198 LORING AVE - BUILDING INSPECTION (4) ✓ INSP
The Commonwealth of Massachuse `
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Departmentofmpf2e tf/ty ^NlassachuseltsStateBuiIdingCo`tte(731)C )�' ��
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 M and Lot M 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 MA State Curie used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ Demolition 13 (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 ❑ e
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Dcscript'on of Proposed Work:
l
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): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Fluois/Stories(include basement levels)&Area Per Fluor(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❑ H: H1 h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ I-2❑ 1.3❑ 1-4❑ hL Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage 5-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA Cl IIB O IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION T 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❑
required❑or trench or specify:
Private❑ or indentify,Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way; I-Iazards to Air Navigation: MA I lht a nmmi„. n I . • -I , .;pac
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes O or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Cade: _Use Group(s):_ Type of Construction:_ Occupant Load per hour: _
Does the building,containan Sprinkler System?: _ Special Stipu lot ions: ___
S
S
SECTION 9: PROPERTY OWNER AUTHORIZATION
ame and Addr,ss of Property Owner /
a� , fcT�L���.� A,-e SG 1 -P
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
7LL- SF -( -6 K/ ct-ve EcLs, PP;ArrCCti
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 building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
06LWG
Com y Nam
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Name of Person Respo Bibple for Construction License.No. and Type if Applicable
�1U= Pda jewjtrr S
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:1VORFFI6'COMPI NSNI'ION'INSURANCE AFFIDAVP 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? Yes❑ No ❑
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
I. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ C/ — appropriate municipal factor)=$
3. Plumbing $ p v
.1. Mechanical (FIVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ (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
(ap�pl ication is true and- ;rte-rdlftv-b t of my knowledge and understanding.
Please print and sign name a� Title Telephone No. Date
Street Address City/Town - State Zip
1 `
Municipal Inspector to fill out this section upon application approval: �O�jiO o[ �d
Name Date
. Y
• � s
CITY OF SiU E.NI, N-WSACHUSETtS
/ T BL•ILE)MG DEPARTMENT
3 r •l 120 WASHLNGTON STREET, 3'a FLOOR
TEL (978) 745-9595
FAX(978) 74(1-91M
KI.\IBERLFY DRISCOLL
A-%yOR ')Hoxw ST.MER&B
DIRECTOR OF PUBLIC PROPERTY/BEADING CONNISSIONEA
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t ilicant Inrnrmatinn14 Please Print Le ibl
Va1nC lBusituss,Organiratinm•Imlividual): �V-2 v ulr—
Address:
City/State/Zip: S I �� O I `( 7 Phone H: 7 1�-
,1rc you an employer'!Check the appropriate box: D
prnJect(required):
1.El I am a employer with 4. 0 1 am a general contractor and 1ew construction
employees(full and/or part-time).• have hired the subcontractors
2.161 vn a sole proprietor or pnnnur• listed on the attached sheet. temodeling,hip and have no employees These subcontractors have molitionworking'for me in any capacity. workers'comp.insutantt. ilding additionjNoworkers'comp.insurance 5. ❑ We are a corporation and itsrequired.) officers have exercised their ctrical rcpain or addiiions3.0 i am a homeowner doing all work right of exemption per MGL mbing repairs or additionsmyself.(\'o workers'comp. c. 152, §10),and we have no orrepairsinsurancerequired.) t employees.jNo workers' er
camp.instarance required.)
'Any upplicam nut chcchs box II Waal at"rill uul cam",lion below showing their wodeta'compensation policy udnmallon.
'Ifi—owner,who submit INN atndavit indicating Ihcy am doing all work and then hire outride catanausr most submit a new afedavit indicating such.
:C...Itxwn that ehwit Phis box most mtwhat an nddidunai shut showing the name of the sttbaofurwm and lhclt woden'comp.policy Infamulian,
l ran an employer tliaf Jr pruvid/ng Ivorkert'conrprara/lan insurancefor my employees. Uelow is the policy and fob sire
infortuarion. ,-
Insurance Company Name: O //`
Policy#or Srtf-ins. Liu.d: Expiration Date:
Job Site Address: City/State/Zip:
A Itacb a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Fuiluru to secure coverage as required under Section 25A of,%IGL e. 152 can lead la the imposition ofcriminal penalties of a
line up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm Ora STOP WORK ORDER and a line
of up to VJ10.00 a day against the violator. lie advised that a copy of This statement may be furwarded to fhe Office of
Invritigatiuns ul'Ihc DIA for insurance coverage vcrilicaliun.
/do he order the Lsuud penaldrr of perjury Mar the hifuralurlent provided above is true and c orreeL
S" •n 1 c �7 Vale*! er
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OJ/iriul use rally. Du our write in rkLe area,to be cuntp/erad by trig at town n/Jfeiu[
City car Town: _ ._ . Permiul.lcense q
Issuing Authority(circle une): -- --- .-- ---
L tfuard of ileallh Z. Building Departntcut I.Glyrfunn Clerk J. Electrical 6tnpcdur 5. Plumbing inspector
6. Outer
I Contact Persaw
Phone@:
QTY OF SALEK MASSAaR SE M
iiK +1 BUILDING DEPARTMENT
120 WASHINGTONSTREET,YDFLOOR
ItL.(978)745-9595
KIMBERLEYDRISCOLL FAX(978)740-9846
MAYOR THomm ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING 00AWSSIONER
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 111.5 Debris,
and the provisions of MGL c40, 5 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
S nature of applicant
Date