MAP 46 LOT 127 - BUILDING INSPECTION The Commonwealth of Massachusetts
�} � Department of Public Safety
Massachusetts State Building Code(780 CMR)
,a�
Building Permit Application for any Building other than aOne-or Two-41y: ing
(This 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 addres is"t available)
2 rhLWA
No.and Street City/Town. Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK
Edition of MA State Code used f e&Y21� If New Construction check here O or check all that apply in the two rows below
Existing Building jE7 I Repair I Alteration ❑ 1 Addition❑ Demolition 0 (Please fill out and submit Appenc(ix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: t� S r'B'i.25 51EQilc, ;o tu,,,. .,
Are building plans and/or construction documents being supplied as part of this permit application? Yes O No 21
Is an Independent Structural Engineering eer{teview required? ( Yes ❑ / No III
Brief Descr'ptionpf Proposed Work: 01 00 ._ (Ate Ma tU
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.) -y 0 4 Q,q;'
Total Area (sq.ft.)and Total Height(ft.) J�j= � 4 7C✓�i_
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1.)l A-2❑ Nightclub ❑ A-3 ❑ A40 A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ 11-4 O 11-5❑
1: Institutional f-1 O I-2❑ 1-3❑ 1-4❑ M: Mercantile O R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S.1 ❑ S-2❑ U: Utility❑ Special Use O and please lescribe below:
Special Use R4 c;-':'1 c„'ail
> ir, � D(Y-r �,i _ tt; ic; cy2'541711
SECTI N 6:CONSTRUCTION TYPE(Check as a livable)
IA IB ❑ IIA ❑ IIB ❑ HIA ❑ IIIB ❑ IV ❑ 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:
Public❑ Check if outside Flood Zone 9k• Indicate municipal❑ A trench will not be Licensed Dis os I Site 5
Private(2 or indentify Zone: or on site system �l required®or trench or specify: 0 S'
permit is enclosed.❑ 1 w
Railroad right-of-way: Hazards to Air Navigation: NIA I lists rr<t`...r�m tc„µ[t„pl
Not Applicable4Z Is Structure within.airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No III Yes O No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): ` Type of Construction: Q Occupant Load per Floor:
Does the building contain an Sprinkler System?:A ISl/g_Special Stipulations: _ _
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address Qf Proper ty Owner
Name(Print) No.9nd Street City/Town Zip
Property Owner Contact Inform lion: /�
1� r t"gam +'fir 2 �ttl_ y-y
Title Telephone No. (bus}�ess) Teleph (cell) at)address
If appli//c�aable,the �erty owner hereby,authorizes J� •L�Y2.7
i:� 'D��M,4
Name Stree 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)
[f building is less than 35,000 cu.ft of enclosed space and/or not under Construction Control then check here Wand skip Section 10.1)
10.1 Registered-P-rro^fessional Responsible for Construction Control
< C f �tl c 7 L-p- g7 9 9 _ at �VU Tt 6 7 11 / J
Name Re ant) � �'epj� e N eo. e-mail ad re Re tration Number
l.Cc YL- —C l3 L —
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
NrynQ,
Company Name r
an-T / l� f s c,�- x 90 HIC iy1W3
Name of Person Responsible for Construction License No. and Type if Applicable
t 11
Street Address 0 0 City/Town �, State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:kyURKFRS'CQUWIFNSATION INSURANCE AFFIDAVIT M.G.L.c.151§ 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 IA No O
SECTION32•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
d Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x (insert here
2. Electrical $ appropriate municipal factor)_$—fl--.
3.Plumbing $
Note:Minimum fee=$ J~ (contact municipality)
4.Mechanical (HVAC) $ / �( ' /
5. Mechanical Other $ Enclose check pay t 6 C,1 4�c Vels _
6.Total Cost $ (contact municipality)and write check number here IN 4 9
SECTION 11 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 besnofnow ge and unde din
Sy'�.rV SIh^
_1y i?
Please print and s��i�}}name p� Tithe Telephone No. Date
Street Address u City/Town 7- State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
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 I Inc om lete Not Required
1 Architectural .�
2 1 Foundation
3 1 Structural
4 Fire Suppression
S Fire Alarm may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections X
9 Gas Natural,Propane,Medical or other X
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Budding Survey/Investigation
16 Ener •Conservation Report
17 Architectural Access Review 521 CMR
is Workers Compensation Insurance /t7
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other S ecif
'Areas of Design or Construction for which plans are not complete at the time of applications bmittal must he 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 l7�
iylc 1497'-,2 etc r
Name(Registrant) Tele�ho�n+e o. e-mail address Registration Number
UQ �& � o a! J z 2
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
Discipline Expiration Date
Street Address City/Town State Zip
CITY OF SmEm, 11LAssAcHusms
SULDINo DerAMENr
t3o w.ummm misr.r PLoote
TZL PM 74S.9599
FAX M4 740 W
KIMBERI.EY DR15COiL
MAYOR THOM"Sr.Ptam
Omact oa of Ft."> x mopeltry/aLl Ot>'to coamO wNn
Construction Debris Disposal Affidavit
(required for all demolitim and renovation work)
In accordance with the sixth edition of the State Binding Code,790 CUR section 111.5
bbris,and the provisions of MGL c 40,S 54;
Building Permit# is issued with the condition that the debris tesalting fim
p this work shall be disposed of in a oporiy lid waetie disposal facility m defined by MGL c
111,S 150A.
The debris will be transported by
Vd�u In}1.e,�
(as=of twular)
The debris will be disposed of In :
MdlosITIIWA� 0
(now of hciuty)
,. h MA
(add"of fac yt))
pit ap H=W
14 ' aolz
�m,r�
CITY OF S.0 EtiI, NLAsSACHUSETI'S
BUILDING DEPARTMENT
p• 120 W.ASHINGTON STREET,3'FLOOR
f TEL. (978) 745-9595
FAX(978) 740.9846
KI.\[BERLEY DRISCOLL
MAYORTHOMAS St.PIERRS
DIRECTOR OF PCBLIC PROPERTY/BUUMLNG COMMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians]Plumbers
A t licant Information / v' 7 PI as Print Legibly
Name (Busitxs..orga7nizzattiomndivvidual): jt �Jt rJ/tx ,J/ i � i14 --g/' , g4 ^ P4
Address: k� Tt3�rY11� 41lfrt3 � 1. /
City/State/Zip: oa . MA 0 RIS Phone #: �T�'2- 2 -` , fY
Are you an employer?Check the appropriate box: Type of project(required):
1.0 i am a employer with 4. 0 1 am a general contractor and I
employees(full and/or part-time).' have hired the sub-contractors
6. New construction
2.❑ 1 am a sole proprietor or paMcr•
listed on the attached sheet.: 7. PC Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity, workers' comp,insurance. 9, 0 Building addition
[No workers' comp. insurance 5. Pq We are a corporation and its
required.) officers have exercised their I0.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL i LEI Plumbing repairs or additions
myself. [No workers' comp. e. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers'
comp. insurance required.) 13.❑Other
'Any applicant this checks box tit must also fill inn the section below showing(heir worhps'compnnraawtpolicy information.
'l l,wenwneas who subnit this affidavit indicating they arc doing ail work and it.hire outside contractors mist submit a rxw affidavit inhering such.
=Contractors ukot check this box must attached an additional sheet showing it.narne of the seb-coranictom and their vrutlters'romp,polity infatmarion.
I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and fob site
injormadon.
Insurance Company Name:
Policy 4 or Self-ins. Lic. #:_ Expiration Date:
Job Site Address: City/State/Zip:
,%ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S150.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of die DIA for insurance coverage verification.
I rlo hereby cerrij under a pains and penallks ojperfury that the information provided above is true said correct
Siena ire
0 scial use only. Do nor write in this urea,to be completed by city or town offu'iat
City or'ruwn: Permit/Urense
Issuing Authority(circle one):
1. Board of Health 2. building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.0ther
Contact Perstm: _.,__ .,_.__,.__ Phone#: