site Address e -1 ��i-t S� o AY,6y Sy"• City/State/Zip:�Qj��ii1 lrlrl 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$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cZi4 under the rains and penalties of eerjug that the in ormation provided above is true and correct Si nature: ,Qvv„i— - Date C© 1T. 2' Phone# Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit'License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.Citvff own Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: C 7 Bo:ud of Bniltlm Rc u! ttuev, asrti �i +n d:u'd. , r- e License: CS 104924 A - PAUL MC GOVERN _. 7 ANSELM TERREACE BRIGHTON, MA 02135 kb t S.xpirati0n: 9/15/2014 ( unnui�ivuvr T r-w 104924