172 LAFAYETTE ST - BUILDING INSPECTION (2) �J \��� �
� � The Commonwealth of Massachusetts
i _/� �� Depaztment of Public Sa�ty�F�T�eCE(V��
7� Massachusetts State Building Code(7S0 C1GIR���H(� $t��� eFC
�� Building Permit Application for any Building other tha a One-or Two-Fami�y'Dtvelling
I � "'" , ',-�� :' . � ' (This Sechon For Officia}Use Only) . . — � , � �. : � ..
.,;
Building Pernut Number: •� - '.Date Applied � �' ��' ` - :Building OfficiaL - '�
_. _ ___ _. � .-. . .
SECTION 1:LOCATION(Please indicate�Block#and Lot#for locaHons for which a street address is not�available)
1'1 a. La��.���ti 5 5�1�- ww m�c�o
No.and Street '� City/Town Zip Code Name of Buffding(if applicable)
. . +,;, . : SECTION 2 PROPOSED WORK �''-- �' - ' � �
Edition of MA State Code used if New Consfruction check here 0 or check all that apply in the two rows below
Existing Building Repair Alterarion ❑ �dditlon❑ Demolition ❑ (Please fill out and submit Appendix 1) ,
Change of Use ❑ Change of Occupancy Other ❑ Specify: �'�
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑
' � Is an Independent Structural Engineerin Peer Review r quired? Yes ❑ No ��
BriefDescriprionofProposedWQrk: �fm��£. � pR4S��tii\ J�Ei..r w�ti(�owS awo�
� NEw �.'�a:�-��wT `��C�'.'.I.1C�S Ovt w+`cw £. "niS�..y c...M`�S ��
�P��n.7.tlOV+rS . .�.-`.�$�A � ('�/C (LA^'��S o_+N `1'c c.x.cui 'u'F '3�Cr�r�
SECTION 3:COMPLETE THIS SECT'ION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
� � .. CHANGE IN USE OR OCCUPANCY-.-� � _ - � � � -�- � � � � � �
Check here if an Existing Building Investigation and Evaluation is enclosed(See 7S0 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.h.) �
Total Area(sq.ft.)and Total Height(ft.) �y � �Y� I
- � - =.-SECTION 5:USE GROUP�{Check as applicable) �� ��- � �
A: Assembly A-1 ❑� A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business � E: Educafional ❑
F: Facto F-1 ❑ F2❑ H: Hi Aazazd H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 ❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use 0 and please describe below:
Special Use:
- _ _SECTION 6:CONSTRUC'TION TYPE(Check as applicable) �..: - . -� . ',` �� ..
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VBD i,
SECTTON 7:SITE INFORMAI'ION(refer to 780 CMR 111.0 for details on each item) ._� � I
Trench Permit: Debris Removal:
Water Sup_p/ly: Flood Zone Information: Sewage Disposal: Licensed Dis osal Site
Public tN Check if outside Flood Zone Inditate municipal � A trench wIll not be p
Private❑ or indentify Zone: or on site system❑ required 0 or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: miA Historic Commiss�on Rev�ew Process
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' ,�;� , x, .�, . �
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
r' a L-�-rsT? 10�� � (S
'��-�-�� --� e ►y � i5
�
.SECTION9:�PROPERTYOWNERAUTHORIZATION� - . _ -
._ . ,�., . ,.. : - . _. . . , ..., r _
Namre and Address of Property Owner n ;(�
\ �2�� L.LL � l^�\.J2P-S��-t VJT�.J�L ���SL.�.�;`ti�� NJ� ��SYS
Name(Print) No.and Street City/Town Zip
Pro erty Owner Contact InformaHon:
�P\Q� �bc..lo 7`JI_ 636 8'6�C _ _
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name StreetAddress City/Town Shate Zip
to act on the ro er owner's behalf,in all matters relative to work authorized b this buildin ermit a licafion.
��: -.:SECTTON 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) �� ;: •�•u��= ' %`'���-
If buildin is less than 35,000 cu.h.of enclosed s ace and/or not under Construction Control then check he?e O and sM �Seefion 101
10.1 Re 'stered Professional Res onsible for Constmction Contml" . �. , �� ' � " �• "-' � � -' �c ���� ' '"'
f�eN�.s G��,� S� 7Y5 44�Y drM'..5�,,�.,@ �,��zo., 5 � 8 S
Name�(Registrant) Telephone No. e-mail address ��* Registration Number � � 16
04114.� Sq SA 1 L-- w.n.. 0.4 0
Sfreet Addres� City/Town State Zip Discipline ExpiraHon Date
10.2GeneralContractor � � ' �� � � � ` ' - ` �. .�� -������
� v� 2 Oa-y�'D�
Company Name
R�e`�� �.rvL,^�-- c S ��i o5�b 2
Name of Person Res onsible for Construcfion License No. and Type if Applicable �
G�`(a �`f�'�.,ar�, {��C '�h\q.-� w�.4 0� i 7 6
Street Address City/Town p Stat Zip
(r� 97� 74�/ SbS � Cof� ��5 S�'So �ju�d� � P�ti.n�ry-,,,,y �, � Co�
Tele hone No. business Tele hone No. ce11 e-mail address
�SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c 152.§25C 6
A Workers'Compensatlon 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 si ed Affidavit submitted with this a licarion? Yes❑ No O
.� -4°��i� ` �''° '�SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE "„. "�` '�� ' ��`" � �
Item � Estimated Costs:(Labor � � p��
and Materials) Total Consfrucfion Cost(from Item 6)_$ �� 0
1.Building $ � q� �6 Building Permit Fee=Total Construction Cost x ��(Insert here
2.Electrical $ �O,oo[i appropriate municipa]factor)_$
3.Plumbing $ � Pi o0a a�b
4.Mxhanical (HVAC) � $ � - �O Note:Minimum fee=$ (contact municipality) '
5.Mechanical Other $
Enclose check payable to
6.Total Cost $ �-5 ��G (contact municipality)and write check number here
` "���" x =�SECTION 13:S ATURE OF BUILDING PERMIT APPLICANT �-�' ?� ` � �`"�'� � ' "
By entering my name below,I hereby atte under pains and penalties of perjury that all of the informaHon�contained in this
application is true and accurate to the be m o edge and understanding.
(��bcn� �vaw.�.— ,/�� rc�,a...�.� 9��_ 7w susa
Please print and si name Tifle Telephone No. Date
b 3 `��- �����,.s...}�.,�. 5,��� � ��s�a
Street Address City/Town /State Zip
Municipal Inspector to fill out this secrion upon application approval: � � <</ '� '!Gw � �D����S .
- . . ;. _, .. ;, , ; : "y. Name��: :: , <;� . ,;r� ':'Date �..
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�'
Mazk"x'where a licable
No. Item Submitted Incom lete Not Re uired
1 Architectural
2 Foundation
3 Structural
4 Fire Su ression
5 Fire Alarm ma re uire re eaters
6 HVAC
7 Electrical
8 Plumbin include local connections
9 Gas Natural,Pro ane,Medical or other
10 Surve ed Site Plan Utilities,Wetland,etc.
11 S ecificarions
l2 Structural Peer Review
13 Structural Tests&Ins ecdons Pro am
14 Fire Protecrion Narrative Re ort
15 Existin Buffdin Surve /Invesfi ation
16 Ener Conservation Re ort
17 Architectural Access Review 521 CMR �
18 Workers Com ensation Insurance
19 Hazardous Material Miti ation Documentation
20 Other S ec'
21 Other S ecif
22 Other S ecif
*Areas of Design or Construction for which plans are not complete at the time of applicafion submittal must be identified herein.Work
so identified must not be commenced unril this application has been amended and the proposed construcHon document amendment
has been approved by the authority having jurisdiction.Work stazted prior to approval may be subjected to hiple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Regisfrarion Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) � Telephone No. e-mail address
Registration Number
Street Address Ci /Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci /Town State Zi
Discipline Expirarion Date
; CITY UF S.�I..E�i, i1,��SSi1G�=it3SET'T'S
• Bti ILD�i IG DEP�R'I'�tE�i7
• ' 13O W.iSHII•1GTON$T1tE�'�',3�O FTLbO$�
`� '�'°"` 'YIEL. (978) 74�-+��95
FAx(97� 7A0-9846
���FRT RY DRISCOLL
MAYOR ���S`t'.Pf�11RB
I71RFCtOR OF AL'HLtC PROPERTY�$L'II.DAVG CO�L�{iSSfdhiER
Canstructian Debris Disposal Af'fidavit
(required for a11 demotition and renovatian work)
In accordance with the sixth edition of the State Building Code, 7$0 CMR sectinn 1 I 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Perrnit# is issued with the condition that the debris resulting from
this work shail be disposetl of in a properiy licensed waste disposal facilify as de$aed by MGL c
111, S i SOA.
The debris wi(i be transparted by:
CPS� I�f' w'°3�z-
(nama of hauler)
The debris will be disposed of in :
(name of facility)
{address of'facility)
signaiur�of permii�pplicant i
4 7-�� /S.__ I
ilaie
dcbriu2dce
,'" Ci-rY oF S.��r, ti�I��ss�cxLs�.�rrs
• BL't¢.n��DsP�RriE,��t
+ ' � 1?0 WASH�IGTON STREET, 31O F'1UOR
`` '0'} T�I.. (9'78} 7�t5-9595
F,�c(979) 740-98A6
KItfBERLEY DRTSCOLL
��jrlYOR 'IIiOM,�s ST.PtF.RR6
L7tREGTOA OF PtiBLfC PftOPERTYi�t'�L'�tG GO«lISSIbNE�.
_ ._ ._.,_�,...,_.
Workers' Compensation tnsurance Affldavit: Bailders/Contractorsl�iectrecianslPiumber�
Anplicant information Please-Pnnt Leeibiv
Vame�a�st�wor�,,mr�rioNi���;aw�1: C� t� d2. O�YwA�� ��.{.,
Aad�ss: 6 3 '/a S��F���„, �1., � - -
City/State/Zip: S"'�S`^ /W� 0�5`� phone N: (�_1 '� g39 Soso
A�r-e�,/yop an emptoyer?Cheek the appropriate boz: Ty�re otproj¢ct(requlretl)i
l.t,46 �am a cmployer with /°" d. [] 1 am a gr nrral conhactor and I 6. ❑Netv cnnatxvcdbn
emplayees(futl and/or paxc-time),s have hired tke sub-conttactbrs
. � 7. emodelin
i ri ta o listed on the attathed�eet. • � K
2.0 1 am a so t ro e r r iutner-
P P A
�hip and have no amp3oyces Thest sub-oontracrors have $. (�Demoliiion
workin� for mc in any cepacity: workers'comp.in§urance. q, (� gui!(ling 5dd'etion
(No woricers'comp. insurance 5. 0 We are a coc�ration and'crs �0.[7 Electrical repaus or addiiions
requirerJ.] officers have euercised theu
3.� 1 am a homeowncr doing all work right oEcxemption pi:r MGL t t:�Ptumbing repairs ot udditians
myseff.(Aio workers'comp. c. 152,§1(4),and we have no (2,[�Riwf rep�iri
insurance required.j i employees.[No workers' �3.Q Other
cornp. inrurance required.J
_ - ------- -_ ---
•nny appliaw tir�chake bon p I must alu�fill out iMn secti�be�ow elrowing tRetr workpi'cwfipensatipn paliry mlbrtiuuuln.
11 fMner�wnen who submit thK affidavit indicating�hey are doing nll work aed ihcn hiro m„aidt contrattore rnust w6mit t�v aRldavit imfimling weh.
=Cw�tr.u.Yon�Iw1 cAetk thie bac muxt anached an aJdifional elceet shtiwing iM�ste o(flm wMqtmtectots and Iheif wm4en'amiy:poliry informatiop.
)am«n e�nplayer that dc prnvi6ing wnrkers'rompensatloa inst�rantt far my emp/oyees. Below�s the po/lry dnd fob stte
injarmatian. /�
Insurance Company Vame:_ /-' � `��� "� ��S eo �-NSv2.e�r c�
POIiCy�Uf SCI(-1JL9. LLC.J�: W L�C 3 l 1 Z ( I � �pitntibn D�tc: � ^ (_^_ � �'
t '1�- LaY�� � ,�,.�q.
lob Site A�leiress: (/ � S� Ciry/State/2ip: �"�� t�—
-- -
Attaeb a copy ot t6e workers'compensation poltcy declaration page(showing the poitcy humber uad expiratioo daEe).
Failure to wcure coverage as required undor Sectiari 25A of MGL t. 132 can Itad ta tlie irYlpositioi�bf crimin�I penaltiea ofa
firse up ro S I,i00.00 and/or one-year imprisonmenq as wcll as civil penalties it5 the foiid oFri STOP WORK ORDER afld�firiE
nf up to S250.00 a day a6ainst rhe vinlator. 13e advised ctiat a cepy uf this�tatnmeriC may&d forwuPded to tHe f�tYice of
(nves�iga�iuiu uCthe DIA for insurance noverage vcnfic�titin.
_... . . .-------.._..._
/du/�errby rrrlljy iide�th pulns anr!pena/tler ojperjury rhaJ rhe i�iformnlloe providrd ubuve is iPue und corrrcG
Sis!na�urc: Oat0' �I - aS � ls
Phonc�: 6 I1 Ql3 S SO SU .
. _ _. _ ... -----.._... ----- ------ . .,__.--
' O�ria!usr aily. Do not writa ia this a�erN�o be c�mpleted by city o�towa h�claL
City or"1'uwn: ��,_ permitll.icense tt
—_ _, __ _ _ _
Issuiog Aulhority(circie onc):
i. 13uard of tle�rlth 2. Building Depurtme»t J.Citylfown Ctetk A. �Iectrical Inspector 5: Plueubing inspectur
6.Olher
Contact Person:
._..._.._--._�. Phone#:
� Initial Construction Control Document
� To be submitted with the building permit application by a
R ; Registered Design Professional
for work per the 8`h edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: xxxxxxxxxx� Date:9-14-2015
Proper[y Address: 172 LAFAYETTE STREET
Project: Check(x)one or both as applicable: New construction x Existing Construction
Project description:RENOVATIONS
I Dennis J. Gray MA Registration Number: 5185 Expiration date: 08-20-16 ,am a registered design professional, and I
have prepared or directly supervised the preparation of all design plans, computations and specifications conceming�:
x Architectural Structural Mechanical
Fire Protection Electrical Other.
for the above named project and that to the best of my knowledge, information,and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR), and accepted I
engineering practices for the proposed project. 1 understand and agree that I(or my designee) shall perform the necessary .
professional services and be present on the construction site on a regular and periodic basis ta
1. Review, for conformance to this code and the design concept,shop drawings, samples and other submittals by the
contractor in aceordance with the requirements of the construction documents
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiaz with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regazding the provisions of 780 CMR ]07.
When required by the building official, 1 shall submit fieid/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work, I shall submit to the building official a `Final Construction Control DocumenY.
Enter in the space to the right a"weY'or
G\5�(RED ARCy�t - .
y'yo�a�\5 J.�.�fpJ,
< .
No.5185 �
a eds,ow
o "a'c
9
[)ry
electronic signature and seal:-
Phone number. 978 745 4404 Email: dennisgray@verizon.net
Building OffiCial Use Only
Building Oflicial Name: Permi[No.: Da[e:
Note L Indicate with an`x'project design plans,computations and specifiwtions that you prepared or directly supervised.If bther is chosen,
provide a description. .
Version 06 1 I 2013 '
�
� Initial Construction Control Document
� To be submitted with the building permit application by a
A ; Registered Design Professional
for work per the 8`h edition of the
'� Massachusetts State Building Code, 780 CMR, Section 107
Project Title: xxxxxxxxxxxxx Date:9-14-2015
Property Address: 172 LAFAYETTE STREET
Projecr Check(x)one or both as applicable: New construction x Existing Construction
Project description:RENOVATIONS
1 Dennis J. Gray MA Registration Number. 5185 .Expiration date: 08-20-16 , am a registered design professional. and I
have prepared or directly supervised the preparation of all design plans,computations and specifications concerning�:
x Architectural Structural Mechanical
Fire Protection Electrical Other:
for the above named project and that to the best of my knowledge, infortnation, and belief such plans,computations and
specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted
engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary
professional services and be present on the construction site on a regular and periodic basis to:
l. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the
contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at intervals appropriate to the stage of construction to become generally familiaz with the progress and
quality of the work and to determine if the work is being performed in a manner consistent with the approved
construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official, 1 shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building officiaL
Upon completion of the work, I shall submit to the building official a`Final Construction Control DocumenY.
Enter in the space to the right a"weY'or
� G\S�E0.ED AR�yi
p`�o�p\5 J.C�fo
No.5185 � � - �
; Bosrow
� 1N80.
y
�)N
electronic signature and seal:-
Phone number:978 745 4404 Email: dennisgray@veri2on.net
Building Official Use Only
Building Ofticial Name: Permit No.: Date:
Note I.lndicate with an`x'project design plans,computations and specifications that you prepared or directly supervised.If bther'is chosen,
provide a description.
Version 06 11 2013 !
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