353 LAFAYETTE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
0. Department of Public Safety.
L.-
t .:
\Lusaeluuelts SLdc Building Cnnle(780C\IR)
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)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
` Edition of\L\State Code used If New Construction cluck here❑or check ell that apply in the two rums below
a Existing Building 0 Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No f3�
Is an Independent Structural Engineering Peer Rev'ew re Yes YesJ❑ No W�
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 C\iR 34) ❑
Existing Use Group(s): _ Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq, IL)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 ❑
17: Factory F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ 1-1-3 ❑ H-a❑ 1-1-5❑
1: Institutional 1-1 ❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4 ❑
S: Storage 5-1 ❑ S-2❑ Uu Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
I:\ ❑ - III ILA ❑ IIB ❑ IIIAC3 111813 IV ❑ 1 VA Cl 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❑ Cheek if outside Hood Zone❑ Indicate municipal ❑ �\ trench will not be Lia•nsrd Disposal Sitc❑
required ❑or trench or specify:
Private❑ or indentifv Zone: or an Site Sys tent❑ J ermit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation:
Nat:\pplirable❑ Is Structure within airport appn+ai h area? Is Ilmir rovicw annplclrJ.'
or Consent to Buildn eclosed❑ Y .N cs❑ or o❑ Yes❑ No ❑
SEC"I[ON 8:CONTENT OF CERTIFICATE OF OCCUPANCY
rditinn of Cute: _ L'sr Gnny+(s)- ________. I\'pt.of Construction: . _, __ - 0, Load pvr Floor:
I)ors Ihr building;ionlo iit an tiprinUvr System.': ____ tipn ial tilipulatiuns:
Sr9tigAl%e --7n6
- - I
SECTION 9: PROPERTY OWNER AUTHORIZA'1lON
Namc and Addrss lit Property Owner
Name(Print) Nu. and Street City/Town Zip
Property Owner Conti}-t Information:
CGhhi e �a�CdS g7k 7yY/0/7 _
l'itle 'relephone 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 properly 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
1 i`co%pft./5 M-137 t10,99
Name(Reyistrant) �J Telephone Na c-mail add y}5 �/ O Registration Number
/D /Se//e4d �01 5a /,ee�t /� i`7'Y `/'7
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
comp an Name �.
5 �X i e C,S 6 5 033 4 h,l,k6
Name of pPerso//n Responsible ffof C structi m License No. and Type if Applicable
(O j�C-l/Pti ✓ /�o SG )earl C 70
Street Address City/Town State Zip
9 r337 GO phi��C h�� Y (PCokpte4$7, . H P7
Tole phone No. business Telephone No. cell e-mail address
SECTION11: tv()i,KFNS (-ON11tV'ArO.N I,vV_UI,'ANC1,:v I+naWlt M.G.L.c. 1 2.§ 25C6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ o-p
Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
A. Plumbing 5
J. Nlechanicol (HVAC) S Note: Nlininump fee=$ (contact municipality)
9. Mechanical (Other) 5 F.nrluse check payable to
f,.Total Cost 5 / Q Ppz G6 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my nante below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
applica!tion is true and/accurat/e to the best of nn/�'owludy ,,aaj�tt I U IILr�Standing.
Please print a I'l sign name 0 _— c / Title Trle drone N.
tilreet Address City/gown , State Zip
Municipal Inspector to fill out this section upon application approval: r/7 —
Name Date
CITY OF SALE(
PUBLIC PROPRERTY
DEPARTMENT
\I\1,41
12:\Vd Mr1AG i11,\i18EAT a i,\IFM.A1.111.1t.111 q l n J197�
I'ra. 77F:yo3'13 0 1:\.v v7Y•IIC'rMM
Workers' Compensation Insurunee %lllduviC Builders/Cuntracturs/Electricians/Plumbers
\ ) )Meant In unnallo
/' �/ Pl � Print Le 'hl
Niunclllusnsciil)rganv+linNlndtsnlualC /r�C r t/1 �Ld s7 GI/�j
Address: le�)
Cily,srarzZip. Sq /cam �/r4 o/��Q l �i 7Ss- 3 37 -y�q
I hone I/:
I .\re)IOU an eagrloyor'!Chock the approprlett bus:
1,❑ 1 :m)a cmpluycr with 4. 01 ,un a general cobltactor and I 1)Pe 11f pro)oct(mli lred):
mnplu)ccs(lull+nd/ur part-time).• hove hired the.suh•cuntracwrs r1' ❑new construction
ILI
2.O .un a sole prnpricttw ar partner- listed on the anachcd sheet 7. Cl Remodeling
v11ip and have no ompluyees Them subcontractors have
\vurking tilt me in any capacity, workers'comp, insurance. d' Demolition
I No wnrkchl'cutup. insurance 3. ❑ We are a coi 9. ❑Building addhiun
required.) pontinn and its
otHcen have avetsiscd their 10.0 Electrical repairs or additions
3.❑ I ant a htinhti Wticf a'co all lvefk right of axemption par MCL 1 I.(]Plumbing repairs or additions
myself. (fv'o \vnrkcn'comp, c. 132,§1(4),and we hove no
insurance rcquired.J r clnpluyeus. (No workers' 12.[] Ruul'repoin
cnmp, insurancarcquind.J I�.�UWar
��q•;grhe+ta q,W eheCY1 boa nl'Tuar aIW(ilt uw Iha w•e1N11 klow
'I IunMrwrwn why iullnlil this amdavil inulutin , aW,Yn1Y 11VIr wwYwe'eon, naatun
j AuY+n JuinY all,vurA a,se uµyl Aye wlside•N,ms TWtl.WN"il a nM+In4avil irWiavlin .,
•r,Mtnvnw.tAq aAeeR Ihia Asa mtw+aaAar en aeaniu,rl shim AuwinY iha namt of(ti Iee+arracl aY and then wuhare'
_ Y MA.
alim
/am an eluployer that IF prul4ding workers'ru/nprnrnllon lommmnct/ar lily r/np/uprrr. Brian Is/h pv//y un%a1fto
s
hiforara/ia6
Insuranue C'umpany Valne:
I'nlicy 4 or Sclr•ins. Lic.H; — - -
-- Expiration Date:
)ub Sita Addreivt
attach x copy of 1110 srorkan'cumpensatlan Policy dtelaratlun Page(showing t'helpolicy number and e.vplratlun date),
I;allule w eceurt coverage as required under Section 23A ul'.%IGL e. 132 eau lead to ills imposition oferiminal penalties of.a
tine IT rn SI 500,r10+nd/uruue-yFar imprisumncnt, as well ar civil(witalliu in the lunn Ora STUp 1YURK ORDER and a riot
of up rn i 5O(X)a Jay.,guinal iht vLllaror. tic advi.tcd that a eupy urthis oulemunt(nay be lurwardcd la the Ulliee uC
Incvan gaunna ul';he Ulr\ :Or imurar'ee cnvcra3u \critic+Uun.
/du/ren•Ay t crli/Y un,/er(hr l r nr/prt nlNa' p ery thti in/Lnnallon ruril/rd p Above is tru
e and a•orrrrA
7:—�—
Cill"I'llillnr airly, pu nnI nvirrIbis urru, to br ruuryh•Ird by wilyurlmru/1It'iuL
rnn: _ Permit/I.1ci,me/ulhurily (circlo one):,f Rc+hh !. IluddhrqCil).'Iowu Clerk J. L•'Icctric.d Inspcclur :,nun: i
r
information and Instructions
v defined as"... in the service of another tinier.uly cuntract of hire.
>l.les.lc lluaell3 Vena�al Laws chJytaf I)2 IC,(Wfe3 J every person II e111gIIo)ar3 to provide wUrker3 compensation for(heir enlyluycea.
Iltrsu.url to litls Nalula, an Impte l'N 1.
vpreas or tinPlwd, oral or written." or any two or inert
�n,•repfuyar,a Joined as"an individual,Partnership..Issoeiaaua,coryorotiun ter other lagdel entity, Y
,�r,hc I, ,Cgou,g engaged in alomt enterpr
ise and including ilia lags1 rcpresantarives1u a^deceased
�lo)tes.IHowvvcr he
,ecerver or uualca ul'.m individual, paamerahlp,assoewuor or other legal ancsijty, s Lh e e
owner of a dwelling house having{nnotn r than three apartmenu and who resides therein,ter Iht occupant of the
unenant thereto shall nos because of such employment be deemed to be an employer."
.Iwallmg house of another who employs Woos w do maintenance,cumuucliPn or repair work tin wch dwelling Ouse
or nn the grounds or building app
censing agoilcy
�IGL chapter 152. §25C(6) also state::;o&business ness or to corstlist*or local truet buverY! ildings lathe oall mmoawaulre for ed. r
tabu arldeact u(cumpUaaet with the Insurance coverage required:'
renewal of r a has
ter pitrmlt to uy of its political subdivisions shall
:lyplicunt Hlao has not produced acceptable
kadiuunully, MGL chapter I5I. a25C171 sautes"Neither the commolualal four my
enter into any contract Yor the Parfumwnce ul'public work until acceptable evidence ul'cwuyliarlce with the insurance
re ttf int aan of this chuptar have been presented to the contracting authority."
Applicants g p to our situation and.if
uddcautlas)and phone numlaer(s)along)with their certiflcutals)of
please rill out the workers' wmpensation affidavit completely,bynaheekin dlP boats that e employees other than the
neccssury,supply ,tuisaontruclor(s)n une(a),
insurance. Limited Liability Companies(LLC)or Limited Lion( Painsuran s(if an
nelnber or partners.are not required to carry worker' conlpansati suburitted to the Dep tma t of Industrial
employees,a policy is required Be advised that this affidavit o may
be unit or license is beings requested, not the Deportment of
\ccidents for contlrmotion of insurneo coverage. Also be sure to oils tad date the ul'flJavlt. Tu affidavit should
he rcta,nled to ilia city or town that the application for the pe
Industrial \c%adcnts. Should you have any queauaoa regarding{the low Of if you am required to obtain a workers
culnpeMotiun policy,Dteaw call the Dep,trtrttenl at the number listed below. Self-inserted companies should enter their
umber on the a ro aisle lino.
.elf-insuranct license n
Cary or Towa Officials
you to till gut in the avert the Otf)ea of Investigations has to contact you res ads t the applicant
Ptca+e he:ore that the affidavit is complete and printed legibly. The Department has provided u space at the Item
of the affidavit fur Y rmiNicense nwnbs:r which will be used ass reference number. In addition,an applicant
M.'aw be sure to till in the Pc applications in any given year, need only submit one affidavit indicating current
that must submit multiple yenn't"'c"i 's's app under ,fob Site inanyAddress"the applicant should write"all lucutiuns in (city ter
policy information ail necessary) '
s or marled by the city or town Inay be provided to the
ch
town)•",N copy of Ilia ufliduvit that has been officially stamp' sit be applicant as proof that a valid aiflduvit is on file for Nature Permits
it not related to any bustinesslor commercial venout ture
Where a hulna owner or citizen is obtaining a license or P
dug lieansa or Permit w burn!saves etc.) said Person is vOT required to complete this affidavit. ua,uons,
IUYi�tlgatluns lvuuld IIAe to drank you gal LIv711Ice fur your COupefatlr)II and should you haw.InY 4
plea,e do nut hesifarc to give us a call.
f he U,P:uuncnt's address, telephone and fax number:
The Commonwealth of Musachusetta
Department of industrial Accidents
OfRee of IavestlQadona
600 Washington Street
Boston, MA 02111
Tel. N 617.727E 00 617-7I of 1.977-MASSAFE
www.myss.gov/die
CITY OF S,V.&Nfq AAss iCHusET'1"S
BL'ILDLNG DEPART LLir
110 WASHLYGTON STRgzr, Ya IZOOA
I-EL (978) 745-9595
F.
�x 97 7�9
K1\®taRLEY DRI3COLL ( � 84
MAYOR M0-%LU ST.PM"A
DI o AFLT AOFPI.'BLlCpROPFATY/Bl;[LDLYGCO.%CVI55lOVEA
i
Construction Debris Disposal Afttdavit
(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 a 40, S 54;
Building Permit tt is issued with the condition that the debris resulting from
111 work shall be disposed of in a properly licensed waste disposal racility as defined by MGL c
111, S I SOA.
The debris will be transported by:
(n:une of hauler)
The debris will be disposed of in
(nam7'a of fanliiiy)
(Iddre»or Nobly)
flynamre ofpermt jpplicanr
L,�e