172 LAFAYETTE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
,ten (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 ruLD&vail e)
I 11a. 1,Ay-C i}� S'�r:EF Sp\c. . Ok"LIb m
� c�
No.and Street City/Town Zip Code Name of Building(if atp ppaf'icabletD rn
n
SECTION 2:PROPOSED WORK cr 5m
Edition of MA State Code used If New Construction check here❑or check all that apply in the owscbegv
Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ Demolition 2 (Please fill out and submit openc@ 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Ln n
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 0 '
Brief Description of Proposed Work: ice+ sow NN-Mo`A it,, oi' r k+ b4_f+ao..S wp l\$
C Cc V itj PZ! ck F'1oo�.w I F vn ( AA E S' c ni N EL.0
v
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 ❑ A-4❑ 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❑
I: Institutional I-1 ❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-111 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 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl}: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public[� Check if outside Flood Zone Indicate municipal A trench w�of be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required For trench or specify:
permit is enclosed❑
Railroad right-of-wa Hazards to Air Navigation: MA Flistoric Commission Review Process:
Not Applicable l Is Structure within airport ap oach area? Is their review complet d?
or Consent to Build enclosed❑ Yes f] or Not Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): T e of Construction: Occupant Load per Floor:
YP P
Does the building contain an Sprinkler System?: Special Stipulations:
ICI Uo3
Sca)-7 G ( I
f
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
IF-9%R _ LLC
Name(Print) No.and Street City/Town Zip
Pro erty Owner Contact Information:
Tell - 0 t F6 ?L t11 _ 4ac_ q:o_15 R, Mm6CCk,7QCr,
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 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)
f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
1J f7"r 7S Cs['ay 9luu _745 940 dews utfmcj UEr-r , REF S155'
Na e gi ant Telephone No. e-mail add Registration Number
� �a�y Sg"Azc SA res�\�,,,� ww ot4-?u jq2c1 AQ!)! 3 t 30 lS
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
631l,-L- �>✓ . Ate.
Street Address - City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVTT 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❑ 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 $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ Ze20L0. ^ (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
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: �
Name Date
k
r
CITY OF S�UXNV1, NLXSSACHUSETTS
BUILDING DEPART\lE:NT
120 WASHINGTON STREET,Sao FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAs ST.PtFmm
DIRECTOR OF PUBLIC PROPERTY/BUILDING COJLMSIONF-R
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Leeibly
Name(Busir ss;Organizatiorvindividual): C tAt�, Dt-y--,A-\\. �-7.C-° _
Address:
City/State/Zip: Phone #: t Zg L( 5°Sj
A�rej'ou an employer?Check the appropriate box: Type of project(required):
I. 1� 1 am a employer with 1 d 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the subcontractors
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. (v_j Demolition
working for me in any capacity. workers'comp.insurance. 9, 0 Building addition
[No workers'comp. insurance S. 0 We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp. insurance required.]
•Any applicant that checks box 0I must also fill out the section below slowing their workers,compenmarion policy into rmation.
'I Inmeuwnen who submit this o ffdavit indicating they are doing an work and then hire outside contrmom must submit a new affidavit indicating such.
'Contro,ton that cheek this box must attached an additional sleet showing the name of nu subcontractors and their worker"comp,polity information.
t um an employer that Is providing workers'compensation Insurance for my employees Below is the polley and Job site
information.
Insurance Company Name: iN�Xc o `/rt//pt.4/)D,- C6,
Policy#or Self-ins.Lie.#: ���� /�✓ Expiration Date:
Job Site Address: i 1 Lay r`,y 4�, S V f Et City/State/Zip: 3A `°•- A*A d (`C l0
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 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the D1A for insurance coverage verification.
t do hereby re tJnde the pains and penalties of perjury that the information provided above is true and correct.
SiLnat tr •
Date:
Phone#: 6 (-1 83 q 505c)
Official use only. Do not write in this area,to be completed by city or town ofJiciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
i
Contact Person Phone#.
r
CITY OF Smyml INLAssAcHLSETTS
BunDLNG DEPARnm,\-r
• 120 WASHINGTON STREET, 3*0 FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI.xiBERLEY DRISCOLL
MAYOR THo"ST.PtEm
DmECTOR OF PUBLIC PROPERTY/BUILDWG CO\MaSSIONER
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 111.5
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:
(name of hauler)
The debris will be disposed of in
(name of facility)
�o2tiy?t 5�ri,A I \ FFinu&r
(address of facility
signa a of permit applicant
s -aa- 15
date
a�nd��ra�