11 MOUNT VERNON ST - BUILDING INSPECTION . y
The Commonwealth of Massachusetts ."I 1UNAL
The
o '7 p�l [ Department of Public Safety 181� APR Massachusetts State Building Code(780 CMR) 'IRIS A b- 3 b `
Building Permit Application for any Building other than a One-or Two- a ily D el ' g
is Section For Official Use Only)
Building Permit Number Date Applied %' _ •`°` ' Building Offi¢iaF "'
"- SECTION 1:LOCATION(Please indicate Block'#and Lot#for locations for which street address is not available) s,+
li k-k. '�,E 3W- 7n\2M CAC'7n
No.and Street City/Town Zip Code Name of Building(if applicable)
FIN. '} ......;,:_` °. .. ': SECTION2: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❑ Alteration ❑ Addition❑ 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 ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No CC
Brief Description of Proposed Work:
t
SECTION3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION OR
---CHANGE IN USE OR OCCUPANCY NOT Pi-R2 G LF '
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
2 , j�0 SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) a
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable) - `'•"_
A: AssemblyA-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Factory F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Ins * tional 1-1 ❑ I-2❑ I-3❑ 1-4❑ 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 ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
.:. SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) . . '` E
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
r A trench will not be Licensed Disposal Site 91
Public�( Check if outside Flood Zone 0Indicate municipal J8( required'®or trench or specify:Sme,
Private❑ or indentify Zone: or on site system❑
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable IK Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No X 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:
11
sly
-<: - SECTION 9:'PROPERTY OWNER AUTHORIZATION ,`
.Name and Address of Property Owner
('ncP.l IU. COr \\ MF .rP,.-.n.V� 1 �r_l�cv. pIQZO
Name(Print_ No.and Street City/Town zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail ac dress
If applicable,the property owner hereby authorizes
G k At Gnc�i 50 /yi\\
Name Street Address City/TovVn 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
mot:• �. If building is less than 35,000 cu.ft.,of e e a enclosed s acnd/or not under Construction Control then check here O and ski 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 =' :E _•
-�� A
Company Name G
Name of P rson Responsible for Construction License No. and Type if Applicable
2 � 01 $
Street Address ; City wn State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSA'110N 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❑ No ❑
'AL .., -, ' i,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 $ O _ appropriate municipal factor)_$
3.Plumbing $ _7
4.Mechanical (HVAC) $ Q1 A Note:Minimum fee=$_ (contact m ci ali�ty)
5.Mechanical (Other) $ N/A Enclose check payable to
6.Total Cost $
3 4 50 .CO (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BL3ILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains a d penalties of perjury that all of the information contained in this
ap 'cation is true and acc rate a best knowI dg a d understanding.
y/may
Please pr t and sign name Title Telephone No. Date
`mil Mal Rra 1 &M _fig
Street Address City/ wn 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'Y'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,Propane,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/Investi ation
16 Energy Conservation Report
17 Architectural Access Review 521 CMR
18 Workers Compensation 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
Q IV' I515o6
N e(Registrant) Telephone No. e-mail address Registration Number
1c)\ Ln�;nn i� [' SI Sexurn Mfg \a7r: LIiecx"c'
Street Address City/Town State Zip Discipline Expiration Date
CSC L_vw\l Z6,55
Name(Registrant- Telephone No. e-mail address Registration Number
1Q fix cnicc�nna , Qd 'S a LOr, P4,[A G-7
Street Address City/Town State Z] Disciplm xpiration Date
Name(Registrant) Telephone No. e-mail address
Registration Number
Street Address City/Town
/Town State Zi
Discipline Expiration Date
(�J Massachusetts_pe
wr_J Board of Building
Re artment of Pubiic Safety
unstructio„Su 9n is(j. s and Standards
Lice 7786 or
License: C5,0778g5
OYJ
G �BEiEN
so MILLltoo
'QvGSTO A r
_ cOtnn1,551p,iBr 14t:1
Expiration
s 04(28f2014
Unrestricted-Buildin
contain less gs of any use group whth ch
than 35,000 cubic feet(991 p of
enclosed space )
Failure to Possess a current edition of the Massachusetts
State Building code is cause for revocation of this license.
For DPS licensing information visit: www,Man.Gov/DPS
I
CITY OF S�UZNf, >tiL1SS:ICHUSETTS
8L'ILDLIIG DEP:IR'M&NT
130 WASHNGTON STREET, 31O FLOOR
°.' TEL (978) 745-9595
F.ALX(978) 740-9846
Kl\IBF.RL.EY DttISCOII.
NL4Yoa THom SST.PIERM
D(.QECTOR OF PUBLIC PROP ERTY/BCILDLNG CON
pI(gStONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section t 11.5
Debris, cuid die provisions of N101. c 40, S 54;'
Building Permit Jt is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by ,MGL c
111, S 150A.
The debris will be transported by:
y
(name of Ulu)
The debris will be disposed of in
(nameoFfacility)
Oddres.t of facility)
n
signature of permit app6ca tt "—
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