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24 NORMAN ST - BUILDING INSPECTION (2) �a ► ,� r g r ©© REC�IVE_D .`77 - GK 23c7 Srovinac The Commonwealth of Massachusetts M1, 1{,., Department of Public Safety 014 NOV 31 A 11: 54 C yV, p ► -i r:l Massachusetts State Building Code(780 CMIR) Building Permit Application for any Building other than a One-or Two-Family Dwelling .(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 address is not available) rt 071-/ NUMA-i Ci •'M OIT2 f, -0?y d f.,Iy q-J ( a-ula ils)- . �) No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK I Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below ^� Existing Building Repai Alteration ❑ i Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix t) Change of Use ❑ 1 change of Occupancy ❑ 1 Other ❑ Specify: Z.SOO SC1 T QfV Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No`.W !_ Is an Independent Structural Engineering Peer Review required? Yes ❑ No* Brief Description of Proposed Work:_2QMAJX CJb l- in/ r2orvT CE {7 S c dN d F knoi 0/ / zjwJv lgTid'N 4! NF£D q�vv> rti� . r? �S r rtr .,U • no4r 4� SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE W USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 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.) Y Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-I Cl A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ ft: High Hazard Ff-1 ❑ H-2❑ H-3 ❑ Ff--I❑ H-5❑ 1: Institutional I-1❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4$( ❑ Special Use O and please describe below: S: Storage Sl ❑ S-2❑ U: Utility Special Use: SECTION b:CONSTRUCrION TYPE(Check as a licable) IA ❑ IB ❑ 1[A ❑ IIB ❑ ITIA ❑ 111613 IV ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required❑or trench or specify: 9U/Jdn/ Private❑ or indentify Zone: or on site system❑ permit is enclosed ❑ 724 6C�i-+ed 7'4A,%d< Railroad right-of-way: hazards to Air Navigation: I I Ii t ri,(.' ....n"'i "la,w ,, I n•yr.q Not Applicable O Is Structure within airport approacln area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ 1 Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): type of Construction: . Occupant Load per Floor: Does the building contain an Sprinkler System?: ._ Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZAF10^t i Name and Add'rbss•of Property..Own er ;it 1 -i0/z Name(Print) No.and Street City/Town , Property Owne/. r r Contact fnfornidtion:-a Title Telephone No.(business) Telephone No. (cell) a-mail address If applicable,the property owner hereby authorizes Qrycr Tt'n I.,� �b ar�t0"1 a s. Q�S), 4 �_ ulYso Name Street Address City/Town State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.It of enclosed space and or not under Constmction Control then check hen O and skipSection 10.1 10.2 General Contractor --- /09(.(Su-Y P,Ca i"3v i Company Name q'i-,c-z T;2 k-k -a-1 Zl�'� 4;ct�57 Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip 7!f 47)—YPOC, Q7�-$!S h 3 -- s ram/ 7 r g(/� G ✓fir 1. (d Telephone No. business Telephone No. cell e-mail address SECTION 11:WURFEKS'CONIVFNSAI'ION INSURA!NCti AI I'IUAVfI' 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 ❑ SECTION IZ 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 $ d. Mechanical (PIVAC) 5 Note: Mininum fee=$ (contact municipality) 5. Mechanical Other $ Gp Enclose duck payable to 6.Total Cost 5 O l G (contact municipality) and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under tl pains and penalties of perjury that all of the information contained in this rp lication is true and accurate to the b� of i (ow4edyze and understanding. /N Please print and sign name Title Telephone No. Date Street r\d Tress Cil /Tu,yyn tate Zi 3 ,yf ] tom v4X q36, Municipal Inspector to fill out this section upon application approval: Name Date