0076 LAFAYETTE STREET - BPA 13-726 The Commonwealth of Massachusetts
Department of Public Safety
` Massachusetts State Building Code(780 CMR)
Ulf\YA Building Permit Application for any Building other than a One or Two Family Dwelling
(This Section For Official Use Only)f 10
Building Permit Number ° Date Applied
SECTION 1 LOCATION,(Please indicate Block#and Lot'#for locations foi which a:street address is not available)
og-/ .ram f .F 7S4 ev t o t c? ?0
No.and Streett LIM, City/Town Zip Code Name of Building(if applicable)
v SECTION 1 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❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition Ph (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 19
Is an Independent Structural Engineering Peer Review required? nn - n Yes ❑ No �
Brief Description of Proposed Work: PPi'.+oy'vw ��a55 ff'�(-?GtA' -Per0V- �7��2 O-F �e&r7
Ir1a5s des + ,Sf�e/ l �Lcye r 6.�_�
SECTION 1 COMPLETE.THIS SECTIO_ N IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR '
.: :.CHANGE IN USE OR OCCUPANCY'. :
Check here if an Existing Building Investigation and Evaluation is enclosed(See780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION4::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.asiapplicable) - -,
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 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 ❑ I-2❑ .I-3❑ I-4❑ M: Mercantile❑ R: Residential R-113 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 ❑ F IIIA ❑ IIIB 0 IV ❑ VA ❑ VB ❑'
' SECTION 7:SITE INFORMATION(refer to 780 CMR_ 111.0 forAetails on each item)
Debris Removal:i Permit:Water Supply: Flood Zone Information: Sewage Disposal: Trench -
Public❑ Check if outride Flood Zone❑ Indicate municipal❑
A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required ❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA.Historic Commission Review Process:
Not Applicable�d 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:
' . . .
�•` `-PROP
ERTY OWNER:9UTFIORIZATIOiV "
v 4f
Name and Address of Property Owner
KCG LLC / 7Juezlo0 54 • Sor>7.e,avtAa MA
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
o_ spa
Mph
Title Telephone No. (business) Telephone No. (cell) e-mail address - -
If applicable, the property owner hereby authorizes
S M J 7 .Tualoo $ 4, .so'e-ty- //e AV,
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 CONSTRUCTIOC N ONTROL(Please fill out.Aopendix 2)N,
__ an, N - ' =
If buildtn` is less than 35,000 cu.ft:of enclosed s ace and(br nofundec Construction:Control then`elieek here.O and sk i Section 10.1
10.1 Registered Professional Responsible for'Construction ., .7"• .. ° .."'.,
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor', ss r r` _ -: n - •..". ,•_, ,-s'-. ..,
u C Q$ CoctS T- -F/-LCG k— r
Company(Name
T M \ ) CS B op
7 0 7
Name of Person Responsible for Construction License No. and Type if Applicable
( 71 ee51--41LJ 54 , Sa (e_,_�, /11A dl R 7d
Street Address City/Town State Zip
a78-366_ /R6�!
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKER5'COMPENSATION INSURANCE AFFIDAVIT` M.G.L.c.15r '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? Ye No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE-,' k. `•._ : -
Item Estimated Costs: (Labor O o 0 0 11
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 (tiVAC) $ Note:Minimum fee=$ (contact mumc a�ykp)
5. Mechanical Other $ (245h
Enclose check payable to
6.Total Cost $ /( 080. O O (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 T 10,10
a No. Date
17l (3ogrt/ Sf• SR �e pr $ r(7 e
Street Address City/Town State
Municipal Inspector to fill out this section upon application approval.,"
- Name. Date - .
CITY OF Siu Em ANSSACHUSETTS
BUILDING DEPARTm&NT
120 Cf/.1SHLgGTON STREET, 3'o FLOOR
TEL (978) 745-9595
Rut:(973) 740-9846
Iv.\[BF Rr F,Y DRISCOLL I HoatAs ST.PtautH
MAYOR DIRECTOR OF PUBLIC PROPERTY/0UM.CIL`NG COJLMISSIONER
Workers' Coinpensatlon Insurance Afffdavit: BuilderslContractorv/Electricians/Plumbers
Applicant information /— 1_ — /� 7 Please Print Leeibiy
V:l1710(OusinessUrynir/a�liu vIndividual): /u S COGI$ r l—7 Iz-(C_ I— C Cif 1
Address: S�1�q
City/State/Zip: q ��'� /"Ifi Phone h: q 79 EL 1-4 LM y
Are you an employer?Check the appropriate boxt 'ryps of project(required):
1.0 I am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction
dinployees(tLll and/or part-time).• have hired thesub�camnetors
2. 1 am a sole proprietor or puller- listed on the attachod sheet t 7. ❑Remodeling
.ship and have no employees These subcontractors have V. 0 Demolition
working rur me in any capacity. workers'comp.Insurance. 9, 0 Building addition
(No workers'comp.insurance 5. 13 We are a corporation and its
required.) officers have exercised thdlr 10.0 Electrical repairs or additions
3.0 1 ran a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. C. 152,y 1(4),and we have no 12.[]Roof repairs
insurance required)t employees.LNG workers'
comp.insurance required.) I7.O Other.
•Anyappllcauaduschceks boar) must also,ail out the awtiuo below showing theirworkeW eompenudon poilcyintbrm,Ilan.
'I hvnvuwmtn wha submit this atltdnvit indicating they an doing all work and then Mrs oubidecontnatoa must submit a new alndavit indicting such.
:C,mtmuton thol ch«k this bat most anaahod ass addillurml skal showing the name of the nttsadmnetore and chair wurtten'tamp.polity inrurmaeen.
fain un eerpluyer rhaNs prov/dln,r Ivarkm'campeuadan lnsurnnce jar ary ampluyers Below 8r die polley and/oh s•!le
injan+rullons
Insurance Company Notre-
policy 4 or Self-itu. Lie B: Expiration Date:
lob Slid Address: City/State/Zip:
AItacb a copy of the workers'compensation pulley declaration pals(showing the policy number and expiration data).
Failure to secure coverage as required under Section IJA of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51,500.00 and/or one-year imprisonment,ax well as civil penaltes in the farm of a STOP WORK ORDER and it line
of up to 5250.00 a day against the violator. Ile advised that a copy of this sntement may lad furwarded to the Ofticd of
Invvstigwiuta ul'thd DIA fur insurance navemya veritiealiun.
/du hereby Ce IfJ urJrr th/r/pulps u++J p�srelr/)er upper/ury t/ruf rAt G+junuwlar provlJaJ abuuvi is true rase cdrrerL
F__
euwn: __ _ permir/L)censc,9
uthurRy (circle one):
of health !.Uuildlnq Department I.Citylfnwo Clerk 1. LIeetrleal lrupector 5. Pluotbing Inspector
ermn:_ _.- ... 1'hano tl:
I
�.e 4r , r �
_ Y CITY OF 5'1LE1 f, NLUSACHUSETTS
BI:LLD LNG DEP.+RT.%LFUNT
I301f AMLNGTON STREET V FAO
TEL (978) 745-9593 R
:<IJIBERLEY D2lSCOLL F•I't(978) 7-10-9344
A UYOlt '1110a4U ST.PIERM
DIRECTOR of PCDLIC PROPERTY/13LUDLNG COJL%tI55i0NER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
fn accordance with the sixth edition ofthe State Building Code, 730 CNIR section I 11.5
Debris, and the provisions of b1GL c 40, S 54;
Building Permit I# 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 t'Y1GL c
l 11. S 150A.
The debris will be transported by:
j6a5 CogS4—
("ante ut'hauler)
The debris will be disposed of in
—
(nanta or tacility)
(adJress or tacility)
siyteture ufpern t applicant
data --
I
�1
+t rlassacrusPns -'Oc.oariment rn P.rblicCafety`
Board of Building, egulations and Standards
Coastructii ri Super is"nr "
License: CS-088707
TIMOTHY S DEC LtREA'"'
5 EVAI'S RD
PEABODY MA 6196
J,41 +' Expiration .
Commissioner 07115/2014: