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14 MALL ST - BUILDING INSPECTION (7) 1-l- $ Z� S ESN T The Commonwealth of Massachusetts _ - Department of Public Safety Massachusetts State Building Code(780 CUR) Building Permit Application for any Building other than aOne-or Two-Family Dwel ing � (Phis Section For Official Use Only) Building Permit Number: Date Applied: Building Official: ll r,t SECTION 1:LOCATION(Plea a indicate Block#and Lot#for locations for which a street a dress If not available) tlI 7 7" N No.and Street City/Town Zip Code Name of Building(if applicabler}� SECTION 2 PROPOSED WORK m Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below In Existing Buildingg, Rpi,;N I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (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 0, (�^ Is an Independent Structural Engirt Peer Review required? Yes ❑ o CK �I Brie D pfi of Work CY`+ e T ,e h evt e N 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): I Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 3 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❑ 1 B: Business ❑ 1- Educational ❑ R Factory F-1❑ F2❑ I H: High Hazard H-1❑ H-2❑ H3 ❑ H4❑ H-5❑ L• Institutional I-1❑ I-2❑ I-3❑ I-4❑ 1 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 ❑ HA ❑ HB ❑ IHA ❑ HIB ❑ 1 W ❑ VA ❑ VB ❑ SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit. Debris Removal: A trench will not be Public.g- Check if outside Flood Zone Cl Indicate municipal� Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commissicm Review Process: Not Applicable❑ 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 Group(s): Type of Construction: - Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: R t ( Q-u , 1 ' l P.fa u LA, 0 — N CO N D o PrSSp L I SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner ly-lb�tx1154 COnc 9 IH.kc<<�S� �Gt�etM A O/9'70 Name(Print) No.and Street City/Town Zip Prrooperty Owner Contact Informa(tiio�n, -(,q j d, �A1J�. �1 LJS�c_f0 I-'I_ - Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the prop ty owner hereby authorizes �n l� � t'4 me-co $K Pe-&-AV SO Ultibrl e P A Name 1 SSeCUfr-eSStmet Address City/Town State Zip to act on the property owner's behalf,in all matters relative to work authorized by this buildtnpermit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) building is less than 35,000 ca.ft.of enclosed space and/or not under Construction Control then check here❑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 v coor-, Q" ' S C��om-f any Name Le — AZNCY 0IL Name of Person Responsible for Construction License o. and Type if Applicable Ti Po �� A�� SorJ�tlbt�J � , AA ois�6 Street Ad City/Town State Zip 7VJ 73 Z3 1 — �k�e"fa x lc'64Q i f - co wA Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDA VFf M.G.L.c.152.§25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents most 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 O No ❑ SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor O 6 and Materials) Total Construction Cost(from Item 6) 1.Building $ 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 $ 2,j y j G (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 application is true and accurate to the best of my knowledge and understanding. Please print and si e Title Telephone No. &te? N �� v� So(J}1tb1� eQCsre µ� ots� O Street Address City/Town State Zip 9 Municipal Inspector to fill out this section upon application approval: Name Date 1 - 16 � 3� M� � �� i CITY OF S.�ti�, UxSSACHLSETTS BultziNG DEPART M&NT t a• 120 WAsFuNbaTON STREET,r FLOOR �-0j T M (978) 745-9595 FAx ri a) 740-9846 KIJiBERI EY DRISCOLL T ,LIAYOR Hon%s ST.PtFM DIRECTOR OF PUBLIC PROPERTY/BU DL\G co%muSsIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �q a� Please Print Le ibl Name 18usimssOrWizatioow[ndividual): (; e VlL- Address: P) q t Ce C k A"V Ir— g'D CitylShatelZip: S bry 2 AolS Phone 0: Z71/ ?30Y031 Are you to employer?Check toe appropriate box: Type of project(required): 1.11 am a employer with 1 4. ❑ 1 am a general contractor and 1 6. ©New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet% 7. Remodeling ship and have no employees These sub-contractors have g. ❑ 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.) officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MOL I I.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' comp.insurance required.) 13.❑Other -Any applicant that clerks has rl must also fill not the section below showing their worker'compensation policy irarurntation. t I I.vnemvrcr,who submit this affidavit indicating they am doing all work and then hire outside contractors most submit a rrm affidavit indicating such. :Cunrracton that check this box mtet anaclxd an additional sheet showing the some of the sub.cenuucwas and their workers'comp,policy infotrwtion. I am an employer that is providing workers'compensation insurance for ray employees. Below is the policy and Job site information. �—{ �� /'VAS 1 Insurance Company Name:�'1l U I[/ Policy#or Self-ins.Lic.#:� q1 c51 Expiration Date-. Job Site Address: 14 /"\15 r S 1 eVVIL A� City/State/zip: Attach a copy of the workers'compensation policy declaration page(showing the polity number and expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigutimis of the DIA for insurance coverage verification. I do hereby certify ar der the pains and exalt! Jury that the information provided aboveu and correct 1 ' ai re: Date/ / � l Sl- ^- Phone#: �/ 7 Ly70 D)Ticial use only. Do not write in this urea,to be completed by city or town ofciaL City or Town. Permit/IScense#_....... ___. Issuing Authority(circle one): 1. Board of health 2.Building Department 3.City/fawn Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Office of CansuiuerARairs&'B sme68 Regolahon y. IV HOME IMPROVEMENT CONTRACTORSExpiration 8/2016� Qividus OUR .� ! GLEN LATOUR 84,PARK SOUTH BRIDGE M raa5E1/'� Ueders ,;:. Massachusetts Department of Public Safety .�� Board of Building Regulations and Standafds License: CS-081052 Construction Supervisor q, GLEN A LATOUR . j 84 PARK AVE SOUTHBRIDGE AAIF, Expiration: Commissioner 0812012017_ - OIL 5 her k oar S Zxg F�oor Joy �' I�O OC , Hx q F�7S rej TO r4 i S i n I bcg o V4,-V-F ou. I ILI AuD l.e& et- LOCkto Ce�n�ec p 0 5� an r5 © �l lVC ` n's The 14-16 Mall Street Condo Association has contracted Advanced Building Services for roof work as of October 30, 2015. «- Emma Wade, Trustee Date 14-16 Mall Street Condo Association r