38 PEABODY ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR) .
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(I'his.section Fo Official l7se Only) ..." .. .
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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 of Building(if apphc�e)
;,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 VJ Alteration ❑ 1 Addition❑ 1 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 ❑ NoJ
Is an Independent Structural Engineering Peer Review required? Yes ❑ No. 6a
h Brief Description of Proposed Work: ' •C ',� C.
_ x SECTION 3:COMPLETE THIS SECTION IF EMSTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
". •r , -' '=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): - -
:il„ 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): e - '
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
` F: Facto F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ H-2❑ - H-3 ❑ H-4❑ H-5❑
I: Institutional. I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ It Residential R-111 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use El and please describe below: '
Special Use: -
"`" SECTION6:CONSTRUCTION:TYPE (Check as applicable) "
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 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❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazazds to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑. Yes❑ or No❑ Yes❑ No ❑
:f 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:
i
- ... SECTION 9: PROPERTY OWNER AUTHORIZATION _ r -
Name and Address of Property Owner
/
N e(Print) No.and S eet a City/Town Zip
Property Owner Contact Information: -
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Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes -
w k",( `CIoS\ "mn (�1am5 1�� ca `iae IlX) n _ O�1lnq
e Street Address City/To 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)' -
ff building is less than 35,000 cu.ft.of enclosed space and/or notunder Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control -- -
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Name(Regis6- t) Telephone No. e-mail ad'dress Registration N=— ber
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Street Address Ci ToTo State Zip Discipline Expiration Date
10.2\General Contractor
Company Namer�.� U uYq p, -
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
Telephone No. (business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COWENSATION INSURANCE AFFIDAVIT 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' ance of the building permit
Is a signed Affidavit submitted with this application? - YesL9' 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 $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to -
6.Total Cost $ O{��jl,Q (contact municipality)and write check number here
SECTION13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that all411he' ation contained in this
application is-true and accurate to the best o my knowledge and understanding.
1 Plea rint and sign n e - Title Te hon Dated \\,oc`
Street Address City/ wn Zip
Municipal Inspector to fill out this section noon application approval:
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Name Date