24 LYNDE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
7. t Department of Public Safety
\IassarhusrUs State l4uildini;Qnle(7811 C\IR)
Building Permit Application for any Building other than aOne-or Two-Family Dwelling
(Phis Section For Official Use Only)
13uildinl,,I'crntit Number: _ Dale Applied:/
SECTION 1:LOCAL 10N (I'lease indicate Block M and Lot N for locations for which a street adqFtIrs is not availab e
V( I I I It k t rVkqj City/gown Lip Code .Name of Building(if applicable)..---
SECTION 2:PROPOSED WORK
Edition of \f:\Slate Code used_ _ If New Construction check here❑or check all that apply in the Iwo rows below _
Existing Building❑ Repair Alteration ❑ Addition❑ Demolition ❑ (please fill out and submit Appendix 1)
Change If Use ❑ Change(if Occupancy ❑ Other ❑ Specify:--_ ------ ---
Are building plans and/or const r»c Lion dtx'u men is 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:.
SECTION 3:CONIPLETE'ritis SfL�CTION 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 CNIR.3a) ❑
Existing Use Group(s): -- Proposed Use Gruup(s): --"
SECTION 4:BUILDING MIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)dr 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 ❑ A4❑ A-3❑ 1 B: Business ❑ E: Educational ❑
F: Factory F-I ❑ F2❑ Ili h Huard H-1 ❑ 1-1-20 11-3 ❑ 11-4❑ 11-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ hl: �Ylercantilc❑ R: Residential R-I❑ R-2❑ R,3❑ R-1❑
S: Storage S-1 ❑ < S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONS'rRuc TION [WE(Check as applicable)
IA ❑ 190 1IA ❑ IIB ❑ 1IIIA ❑ 1111313 1 IV 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 7NB CbIR 1111.0 fur details on each item)
Water Supply: flood Zone-Information: Sewage Disposal: 1'rench Permit: Debris Removal:
Public❑ Check if outside Hood 4nx•❑ Indicate nuwicipal ❑
.\ Irn'101 trill nut be Licensed Disposal Site Cl
--
Privaty❑ or indentily Lune: or on site system ❑ n•quire -_.. .. ..
prnnil i d❑or trench or.pecifv:
s encluscJ❑ _
Railroad right-of-way: Ilizards to Air Navigation: 'd t i ..i,,.,
Not \pplic,ible❑ Is Stntchue within airport opproec h.vea' Is Ihcir rev irw nnnpleted'
Of C nms'ul to Build rnclost'd ❑ 1 cs❑ or No❑ I Yes❑ Nu Cl
SECTION Y:CON I FN ['OF ClAt I IFICA'I IT OP OCCUPANCY
If down of Code: __ ... Lse Graup(s): - - _- Is pool Cnn.truc»on: 0,,upanl toed per l loor.
Dnes lhr building,wmaitl,m Sprinkler 5v.lom': tipec i.11 Stipulation+: "
STC'I'ION 9: PROPERTY OWNER AU'HIORIZAIION
:\tune and Address ut Property Owner
Nome(Print) No.and Street City/Town Zip
Property Owner Contact Information:
I isle Telephone No.(business) Telephone No. (cell) a-mail address If applicable, the properly owner hereby authorizes
-_- ---Name - -----Street Address _— -City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorizrd b• this building, permit a t plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
1f building is less than 15,1)IN1 cu.0.of enclosed space and or not under Construction Control then check here O and skit Section 10.1
10.1 Registered Professional Responsible for Construction Control
>Q � � qT%.3 W-201 - EYnIC fYec,c 88 �3Z C S
Nance(Registrant � Telephone No. rfkt&{(IrlsPC Registration Number
S(s�er D $AVERNILL � m/R3o _ -92^201
Sheet Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Nome
Nance of Person Responsible for Construction License No. and Type if Applicable
Sheet Address City/Town State Zip
Tcle,hone No. business Telephone No. cell e-mail address - --
SECTION 11:\ct v t i.l _' (Will i It, I�-In:.\\l.�I v 111 .\vl I M.G.C.c.152 25C 6
A Workers'Compensation Insurance Affidavit from the AfA Department of Industrial Accidents must be completed and
submitted with this application. Failure h)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
'Ind Materials) Total Construction Cost(from Item 6)=S_
I. Building S Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical 5 appropriate municipal factor)=5
I TIU nbing 5
J:.\IeChaniral (HV:1C) S Note: Minimum fee=5 _(Contact nu llicipality)
3. ,Mcchanical Other S
Enclose check payable to
h. rotal Cost 5 ljrCV.ed (Contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Ify catering un'name below, I hereby altC•.st under Ili•p tin s,m I pcn,dties of perjury that all of the information contained in this
application is true and accurate to the best U -.Ica};e and understanding.
19e,lse print and si};u name IvIcphone No. ate
titrcet .\ddrn'ss cll.N town �f State /ip / JI
Municipal Inspector to fill out this section upon application approval: _ 4,�W - _1Ov�o /
. Name Itoto
CITY OF S:1I E.�I, AxsSACHUSETTS
13UItDING DEPAIUMENT
120 WASNCdGTON STREET, 3aa FLOOR
TFL 978 745-9595
FAX(978) 7404846
ICI\tBERS.EY DRISCOLL
NVLAYOR THo.%w ST.PI>_axa
DIRECTOR OF PUBLIC PROPERTY/Bun.DmG CO',MISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractorv/Electricians/Plumbers
ALIlI_(cant Information / v / D Please Print Legibly
V;ImCIBusitxssOrOaniratiunln.lividua /T��l): rE (����(-
Address: 1/CN <)rS _ 0� 111AllE�Hxl
City/State/Zip: ffAVELPIA1 G /1* Q1&3,V PhoneN: q��"�
Are you in employer?Check the appropriate_box: Type of project(required): -
1.❑ 1 am a employer with 4. ® I ;un a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8, [] Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition
[No workers'comp.insurance 5• ❑ We are a corporation and its
required.] officer have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'cump. . c. 152,§IM,and we have no 12.❑ Roof repairs
insurance required.)t employees. [No workers' 13 ❑ Other
comp,insurance required.]
Any applit.ain dw chwks box At must at* fill out the seciiuo bulowshuwing their workea'compen of policy Wit rm Ilion,
'I Lvnvownsons who uhnnit INS Affidavit indicating they am doing all work and then hire outside contractors noon$11hmit a new aatdavit;ndiainy such=tlmlm.I00 that Owls this box most vouched an.ulditional sheet showing the noire of the aub.unimton and their worker'wrap.policy infemution.
/mn an employer that is providing worker'compeoasmion insurance for my unployeez Below Is the poBry and fob site
information. rrr 1 rL 7
Insurance Company Name: 1_r Rr44_N1(�7L/ / ,(
Policy U or Srlf--ins. Lic. tl:(Al
_ ip 7 C`07 1piralion Date:_
Job Site Address: City/State/Zip:
.Attach a copy of the worker' compensation policy declaration page(showing the policy number and expiration date).
Failuru to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 11,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S25000 a day against the violator. Ile advised that a copy of this statement may be fur-warded to the Oftica of
I"veil i gatiuns of ilie DIA for insurance coverage vcrilieation.
/do Hereby c i y r der dte pales mod peoullies of perjury rout the infurutution provided obuve,is true and correct
paid: IZ- 12- 2C1i
iD/Jiciul use only. Do not write in this area, to be completed by city or lawn ojjlcial
ICity or'ruwn:
—_ . __ PermitfT.lcense d i
Issuing Auuliurily(circle one): -- _— --- - i
1. Board(if Ilcalth 2. 13uilJinq Department
G. Other 1.Cilylrown Clerk 7. Electrical Inspector 5. Plumbing Inspector
. --- — -- --------- I ._
i Gmluct I'urv-nc _ _ Phone;h.
i
Information and Instructions,
.\lassachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
NIGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152,.§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. if an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Scif-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennidlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"ail locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Oftice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Rcv:icd 5-26-05
www.mass.gov/die
el -�
CITY OF 5,u-E•«, A1SS:ICHUSETTS
OULLDLNG DEP.IATTIENT
120 W.UHLNGTON STJW, )'O FZOOII
TV- (978) 743-9595
K13(3ER' Y DRLSCOLL FVt(978) 740.9846
MAYOR Nomu ST.FMiu
1)IRECTOItOPPLBUCP40PEtZY/131:MDCIGcosa ssio.%EI
Con9tructioa Debris Disposal Atfldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I
Debris, and the provisions of MGL c 40, S 54;
Building Permit q This work shall be is issued with the condition that the debris resulting from
1, S I SOA. disposed of in a properly licensed waste disposal facility as defined by b1GL c
11
The defbriis�will be transported by;
--/ L�t I
(name ul'houler)
The debris will be disposed of in
(++ me o—
(iddrm orracdny)
+�ynanue ormm+t Ipplumt
2- IZ�1