71 PALMER ST - BUILDING INSPECTION (2) The Commonwealth o assachuset#s
DepartmentStateB riding �safet IA P ''- g2
Massachusetts State Building Ebb*CIA)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
1 (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)
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No.and Street City/Town Zip Code Name o uilding(if applicable)
(I� 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❑ Aitemtion ❑ I Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ I Other ❑ Specify:
Are building plans and/or construction docmnents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engmeerin Peer Review re aired. Yes ❑ No ❑
Brief Descri Lion of P oposed Wurk: or r29
IrInA 5
IYI
W114
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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): 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.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ -
F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ 1-3❑ 14 Cl M: Mercantile❑ R: Residential R-113 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)
[A 17 IB ❑ 7 IIA ❑ IIB ❑ IIIA ❑ I1I1113 IV ❑ 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:
A trench will not be Licensed Disposal Site Cl
❑ Check if outside Flood Zone❑ Indicateos municipal ❑ required❑or trench or specify:
Private❑ or inden[ity Zone: or on site system❑ permit is enclosed ❑
Railroad right-of-way: hazards to Air Navigation: :mi\I_i t.,is Coumu,sion IA♦u � I [yir5ti:
_- ......- -_-_ _.....
Nut Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Y's❑ 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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Propert.�Owner
Ld G
Name(Print) ii No.and Street City/Town Zip
Property Owner Confac't I'formatio: "'
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 budding permit application.
SECTION.10:CONSTRUCTION CONTROL(Please fill ouf Appendix 2)
If buddingis less thin 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip 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
All Plo F1ecinc-
Company Name
Name of P leik Construction License No. and Type if Applicable
Street Address i /Town_ .. - State lip, >>, - . .
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Telephone No, business Telephone No. cell a-mail address
SECTION 11:F1'ORKER.S'CONVENSA'I101N INSURANCE AFF'IUAVI'1 M.C.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 12:.CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Budding $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $
iEnclose check payable to
6.Totil Cost $ (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.
Please print and sigt name Title - ' Telephone No. Date
Street Address City/Town State Zip II
Municipal Inspector to fill out this section upon application approval: /uj(., ✓ /3
Name Date