25 PEABODY ST - BUILDING INSPECTION (2) 3 (L( - I GK 2.z FS 1 0314 2;1
The Commonwealth of Massachusetts
q� Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-'or Two-Family Dwelling :
;-.,(This Se ton For Official Use Only)kr_;.� ;_'11
Budding Permit Number. �Bwlding Officral r
_ _ -
SECTION •LOCATION'(Please indicate Block.#and-Lot.#for-locations for which dstreet addr'es"s is not available)
� S Al-r✓"1`n Nat:�t,C�(zlp
No.and Street 4ity/Town Zip Code Name of Building(if applicable)
SECTI
, ON 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❑ 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 ❑
Brief Description of Proposed Work:
E1�0�1t ?� EX TttJ r1 W 1N EDO S
SECTION 3:COMPLETE:THIS SECTIONIF EXISTING BUILDING-UNDERGOING RENOVATION,ADDITION,OR
a 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):
a?�.v .b .,; SE MON 4:BUILDING`HEIGHT AND AREA" �- t
- Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
*. SECTION S:USE GROUP(Check as applicable)" ,
A: Assembly A-.1 O A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Factor . ,F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 0 H-5❑
I: Institutional I-1 ❑ I-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage S-1❑• IS-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
p. , ; ;SECTION;6;CONSTRUCTION TYPE(Check as,applicable) ::.' ,
IA ❑ I& ❑ IIA,❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
"- SECTION`7rS[T6 INFORMATION"(refer to 780,CMR 111.0 for details on each ttem)
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❑
Private❑ or indentify Zone: or on site system❑ required❑ or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA Historic Connnission Review Prcccss:
Not Applicable 0 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 Code: Use Group(s): _ Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
' ,,:SECTION 9: PROPERTY OWNER AUTHORIZATIOIV,3:- 'r" ;
Name and Address of Property Owner
lcma� Ggr,A � �.� 01970
Name(Print) �+ No.and Street City/Town Zip
Property Owner Contact Information:
�actl t`l 1 +✓s Z-� S3?D Q?�a7� /?�Ld / ��l 1 � l P. A��'�e rrs@
Title Telephone No.(business) Telephone No. (cell) d - e
if a licable,the p o erty owner hereby authorizes f I O
tS f 7o Read Ord % r% A 0
ame Street Address City/Town State Zip
to act on the property owners behalf,in all matters relative to work authorized by this building permit application.
r
-� = SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2) 3': '
= Iibuildiii ,is less ttfam35,6o0 cu:ft.cif enclosed space an`d/or i of under Construction Control then'chefikhece b and skip 6ecuon 101
1d:1 Registered Professional Res onsible' br.Construction Control"` I`,
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General,Contractor'
Company Name
to �-V kV-e e ltii ( SFA 0 159 13 3
Name of Person Responsible for Construction License No. and Type if Applicable
4 3 �_ k A�10A TU�-- ST L bm l A) IJT 2 ,vim 01U 3
Street Address City/Town State Zip
@� 6 ?�� � Sgh61@Msrv . cr,M
Telephone No. business Telephone No. cell e-mail address
-'. SECTION 11:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT M.G.L::c.15Z:` : C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Acciden ust be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the i K uance of the building permit.
Is a signed Affidavit submitted with this application? Yes Gr No ❑
SECTION 12:CONSTRUCTION COSTS'AND PERMIT FEE .
Estimated Costs:(Labor �j
Item and Materials) Total Construction Cost(from Item 6)=$ 6 �O
1. Building $ ,Q (Insert
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ - . appropriate municipal factor)=$ /D 3•St3
3.Plumbing $ +
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
S.Mechanical Other $ C rTI �a1P on I rwt IX A
Enclose check payable to 1 Rp�
6.Total Cost $ �U (contact municipality)and write chelk 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 rint and sign name Tle Telephone No. Date
U3FI,�N� L! T(5LIJ& 3Yf � _ 1 eoVn 11S "ell M,A- rYIY—G
Street Address City/Town State Zip
Municipal Inspector'to fill out this section upon'applfcationapproval:,- i
_ - „
Name _ , ' `Date N