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39 LEACH ST - BUILDING INSPECTION �b 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 (This Section For Official Use Only) Building Permit Number: Date Applied: I1"ZS"I Ti Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a s et address is not avai ble) ch t 2�1 No.and Street City/Town Zip Code Nor c rry (i 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 Repair 6rUteratiori ❑ 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 ❑ No Is an Independent Structural Engineeri Pee Revww required? //�� Yes�A_0 No rief Description f Proposed Wurk: ✓el' IUJt rq,'6-9 Q lb or'a Pa f - NO !� 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)i 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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ LI: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: institutional I-1❑ 1-2❑ 1-3❑ 1-4❑ M. Mercantile❑ R: Residential R-l❑ 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 ❑ 1113 ❑ ILIA ❑ II1B ❑ IV ❑ VA ❑ 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❑ Check if outside 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: \I\,I,li t i i,Cnnoniw n I _,ic,v I r�_-ss: Not Applicable C�' Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No EV Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): 1•ype of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: (-/'7,- I M j w kE 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) If 60ding is less than 35,000 cu.ft.of enclowd space and or not under Construction Control:then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control Nano(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10:2 General Contractor - - G. 9. � (r-i o n /Company Name 1 �eJGrk —4 Lhwr - mnl�on Responstbl for Construction lJ tcense No. and Type if Applicable _ 3� �L ;�r � ire%eX ©[Ci13 Street Address City/Town / / /' Stater Zip 6 l7(�i 1 COhSf. 1) G A134 a CDiI1 Telephone No. business Telephone No. cell e-mail address SECTION 11:4VOKKP.RS'C-0fQPEN5A I'ION INSUPANCti AfTIDAVIT M.G.L.c.152.§Z5C 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 O-'No ❑ SECTION 12:CONSTRUCTION.COSTS AND PERMIT FEE Estimated Costs:(Labor / G Item a QUOnd Materials) Total Construction Cost(from Item 6)_$ b r I. Building $ Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check Y payable able to 6.Total Cost $ l� Q(,�1� (contact municipality)and write check number here SECTION 3: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 ' a placation is true and acute to the If mymmedge and understanding. PJ}2 p td �fir nnmeR J J/),e✓� Title vqq Telephone N te o.3 a Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: I Il/a711 h Name Date V CITY OF S.1.I.E\,t, iWS.ICHUSETTS BUILDIING DEPARTMENT 120 WASH¢vGTON STREET, 3AO Float C = Tt..L (978) 745-9595 KIIfl3ERL EY DRISCOLL FAX(978) 740-9846 NLAYOX THObLAs ST.PIERRB DnucTOR OF PUBLIC PROPERTY/BCIILDLNG CONI]MISSIONER 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 11 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit 1# 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 rMGL c l 11, S 150A. The debris will be transported by: y ►�or� 51 de. C�,r�,`�IG (name of hauler) The debris will be disposed of in (name of facility) ------(address of facility) signature of permit applicant " �° CITY OF S:U.EDrI, NLiSSACHUSETTS t�� r BCIIDL\G DEPART-,LF-NT • V xl't r�, 120 W.ASHLNGTON STREET, 3'o FLOOR '�� TEL (978) 745-9595 FAx(978) 740.9W KIN [BERLE LL Y DRISCOYOR THOMAS ST.PIE.RM iIF- DIRECTOR OF PUBLIC PROPERTY/BUILDLVG CONIMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n �^ Please Print f,egibi VatnC (13usincssOrganization,'Individual): ��//L (��I� I� �.r'✓P��Y Address: 33 n qi" e r I< C City/State/Zip: P.JEv Jy 01 q 15 Phone #: p/Oa —">kit—a-1 LI L4 Are you an employer?Check the appropriate box: 'type of project(required): I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time)." have hired the sub-contractors 2.[K I ran a sole proprietor or partner- listed on the attached sheet.; 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 officers have exercised their 10.❑ Electrical repairs or additions required.] I 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. f No workers'comp. c. 152, g 1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] -Any applicant that ducks box 01 must also fill uuI the section below showing Chair workeri compensation policy in Ili matiun. 'I lomcou'rars who submit this affidavit indicating they arc doing all work and then hire outside contractors mint submit anew affidavit indicating such. :c.,ntracwrs that check this box most anachcd an additimutl sheet showing du n:onc of the subv:antnctors and their workers'comp.policy infomution. I am on employer that is providing workers'c'ontpeasatlon insurance for my employees. Below Is the policy cord Job site information. Insurance Company Name: Policy#or Self-insi. Lie. #: Expiration Date: Job Site Address: .J 9 LP.C,tl sr- City/State/Zip: ,Sot lepi, - Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failuru 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 S 1.500.00 and/or mu-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 DIA For insurance coverage verification. i da hereby certify fy under the pain,.s/y_atd en Ities of pepury that the infunnadon provided above is true and correct Phone : IpI llgq . Official use only. Do not write in this area,to be completed by city or town offWaL City ar Town: ------ -- Permit/I.lcense# Issuing Authority(circle one): 1. Board of Ifeallh 2. Building Department 3.Chy(rown Clerk 4. Electrical Inspector 7hispector 6.Other Contact Person: .. _ ._.. ..__ Phone#: -- -- [