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22 PARK ST - BUILDING INSPECTION �g � RECEIVEp The Commonwealth of Massachusetts Department of Public SafeV14 N�pp t� 1� Massachusetts State Building Code(780 CMI11 2 A µ} Building Permit Application for any Building other than ne-or Two amily D eIling ' — - (This Section For Official Use Onl ) Building Permit Nu Aber: Date Applied: Building Offici, SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street a dress is not available) No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here Cl or check all that apply in the two rows below Existing Building W"- Repair&( Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No M' Is an Independent Structural Engineering Peer Review required? Yes ❑ No 0' Brief Description of Proposed Work: 1nSte 11 ?1 e4a eV bF1E� i`c7. ri \Z 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 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-1 ❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ [-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: '• SECTION 6:CONSTRUCTION TYPE(Check as a plicable) IA ❑ IB ❑ - IIA ❑ IIB ❑ IIIA ❑ IHB ❑ 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: PP y A trench will not be Licensed Disposal Site❑ Public❑ Check if outside Flood Zone❑ Indicate municipal❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: \i�g _ ,\I,li lon l,ummn5irn1 •'u•w(rocys: 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 Cody. Use Group(s): Type of Construction: Occupant Loud per Floor: Does the building cuntainan Sprinkler System?: Special Stipulations: c�L.E� ; N1✓ w1�.� p(v Wes. h3 Pn- 101 T(Zw1 ci© o S bus SECTION 9: PROPERTY OWNER AUTHORIZATION O Q • Name and Address property,b vner l Name(Print) C M NS.and Street City/Town Zip y?1l 01, IKtGgeS Property Owner Contact Information: WM C�1 rR MPS• _ �(�F _ fi31_ Cd\^,1.�''> -_- Title Telephone No. (business) Telephone No. (cell) 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 bui[Llill&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 then check here 0 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 HC = Company ame NaG � CS _ 1 0 i Tye b me of�erson�Responsibl� or Construction License No. and Type if Applicable U( ft-PA c iti'7t, Street CAdddress City/Town State Zip �I4_Pii I- A6 iu —— 54C.!g F'Q.�u:,.�1 iof•S �'c-�.c+�l., C G Telephone No. business Telephone No. cell e-mail address SECTION 11:tV01aKE1<5'CON111FN:iAI'[ON INSURANCE APHt>AVtI M.G.L.c.152.5 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.Building $ Building Permit Fee=Total Construction Cost x (Insert here 2. Electrical $ appropriate municipal factor)=$ 3. Plumbing $ {. Mechanical (HVAC) $ Note:blininwm fee=$ (contact munJ'CypJli[yl 5. Mechanical Other a p�ri$ Enclose check payable to � L�/\ 6.Total 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 applica ' n is true and accurate to the best of my knowledge and understanding. A % 6� Pry 1 C,C 4�K ���7_ �16C Please EPriint and si�n name Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date { y i CITY OF s'ku ,I, ;tiL-1SSAGiUSETTS t ©I:ILDLNG DEP.IRIMNT 120 WASHLNGTOM STREET, 310 FLOOR �~ T EL (978) 745-9595 FAA(978) 7•10-984S lCI1®F12L.EY DtUSCOLL Tgo.%LASST.Pi qAa DIRECTOR OF PUBLIC P1tOPERTY/8U1LDDfG CONNISSIONEQ Construction Debris Disposal AYtidavit (required for all demolition and renovation work) In accordance with tlhe sixth edition of the State Building Code, 730 CM11 section 111.5 Debris, and tie provisions of tNIGL e 40, S 54; Building Permit # 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 NfGL c S 150A. The debris will be transported by: 1 y (name of Imuler) The debris will be disposed of inn r (nantc of tacdity) (address of Ftcility) s gnaturn ofperrrtit appfieant ----- date -- --