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85 LEAVITT ST - BUILDING INSPECTION S INS PECTU AILSER The Commonwealth of Massachusetts ' Department of Public Safety.TQ1a JUL lb AD 10 , w 6lassachusetts State Building Code(780 CNfR) 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) i3 5 I.evw; H Sf St(eSti 0&A ©1`I 7-6 A,-4!6r Sivee�s No.and Street City/Town Zip Code Name of Building(if applicable) SECTION Z PROPOSED WORK Edition of iblA State Code used_ - If New Construction check here❑or check all that apply in the thvo rows below Existing Building 0" Repair❑ I sAlteralion K I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No JS Is an Independent Structural Engineering Peer Review required? / / ,/ Yes ❑ No Rt Brief Description of Proposed Work: /ws a r re ataale/ do/ exits Tl MA !'P Aa t l Jjanr SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if a n Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 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❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ III: High Hazud H-1❑ H-2❑ H-3 ❑ H-4❑ FI-5❑ 1: Institutional I.1 ❑ 1-2❑ 1-3❑ 1-40 NI: Mercantile❑ R: Residential R-I❑ R-2 Cl 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 a livable) IA III ❑ HA13 11B ❑ ILIA ❑ IIIB ❑ I IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Debris Removal:Trench Permit: Water Supply: Flood Zone Information: Sewage Disposal: Trench Disposal Site❑ Public Pd' Check if outside Flood Zune❑ ludicate nmmicipal❑ A trench will not be p s. required❑or trench or specify: Private❑ or indentify Zune: or on site system❑ permit is enclosed ❑ Railroad right-of-way: Ilazards to Air Navigation: \:1A I.I I n l_�'mni i I,._ w" I r ,, Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed El Yes❑ or No❑ Yes❑ No ❑ . SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s):,, a . Type of Construction: Occupant Load per Floor: Does the building nntLorton Sprinkler Systen?: _ Special Stipulations: MatL,C(D� 1 I n SECTIONS: PROPER'CY04VNERAUTIIORIZATION Name and pAddressof'Proper fy Ow•nerj' �eavi4tsf' 019� Name(Print) :01 ` �Yt. �'� o.and Street City/Town Zip Properly Owner Contact Information: _ C 00 ` -1-�10 __- r dews i COAUO Stem , cow. Title Telephone No. (business) Telephone No. (cell) a-mail address If applicable,the property owner hereby authorizes pan tQ �:oJ�vl 07- . °/Sf. 3z�61l7-70 Name Street Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this budding ermit 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 O and ski Section 10.1 10.1 Registered Professional Responsible for Construction Control ici N. 12` trc0�rl, -a 3Z cPatJ filer am 10 ConStr4c�I Name(Registrant) Tel•phone No. a-mail address ' COYh Re Ufstration Number Street Address City/''own State Zip Discipline Expiration Date 10.2 General Contracttoor ` /� /C t 1DY-Gf'a/9 lON 5'T t o .L.N C Company Name // B �0.Un01 2lOY�0.% Oat6 � �t' CSL — et)f 1l roc Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town �7 State Zip 9A-� 2 0 -as 6 9 �_ ya `d 3,Z er'aue Cei r•rolnlam - CcOS�rudl';a , dAr Telephone No. business Telephone No. cell a-moil address SECTION 11:WOItkERS'CO%II'FNSA PION WSURANCF AFFII?;\VrY M.G.L.c.152.9 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 Estimated Costs:(Labor Item and bfaterials) "Coral Construction Cost(from Item 6) 1. Building $ Building Permit Fee-Total Construction Cost x_(insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing 5 4. Mechanical (HVAC) $ Note: Mininunn fee=$ (contact municipality) 5. Mechanical (Other) Enclose check payable to r— 0 p,y. 6.Total Cost $ j Q 0 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERNIFT APPLICANT By enter my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this applic to is true and ac to to the best of my knowledge and understanding. ['lease print and si�n nanme n �^ t Title �j�d Telephone No. "naw 'OJ'IX lA✓1 JQI'eU/� IMA— Street rJress, ur / �_` City/Town State Zip a p� J T Municipal Inspector to fill out this section upon application approval: `�'�'V'� 17 ) Name Date i r CITY of5 M-EM, ttiL1SS:ICHUSETTS 4 BCILOLNG DEPARTJIE.rT - �`Ci. 120 WASHLNGTON STREET 1'O �.�.-y.; ,�^ FLOOR TEL (978) 745-9595 KI\tDERLEY DRISCOLL FUX(978) 7-W-984S L"LAm"I D'OSLU ST.PtE.Rtta DIRECTOR OF PLULIC PROP ERTY/a U UMLVG CO-NNISSIONER - C'omtructiun Debris Disposal Afttdavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Coda, 780 04R section 111.5 Dcbris, and die provisions of tMGL c 40, S 54; Building Permit hi is issued with the condition that the debris resulting Irom this work shall be disposed of in a properly licensed waste disposal facility as defined by %IGL c t 11, S 1 SOA. The debris will be transported by: ("JNc of hauler) The debris will he disposed of in (name of tacdrly) �—" signaNrc u(tlrrmit appticant ,. CITY OF Scu..EM, AksS.1CHusETT5 BUILDING DEPARTNIEINT 3 � r 120 WASHLNGTON STREET, 3"n F7.00R TEL (978) 745-9595 N-t(978) 740-9846 K1jIBERLEY DRiSCOLL ;/LAYOR TribhtAS ST.PtEQRB DIRECTOR OF PUBLIC PROPERTY/BUIL.OI\'O COMMISSIONER Workers' Compensation insurance Affidavit: Dugrlers/Contractorv/Electrlelans/Plumbers AII ,� Iicant Information Please Print l egibi V;IInC IIla,inext�,Organiralicrvindivid1uuhJ,:.r_( Ze';a 2 as aLI / C Q. �h�` Address: rX 7�l"QCtUQ/ —c" p r 7 �` City/State/Zip: `�rxl -L'CA T Y4 A 01 f�b Phone it: /Z 6 — 7` 7 Q - bit 0z Are yyo'u an employer',,Check the appropriate btnl: Type of project(required): am a amployer with _ �t. 0 I;un a general cunlrnelor and employees(full andior part-time).' have hlrcd the sulruonlYactora 6' ❑New construction 2.© lama sots propriclor or partner- listed on the attaehcd shcot.l 7. k2Mroodeling ship and have no employees These sub-contractors have S. ❑Demolition working I'm me in any capacity. workers'comp. insunsru t. 9. ❑ 4uildingadditian (No workerti camp. insumlico 5. [] We are a corpnration and his requirud.] officers have dxurcised their 10 Q Electrical repairs or additions 2.© 1 nil,a horncownur doing all work right of exemption per MOI. I I.❑Plumbing repairs or additions myself. [No workers'comp. C. 152,§I(4),and We have no 12.0 Roofrupairs insurance required.) t emploYees. (No workers' (g•❑Other cutup.insurance roquircrI j ' 'My uppticmn Owl d+eekY burr 1 mvr,also rill out the uvlion below showing their workoq'eumpenaatiun pulley Inlinmatian. I Iomeuw,M1aa,•ha aulvoil this allitlnvft indicating Ihcy m dotng all work and then hire outside eonirii m+yt suhmh a new stl)davil indicating each. :rlmtmvtota that eht[k this box must uoafhalun nduilivrwl shoat xhnwhtg nle mmate of rho sub•comrretan and Ihek warkars'eamp.pulley htronnotion. /tun an esployde drat lr prus4dlntt workers'rantprtrsedun insurance for nay employees. Fdlo,v is the paltry u+td fob rl�d inftrramrinn. Insurance(:untpm,y Nwric: Policy U ur seif-ios.�Liu,M: ( 2/ Y-/41V/� Expiration Oate: / P?6/4'/ :y Job Site Address: O � oao I tT ,�T , Clty/State/2ip; 0 or A Q/f r6 Attach 2 copy of the worheW campensatlon policy ddelaratlen pegs(showing the pulley number and expiration data). Vail=to sueure coverage as required undut Suctlon 25A of MCI.c. 152 can load to the imposition of criminal penalties Ora tine up to 51.500.00 und/oroncyear imprisonment,as tvcll is civil penuities in the form ur o STOP WORK ORDER and a fine of up to 5250.00 a day against eta violnmr. 17e advised that a copy urthis,Statement may be furwarded to the Oflice or In rostisulions o "?to 01A for insurance coverage verification. r do hereby certify a de the' ebts«ad pen .r of per, ty that the PlArmarlar provWed Uhuve it true and c•��'orr/reel. )Tire' Phi t! rT_ 0//iciu/ase rn+ly, OU nUr IvrifC err this area, to be t anrpleted by city ur rorvrr o/f)rrat I City nr'1'uwn: Pcrmit/i.icenst k issuing Authurity (circle one): I. Guard ul Ilcult)t 2. 12uildinq Ikpartumlrt .).(:itylfu,rn Clerk 4. 1,,Iectrifdl htspcctnr 5. Plumbing hspacwr I G. Odtur t'u nl aft Pv tenor Pharlc