46 PEABODY ST - BUILDING INSPECTION (3) ® 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
-,;(this Section For Official.Use Only) .;
Building Permit Number. il'. = 4 Date Applied: - Building Officral
SE��CI1TION 1:LOCATION(Please.indicate Block#and Lot#for locations for which astreet address is not available)` +. :..
��Q rD t1S� al"m Ta�om � r�iZRtton
No.and Street U City/Town Zip Code Name of Building(if applicable)
SECTION2: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❑ Repam qu J Alteration ❑ I Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
9� Change of Use Change of Occupancy El I Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No J
Is an Independent Structural Engineering Peer Review required? Yes ❑ No pa
Brief Description of Proposed Work:
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:.B_UILDING HEIGHT AND AREPia ''
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 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ 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)
IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7:.SITE INFORMATION-(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
_ Water Supply: - Flood Zone Information: Sewage Disposal: Trench Permit: .
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 0 or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards 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 ❑
=SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: I Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
v +
SECTION 9: PROPERTY OWNER AUTHORIZATION' -
Name and Address of Property Owner
N (Print) No.and Str et _ City/Town Zip
Property Owner Contact Information:
Title U Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
t� �a�(bsl7a un (k�om5��ca ` .a IW r \yj O�\Uq
e Street Address City/To State Zip
to act on the property owner's behalf,in all matters relative to work authoi permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendiz.2)
`* If building is less than 35,000 cu.ft of enclosed s ace and/or not under Construction Control then check here 0 and skip-Section 10.1 "
�i(1:S Registered Professional Responsiblefor Construction Control
trl 1, )- C AV\ n\tarn
Name(Registlr t) Telephone No. e-mail address Registration Number
yZo t1L.V no aro\ug— c711 -
Street Address City/To State Zip Discipline Expiration Date
:10.2-General Contractor
Company Nam(P -
eicv m0,)�2anAo
Name ooff/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'CONVENSATION INSURANCE AFFIDAVIT 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/1'S�1ance of the building permit.
Is a signed Affidavit submitted with this application? YeSb No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 0 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 $ 677j v - (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 informatio contained in this
application is-true and accurate to the best ot my knowledge and understanding.
Fle, =rmtd e Title Tel, o. Date
\ Ali.\ \ c`
Street Address City/ wn to \'p
Muiricipal Inspector to fill out this section upon application approval: .i7iZtl -
Name WKtej