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123 LAFAYETTE ST - BUILDING INSPECTION --F&-I � -�S� 7 355-- l K REGEIVEO —� LL1D is 6 S The Commonwealth of Massachusetts DepartmentI titkV,3et-A � 33 I�yl� Massachusetts State��{{u drYg'11Nde(780 CMR) Building Permit Application for any Building other than aOne-or Two-Fam' D Ilia (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) c--- �•r ' 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❑ Repairfk I 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 O. No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: t t 1 -r 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 CNIR 31) ❑ Existing Use Group(s): IProposed 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❑ 1 H: High Hazard H-1❑ H-2❑ HA H-#❑ 171-5❑ 1: Institutional 1-1 ❑ 1-2❑ 1-3❑ [4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ 5: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: _ SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ - IB ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be N f , required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ r Railroad right-of-way: Hazards to Air Navigation: �I,� _,I_h to C�npnnyi�n tt ng.y t n Gs; Not Applicable❑ 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?: Special Stipulations: CX,rl�l, C�• C• Fob f" u P 0 L4 'V Ala VeKB L. M0 STINK-T - NEM -ro ta1Mky-e• TT•St�NrLlt�p SECT-ION7,9y.PROPERTY OWNER AUTHORIZATION Name and Address of Prope47$w{iu?^;8 1;* 0 �3, �Ht Name(Print) £'E' .C�Nq�.andStreet City/Town Zip L N c - MA �1i8S Property Owner Contact Information: Title Te N .�(business) 6%lephone No. (cell) e-mail address If applicable,Ilie property owner hereby au orizes � �ds' h� v dj�c7dl� Sr E�pF'42�rr' o �/ Name'-" Street Address City/Town State Zip to act on the Propertv owner's behalf, in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out.AppendiIx 2). if buildin is less than 35,000 cu.B.of enclosed s ace and/or not under Construction Control then check here❑and ski Section 10.1 "10.1 Re istered Professional Res onsible for Construction Control Nanre(Registran Telephone No. e-mail address Registration SSrePt Add City/Town State Zip Discipline Expiration Date , (j(p 10.2 General Contractor - S t n d Company N;me Name of Person�r Construction License No, and ype if Applicable 46 (1410)$ !` EVE07 f- T Z 42 i<5 Street Addreress City/Town State Zip �it D l7 � -- Sail 05 cogs C b a 0, Tele hone No. business Telephone No. cell e-mail address SECTION 11:1yORKP1:5'c:i)Nu�EN,,XIJON INSUR: NO: -t;F1D,\ rr M.G.L.c.152.§25C 6 - A Workers'Compensation 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 submittedwith vnh this application? Yes❑ No SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE ; Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6) 1. Building $ O 8uildurg Permit Fee=Total Construction Cost z_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 1. �blechanic;d (HVr1C) $ Note:Minimum fee=$ (contact municipality) $. Mechanical Other $ Enclose check Pay" h7 6.Tohd Cost $ sZS� al y` (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 this application is true and accurate to the best of my knowledge and understanding. Please print and sign name Title Telephone No. Date S&ddres/st t d . Cil /Town State Zip L Municipal Inspector to fill out this section upon application approval: Name Date i CITY OF S'VLE1,t2 N L-USACH Us ETTS ' ©UILDLxG DEpART eNT 120 WASHLNGTON STREET, 1m Ft00R r `1, ItLL (978) 745--9595 F-VX-(978) 7.10-9943 1U1o3El2LEY DItISCOI.L &L-VYOT! THo.%os sT.p mgRa DIRECTOR OF PUBLIC PROPERTY/BCILDLYG CONWISSIONER Comtruction Debris Disposal At'tidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section 1 l 1.5 Debris, and the provisions of NIM c 40, S 54; Building Permit g 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 tNCL e I 11, S 150A. The debris will be transported by: y I ants of hauler) The debris will be disposed or in . (name oY t:icdity) _ ----(adJrassot'tacility) signature of permit applicant latu -- 3 CITY OF SM-EM, lL[ SSACHUSETTS ;• BUILDING DEPART\ff-NT S •� 4 fr + 120 %)VASHLNGTON STREET, 3'o FLOOR TM (978) 745 95 5 F.kr(978) 740-9946 KIMBERLIFY DRISCOLL ;K iYOR THONUS STTIERRE DIRECTOR OF PL BLIC PROPERTY/8L[LDLNG CON11%USStONER Workers' Cmnpensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers A t licant Information Please Print Legibly Name(9ueire Orrganizarit)wlndivi(lual): Address: -- 66 U 4 i 0 n. + City/Statelzip: / Phone N: Alrtr�-r--ee��_y,,ou an employer?Check the appropriate box: 'type of project(required): I. 1 am a employer with 4• ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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 S. ❑ Demolition working for me in any capacity, workers'comp. insurance. 9, ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their MO Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4);and we have no 12.❑ Roof repairs insurance required.)t employees, [No workers' l3.❑ Other��1r'l'IQOvICC<.1i4 �r Gump.insurance required.] •Any applicant nut checks box AI must also fill out the section bclowshowing Ihoir workera'cumpensodun policy inlinmation. '1 h+muuwnert who whmit this of lavil indicating Ihcy are doing all work and then hire outside contractor,most submit a new affidavit indicating such ;C-m,rwlora Out check this box most attached on additiurul shrxt showing the nine of the subaontneton and Ihoir workers'comp.policy information• l ant an employer that is providing workers'conipeitsailon insurance for my employees, Beloty 1s the policy and fob silo iojorauaion. Insurance Company Name:1- tJ�� 1'Y12 F M Ct/ (A/ r�A 5 Policy A or Self-ills. Lic.fJ:. Oil C- 10 ©_3. Q�_ Expiration Date:_ 1 �t i t� Job Site Address: I L 3 � d A -CA ^ f 7-1:( 7 f , City/State/Zip: `73 A I C �Al' Z: y`{ 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 23A ot•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 the form of a STOP WORK ORDER and a fine OF up to$230.00 a day against the violator. Be advised that a copy of this statement may be furwardcd to the Office of Invcstigutions of the DIA For insurance coverage verification. I do hereby e•rrrijy ender tr pr ht.�und penullies ujperfury that the hifvrinmlon proyided above is true cord correctSi I llr L v t phone rt Officiul cur only. Do not write in this area, la be completed by city or lown offirlut City orTawa: .__ Permit/►.►censep issuing Aulhurily(circle one): I. Board of Health 2.Building Department .1.Cilyffown Clerk 4. Electrical Inspector 5. Plumbing f lipector 6. Other Contact Person:_ _. _ Phone INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY 1. NCCI CO CODE: 10456 INSURED: PRODUCER: i SANTOS, SANTIAGO DBA SANTOS FLAGSHIP INS AGENCY INC HARDWOOD FLOORS PO BOX 40399 66 UNION STREET NEW BEDFORD MA 02744 EVERETT MA 02149 Insured Is AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 04-10-13 to 04-10-14 12:01 A.M. at the Insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In m= item 3.A. The limits of our liability under Part Two are: a Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Lima Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, 9 any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A D. This policy includes these endorsements and schedules: o� SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE a� 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 04-01-13 WC ST ASSIGN: MA OFFICE: ORLANDO DA HTFD 05G PRODUCER: FLAGSHIP INS AGENCY INC 266HG 0083 9 � � .. � VRe �parronwouuet��a�QJCfa�ac�u�aello- ' Ofeice of:foosumcrAffairs i Business Regulatkd k ME tion; EMENTCONT eg RACTOR` istration 1g7g1g- - Type .,� xpuahon;- 8/18/2015� . ,:DBA ?- SANTIAGO A SANTOS HARWOOD`FLOOR � SAtWJAdO SANTOS 66-UNION ST EVERETT,MA02149 Undersecretary' - q Massachusetts Department of Public Safety Board of Building Regulations and Standards. a;. ' +r. Cnmtrucnon Superv'Nor t License CS-096763 It Fwl; SANTIAGO SANTbS a 66 UNION STREET#Z 'r^ EVERETT MA 0214 a ` '�= a { y Expiration:: nInenn4A'..