249 LORING AVE - BUILDING INSPECTION (2) 7,
The Commonwealth of Massachusetts
uxc
Department of Public Safety
Massachusetts State Building Code(780 CbIR)
Building Permit Application for any Building other than a One-or'Two
- (This Section For Official Use Onl )
Building Permit Number: Date Applied: Building Off' al:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for w ch a street ress is n ailable)
4041A,745i --<u
No.and Street ty/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in tite two rows below
-- E.xistingBBuilding❑ Repair❑ Alteration Addition❑ Demolition ❑ (Please fill out and submit Appendix l)
Change of Use ❑ 1 Change of Occupancy ❑ Other Cl Specify:
Are building plans and/or construction docmnen is being supplied as part of this permit app licttion? Yes ❑ No B
Is an fridependent Structural Engineering Peer Review required? _ Yes ❑ No 9T
Brief Description of PrLosed Work: .^ /Dvs! f63
s c dt !y 3 1
/H G zsi /s
i c
s P ss f A A
SECTION 3:COMPLETE tIIS SECTION EXISTING BUILDING FINIDE.RcniNG 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 Grou p(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)8r 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❑ 913usiness ❑ E: Educational ❑
P: Facto F-1 ❑ F2❑ H: Hi h Hazard FI-1 ❑ ❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-t ❑ I-2❑ [-3❑ I-4❑ M: Mercantile❑ R: Rtial R-1❑ R-2 Cl R-3❑ R=I❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Speci ❑and please describe below:
Special Use
• SECTION 6:CONSTRUCTION TYPE(Checklicable)
IA ❑ IB ❑ ❑A ❑ IIB ❑ IIIA ❑ IIIV ❑ VA ❑ VB ❑SECTION 7:SITE INFORMATION(refer to 780 CMR 111details on each item) -
Water Supply: Flood Zone Information: Sewage Disposal: ch Permit: Debris Removal:PubliclY Check if outside Flood Zone❑ ha,Iinate numicipal t� Ah will not be Licensed Disposal Site 6Private❑ or indentify Zone: or on site system❑ re O or trench or specify:�j'/�,=�ps enclosed❑Railroad right-of-way: - Hazards to Air Navigation: �I,\,I h t ri t „nun Sin ,yic,� Pn:�r,v:r\pplicabfe❑ 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 Gruup(s): 'Fy pe of Construction: Occupant Load per Floor:
Dues the Special Stipulations:_
�-7 Tw'Sd�'S Ip v� -
r
SECTION 9: PItOPE1tTY OWNER AU'rifORIZA'rION
Name.ad Address 01 Iroperty Owner
��eX�irYc� r�h /���s�aRr Deaf -SE�� �rrtco�f /LIu Aa
Name(Print)
No.and Street city/Tow Z1V
Property Owner Contact Information:
Title Telephone No. (business) 'relepho le No. (cell) e-mail,dress
If applicable, the property owner hereby authorizes �/ ,T
ti_ ��1�[—_ !'dc<Y��S P Sf �IDycc�S yt'rt _l__y._7l/
N1111e Street Address City/Town State Zip
to act on the property owner's behalf, mail matters relative to work authorized by this building ermit a2plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed s ace and or not under Constriction Control then check here O and skip Section 10.1
10.1 Registered Professional Res onsible for Construction Control
Name �ie�r,istrant) 'fcicNh/t))ne No. e)y it ad/d�re'ss ��A cgistration Number • —
7 Ad- A& —z>
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Nam A J / /4 M 69'
U lZez f�3 ff�/G//f Ci} s
Name of P sun Responsible for Construction License No. and Type if Applicable
7 121 CS0, �L
pStreet Address City/Town State Zip/
G ef Li G& d 7�Ya3 rCim+r
' No. business Tele hone Nu. cell e-mail address
Cele hone
SECTION 11:t�'i?I:RIlt:S'CC1RiPISN5;1 PION INSUR:\NCII III I'M l M.G.L.c.152.§25C 6
A Workers'Compensation insurance Affidavit from the MA Department of Industrial Accidents must be completed,uul
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a si ned Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6) $
1. building S Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical 5 .4 a s appropriate municipal factor)=$
3. Plumbing �a
S d Note: Mininuun fee-S (contact municipality)
1. echanical (FIVAC) $
M n
S. Mechanical Other $ Enclose check payable to / /) —
G.Total Cust S QQQo (contact municipality)and write check number here�
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest minder the pains dad penalties of perjury that all of the information contained in this
application is true and accurate to the best my knowledge and understanding.
Please Fund sign name ale telephone No. Date
SUcet Address City/Town State Zip
%Iuricipal Inspector to fill nut this section upun application approval:
Name Date
CITY OF S.U.EE-.I, TNL-kSSACHUSETTS
• BI amNG DEPAR-n NT
F 120 WASHLNGTON STREET, 3"o ROOR
T EL (978) 745-9595
Rk..X(978) 740-9846
KINtBERi FY DRISCO(L
MAYORTHO;<tAS ST.PIERRfi
DIRECTOR OF PUBLIC PROPERTY/BILMEI NG CONWISSIONER
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 c 40, S 54;
Building Permit # 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 MGL c
111, S 150A.
The debris will be transported by:
(name of haul
The debris will be disposed of in
(name of facility) -
(address of facility)
stgna re of permit applicant
date
debrisa If,J,X
CITY Of: Sm.Em5 ilyLiSSACHUSETTS
13UMI)IING DEPART'.M&NT
41A
s 120 WASHNGTON STREET, au`FLOOR
TEL (978)7454595
F.Ax(978) 740-9846
KIJBERf EY DRSSCOLL THOhLAS ST.P[ERRE
,NMAYOR
DIRECTOR OF PUBLIC PROPERTY/BI:RDL`3G COMMISSIONER.
Workers' Compensation insurance AlMdavit: builders/Contractors/Electricians/Plumbers
Anolleant information Please Print Legibly
Naine{UusinusslOrgani:atio ulndividual): `�<< V AS ""` e il
Address: / )Ilille y-fe Sf /t'iat r917T(3
City/Sta(e/Zip:�z5,L,.'Aa , Phone M: %7)L—J-
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 4. 0 I am a general contractor and f
. 6. [1 Now construction
employees(full and/or part-time),* have hired the subcontractors
2.0 1 am a sole proprietor or partner- listed on the attached Acet.t 7• remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working.for me in any capacity. workers'comp:insurance. 9. 0 Building addition
[No workers'comp.insurance 5.0 We.area corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(No workers'cutup. c. 152,$1(41,and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' 13.0 Other,
camp.insurance required.).
•Any applicum that chocks box AI must at:w fill rue the section blow showing their waken'compeoi,rioa policy information.
r I h,meownon who,ubmil this afadavit indicating thry a,doing all workand then Ain outsidecontmcami most submit anew afttdavil indicting such
=Cunnnactora Thal chcsk this box mmt attxhod an additiuosl ah,wt showing Ilw name of subwvnuactan and their works,'comp.policy information.
fain en employer that/s pravfding workers'compensatlon insurance for my employees: Below/s the pollcy end fob site
injonnu!/am
insurance Company Name:
Poi icy U or Self=ins. Lic. d: Expiration Date:
Job Site Address: City/State/zip:
•%ttach a copy of the workers'compensatloo policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ot•YIOL c. 152 can lead to the imposition of criminal penalties of a
tine 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 to S25o.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Oflice of
Invesligatiuns ol'titc DNA for insurance coverage writication
l do hereby certfjy rue r the pants and penuldes of perjury that the hifurmatlon provided above is sue and correct
Da to: Z — /
r
icial use only. Oo not write in this area,to be completed by city or town offklaL
ty or Town: _._ Permiul.lcense# _
issuing Auiliority(circle one):
I. Board of health 2. Building Department J.Cilyffown Clerk J. Electrical inspector 5. Plumbing Inspector
6.Odler _
Contact Person: Phone li:
(