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To be submitted at completion of construction>py ��� ; ' �d?), �
Registered Design Professional
for work per the ninth edition of the -DING DEPARTMENT
Massachusetts State Building Code, 780 CMR, Section 107
Project Title:So bt r Date: 1S1' ermit No. g o -d0 ' Q0 3o7 9
Property Address: IS preA,06 Wiwi/ 1 14/.Hw M u�y►,•
Project: Check(x) one or both as applicable: New construction Exi�sti_ng Construction
Project description: Q00 f Mo e' o\or
I MA Registration Number:O1 ixpiration date: `,- dam a registered design professional,and I have
prepared or directly supervised the preparation of all design plans,computations and specifications concerning:
Architectural Structural Mechanical
Fire Protection Electrical Other:Describe
for the above named project. I, or my designee,have performed the necessary professional services and was
present at the construction site on a regular and periodic basis. To the best of my knowledge,information, and
belief the work proceeded in accordance with the requirements of 780 CMR and the design documents approved
as part of the building permit and that I or my designee:
1. Have reviewed,for conformance to this code and the design concept,shop drawings,samples and other
submittals by the contractor in accordance with the requirements of the construction documents.
2. Have performed the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Have been present at intervals appropriate to the stage of construction to become generally familiar with
the progress and quality of the work and to determine if the work was performed in a manner consistent
with the construction documents and this code.
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
Enter in the space to the right a"wet" or electronic signature and seal: J 4 S d o C taot5
Phone number:1)If(ayy 7 t"t Email: e a So�C,r.Lp e -so\rtocco d•Cd,
Building Official Use Only
Building Official Name: Permit No.: Date:
Version Ol O1 2018