15 LEAVITT ST - BUILDING INSPECTION RECEIVED
NA U uT I The Commonwealth oI MMIMMAWCES
Department of Public Safety _
Massachusetts State Building RAtc!1) At O 3
Building Permit Application for any Building other an a ne-or wo-Family Dwelling
('Phis Section For Official Use Only)
Building Permit Number: Date Applied: Building Offici 1:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for a et ad is not a le)
/S /.E>gyr7 sT vrv,T1 c�11Ew1 ynt9 03 !6
No.and Street City/Town Zip Code
SECTION 2:P SED WORK
Edition of MA State Code used If New Construction c e e or c eck all that apply in the two rows below
Existing Building❑ Repair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 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 Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
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(3v1jd=,� •r�la sTrucTc,rc.,` c><-- f \cur P1+i�N c.ntc,�c
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) 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.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❑
1: Institutional 1-1❑ I-2❑ 1-3❑Q 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
'S: Storage S-1❑ S-2 0 - U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA O IB ❑ IIA ❑ IIB O HIA O IHB ❑ 1 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 9 Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site kp
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation:
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
Edition of Code: Use Group(s): Type of;Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
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a
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
(y);froslAV St9leAr "'oel O
Name(Print) No.and Street City/Town Zip
Prollerty O r tact Information: -
- r7s -� SI 0
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applica e,the property owner hereby authorizes
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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 s p ace and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Company Name
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Name of Person Responsible for Construction / License No. and Type if Applicable kcn V r
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Street Address City/Town State Zip
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Telephone No. (business) Telephone No. cell e-mail address
SECTION 11: 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? YesX No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ /3 SO O 1+-
Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ ZSGO sz�mappropriate municipal factor)=$
3.Plumbing $ S'p of
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 171 009 (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 b st my pwledge and understanding.
Please print and sign name Title Telephone No. Date
o Loc�El L nEA6 0 D�1 a-4- d 9�0
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
J
l}V�'
CITY OF S'UzNi, ;ti[-kSSACHUSETTS
'3C[LDLNC;DEPAMLENT
120 WASHNGTON STREET, Jw FLOOR
T EL (973) 745-9595
KI BERLcY DRISCOLL Rux(978) 740_9945
T NostAs ST.P[Exns
D IRECTO R OF Pl;BLIC PROPERTY/HC=LNG CO\MISSION ER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CM section l l 1.5
Debris, and the provisions of iVfGL e 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of
l 11, S I SOA. in a properly licensed waste disposal facility as defined by �fGL c
The debris will be transported by:
("ante ofhauler)
'file debris will be disposed of in
(aJdre.s of tii�ilit%)
i
1141?1 ure
u(permit a lwa"t
Luc
CITY OF Si r .r.Ms NL�SSi�CHCSETTS
r - Bu ILDING DEPARTNIEINT
' r 120 WASHLNGTON STREET, 3ta FLOOR
TEL (978) 745-9595
Fikx(978) 740-9846
Kl.NBERLEY DRISCOLL
AkYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUULDLNG CO\LMIISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 'To,
!J/1 Please Print Le ibiy
Name (nurine%sOrgtniaaliti ,individu;il): To,h N P" 1y 62A f
Address: Q•(J yG(ps--
City/State/Zip: PRA(3ooy nMfl Phone #: 97�— Yol—�o�ot�
Are you an employer! Check the appropriate box:
'type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
unployces(full and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling _
/ "\ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp.insurance, g, Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MOL 1 I.❑ Plumbing repairs or additions
myself. (No workers' comp. C. 152, 91(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [N'o workers' j; ❑Other
cutup. ,
insurance required.] -
•Anv applicant dot checks box N I must alsu rill uut the section below showing Their workerat cumpensatiun policy inaamaaon.
'I I,eneuwncrs who submit this alridnvit indicating They arc doing all work and then hire outside centncto s most submit a new a?;davit indicting such.
Cumrmtun Thal chuck this box must anachcd an addiliur,al Awl showing llw and their wurken'camp,policy infommtion.
1 ant an employer that is providing workers'c'onipeiisadon hisurance for my employees. Below is the policy and fob sire
information.
Insurance Company
Policy #or Scif-iim Lie. n: Expiration Date:
Job Site Address: City/State/Zip:
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 ofcriminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment;as well as civil penalties in the form of STOP WORK ORDER and a line
Of up m S250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Offitce of
Invo5ngauuns of life DIA for insurance coverage verification.
Ida hereby certify and• he pains ud eno/lea of perjury that the information pro vided abu ve i:s iruueanandd correct
Lam
Phone
_
Official use only. Do not write in this area,to be completed by city or town afJiciaL
(I City nr'I'utvn: Permit/f.iceme#
Issuing Authority(circle one):
1. Bourd of Ileahh 2. Building Beparhncnt 3.C'ity(ruwn Clerk 4. Electrical lospcctur 5. Plumbing Inspector
6.Other
Contact Person: __. — Phone tt: