3 NORTON TER - BUILDING INSPECTION a 1
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The Commonwealth of Massachusetts
Department of Public Safety 1QIq SEP
ul hIaS5delMSCRS State Building Code(780CNIR) 24 53'
Building Permit Application for any Building other than a One-or Two-Family Dwelling.,
(This Section or Official Use Onl )
Building Permit Number: Date Applied: Building Official: _
SECTION 1:LOCATION(Please indicate Block 11 and Lot M for locations for which a street address is not available)
3 Dy R f9/ 7fJ O <j
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK - -
Edition of NIA State Code used If New Construction check here❑or check all that apply I inthe two rows below
Existing Building O Repair Alteration ❑ Addition❑ Demolition O (Please fill qut and submit Appendix I)
❑ eci
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Change of Use ❑ Change of Occupancy Other ❑ S ,
,s
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑
Is an IndependentStructtiral Engineering Pej�Review required? // _ f Yes ❑ No Brief Description of Proposed Work: /'rS/� /rb� 4,Q�/°�PJtil t&I-/-
OF
SECTION 3:COMPLETE TFIIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANCE 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.) -Total Area Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑
F: Facto F•l O F2 Ei Educational ❑
❑ H: Hi h liuud H=l❑ H-2❑ H-3 ❑ H-#❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1 R-2❑ R-3❑ R-4❑
S: Storage S-t❑ S-2❑ U: Utility❑ Special Use❑and p ease describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ 111) ❑ IIfA ❑ f11B ❑ I IV ❑ VA O VB ❑
SECTION 7:SITE INFORNI TION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public P. Check if outside Flood Zone❑ hidicate municipal A trench will not be Licensed Disposal Site
Private O or indentify Zone: or nn site system required ❑or trench or specify:
- permit is enclosed❑
Railroad right-of-way:WJY7 I1"ards to Air Navigation: \I4 I list rn C millmi'o Il.�i•w I'r.c":
Not Appliaiblet. Is Structure within airport approach area? Is their review completed? —
or Consent to Build enclosed❑ Yes❑ or No R Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per IToor:
Dues the builJiny,Contain an Sprinkler Systeni?;__ Special Stipulations:
I t
SECTION 9t PROPERTY OWNER AUTHORIZATION
Name and Addnssvf-Pro erty Owner
01106
Name(Print) CC No.and Street City/Town Zip
Prolyert O1vr r�'r Coh[ac�ilnune4ion: pi f
5Yorl de. `1L mlr— 97�._/T r_ '14 V _ _ W ,O
Title Telephone No.(business) Telephone No. (cell) Mail address
If applicable, the property owner hereby authorizes I —
1 o G'rcle I1)0IC¢51PS 0�603
Name StreJt Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and or not under Construction Control thencheck here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
Com . y Name - 05--1e915VI 3
W-MAw 57294S1E421c
Nam f Person Responsible for Construction License No. and Type if Applicable
! "G;P9CiRe-Z o&r �SrGR ff# Oleo&
Street Address - - City/Town - State Zip r
_7� 353 Ste' ue r � .0
Telephone No. business Telephone No. cell - e-mail address
SECTION 11:MRKERS'COAIPENSn I10N INSURA:NCI MFIDAVfi 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 O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) - Total Construction Cost(from Item 6)_$ &'o
r
1. Budding S - Building Permit Fee-Total Construction Cost x�f ` (Insert here
2.Electrical "� appropriate municipal factor)=$ 9 R. n0
3, Plumbing 5.
d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ C Enclose check payable to
6.Total Cost 3 2(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 besl of my knowledge and understanding.
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x Plea, runt a d sign name Title Telephone No. Date
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Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
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Department of Housing&Communilevelopment 27CE4 M
AA=relEngineering Services Unit SALEN,51AG1970
10O Cambridge Street-Bosto,,NIA 02114 TVI-617 5731169 r.M 617 573-1315
AlTel:6175731159 Fm:6175731335 AUGUw13,2014
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