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530 LORING AVE - BUILDING INSPECTION (2) 36 c� 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 (Phis 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 addHess is not available) No.and Street City/Town iip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If N w Construction check here❑or check all that apply in the two rows below Existing Building Repair❑ 1 Alteration Addition❑ 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 ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brie Description of Propose ork: m ' �p o n r4't IV 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 Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as ap licable) A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business E: Educational F. Facto F-1❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ i-4❑ M. Mercantile❑ R: Residential R-10 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 ❑ UB ❑ IHA ❑ II1B13 1 IV ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Suppir. Flood Zone Information: / Sewage Disposal: Trench Permit. Debris Removal: Public( Check if outside Flood Zone 6 Indicate municipal A trench not be Licensed Disposal Si required 8or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ 1b i` a, —l�.Jw t/r�� Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable e Is Structure within airport ap roach 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: /7P& 7Z) &1'11 2 � T�1 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner 'T)A'V i1'72 k4T7 S-:�O L0621,��,9"F-rr Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Z9 Title Tele hone No. Telephone No.p It" s, ) p ( L— 1�c� email address If applicable,the property owner hereby authorizes G LL // --��4$� vas' t.�^— 1/n .4u �Y //iiI silt 14AA0 _Z"S/ / " O/9-? j Name Street Address C /Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) ' If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1) '- 10.1 Registered Professional Responsible for Construction Control " Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor - - T,� Company Name fs 1, Name of Person Responsible for Constructi99 d Type if Applicable z7 f wih,Dr Lit Streetp !9A Address City/Town // State Zip 6( 7 oay 4. _L� Z/C CD//S26f!!e /O/l I& GO�Ys�G SY'K2T Telephone No.(business) Telephone No. cell V e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT MG.L.c.152.§25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Acciden "must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the' suance of the building permit. Is a signed Affidavit submitted with this application? Yes No O SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ 9--; Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ 3D 8" ,j (contact municipality)and write check number here a 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 accurate to the best kn wled a and understanding.(Tos / Please print and sign name tle Telephone No. Date �� /fJi�_sdr �ocnc /o os :� /� .� d/98 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: .. Name ° Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block# and Lot# for locations for which a street address is not available) No. and Street City/Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark"x"where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Welland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 EnerKv Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material&liti ation Documentation 20 Other(Specify) 21 Other(Specify) ' 22 Other(Specify) *Areas of Design of Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State ZipDiscipline Expiration Date 1�t Massachusetts -Department of Public Safety Board of'Building Regulations and Standards Construction Supervisor License: CS-094090 All Ll p JOSHUA J KOLB" 24 WINSOR LANE TOPSFIELDMA,01913 �..�.+ �-"Moz..M ss Expiration _ Commissioner 05/17/2016 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 152306 Af i 4 .... Type: DBA Expiration: 8/16/2014 Tr# 229906 JK CONSTRUCTION c -I JOSHUA KOLINSKY 24 WINSOR LANE — TOPSFIELD, MA 01983 r C e - Update Address and return card. Mark reason for change. Address 0 Renewal D Employment Lost Card SCA 1 0 20M-05/11 .; �/��ouu�/o�,rl//o�^�///.u/��•/rra�//� License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: F .. a "}TOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation egistration: 152306 Type: I0 Park Plaza-Suite 5170 --:>Expiration: 8/16/2014 DBA Boston,MA 02116 JK CONSTRUCTION _ , JOSHUA KOLINSKY 24 WINSOR LANE /Not TOPSFIELD, MA 01983 Undersecretary vali without signatu The Commonwealth of Massachusetts M rY Department of Public Safety nt x Massachusetts State Building Code(780 CMR) ss`, gc, Building Permit Application to Construct,Repair,Renovate or Demolish any Building other than a One-or Two-Family Dwelling Code and Other Requirements for Building Permits The Department of Public Safety has issued these building permit application forms so that municipalities across the state can move toward use of a single permit form and consistent permit application process. The MA State Building Code specifies the requirements of building permits and the applicant is advised to review and be familiar with these requirements in order to avoid some of the common permit application problems.Likewise the applicant should be aware that some municipalities require that the owner confirm, even prior to acceptance of the building permit application,that no outstanding property taxes,water fees, etc.exist. Filing Instructions 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be reviewed if construction documents, specifications, fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a check for the Building Permit fee. The fee may be calculated using the information to be supplied in section 12 of the Building Permit Application. The check is to be made payable to the local city or town where the work will be done.