33 MASON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
O ® Department of Public Safety
I Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Tw Fa r w rn
. _ ('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 addr rs not available)-
33 HA5orl 6 Sale M oIF70 MA fi al k LA-M
No.and Street City/Town Zip Code Name of Budding(if applicable)
SECTION 2:PROPOSED WORK =
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out nd submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other Specify: 4/
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peal Review required? s J/A_ Yes ❑ Nox
Brief Descri lion o f Propos ed Work: RG OILtLfcN�. 0I'1 t✓ L✓tKKA�✓ �17
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.-. - n
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 applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ 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 ❑ IIB O IIIA ❑ IIIB ❑ IV ❑ 1 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❑ Indicate municipal❑
A trench will not be 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: o MA Historic Commission 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:
o2b press +
3&.,,-:�SECTION 9:.PROPERTY.OWNER AUTHORIZATION
Name and Address f Pr pe O ne�r/'_ °
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name . Street 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.
: s SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) .,."..
If buildingis less than 35 m cu.$.of enclosed s ace and/or not under Construction Control then check here❑and ski Section 10.1 :
10.1 Registered Professional Responsible for Construction Control ` z •%r '" '' '
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor ...
CompanyVQ11 Do-Viso 1 ✓� /O( g!( � _ O/�//C;2—
Name of Person Responsible for Construction License No. and Type if Ap usable
Street Address tty/Town State Zip
_ 61'7 Z7 3a70
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c 152.§25C 6 '
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
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 O. 0 (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.
9Y�1 Igo rMS O r Sa(e 5�re 3 �,0�176
Please print and sign name Title Telephone o. Date
33 rlasoN sf. 5a+-ler� yL4: s�1f�
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
,. Name ''' >s.- Date
I
A e
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,Pro ane,Medical or other
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 Building Survey/Investigation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Com ensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
21 Other(Specify)
22 Other(Specify)
*Areas of Design or 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
Discipline Expiration Date
Street Address City/Town State Zi
e