56 PEABODY ST - BUILDING INSPECTION (2) $2Z
i5Q OMAL SERVICEg The Commonwealth of Massachusetts
Department of Public Safety
P MassachusctlsState Building Code(780CMR)
B�t`iAgg Permit Application for any Building other than a One-or Two-Family Dwelling
_(Iltis 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)
U
pExisfin
Street City/Town Zip Code Name of Building(if applicable)
V
- SECTION 2c PROPOSED WORK
1 MA State Code used_ If New Construction check here❑or check ad that apply in the two rows below
uilding Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Ple:sse(iR out and submit Appendix 1)
♦ Use ❑ 1 ChangeofOccupancy ❑ Other t3,specdy: !
Are building plans and/or construction documents being suppiiml as part of this permit application? Yes ❑ No
r� Is an Independent Structural Engineering Peer Review reQuulred? Yes 13 No ❑
Brief Description of Proposed Work:_` �� l� �V✓1 (.d S'�lti l/Vls
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY -
lFactory
here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR M) ❑
g Use Group(s): - Proposed Use Group(s):
SECTION4:BUILDING HEIGHT AND AREA
.Existing Proposed
Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Area(sq.ft.)and Total Height((t.)
SECTION 5:USE GROUP(Check as a licable)
embly A-1❑ A-2 O Nightclub ❑ A-3 ❑ A--I O A-5❑ B. Business ❑ E: Educational ❑
o F-I❑ F2❑ It: Hi h Hazard H-1❑. H-2❑ H-3 O H-4❑ H-5 O
tutional I-I❑ 1-2 O 1-3❑ 14 O M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3O R-4O
age S•I O S-2❑ U. Utility❑ Special Use❑and lease describe below:Use: SECTION 6.CONSTRUCTION TYPE(Check as a licable)IBO HA ❑ 1180 IIIA ❑ IIIBO IV 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CbIR 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 Cl or indentity,Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: I lazards to Air Navigation: MA I listorl,r Commi,s6m Revw, 1'11tc11:
Not Applicable❑ Is Structure within airport approach area? Is their review completed? _
or Consent to Build enclosed❑ 1 Yes❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
EJitiun ul Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the builJiny,contain an Sprinkler System?: Special Stipulations: __
l— SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
v
�L�r91 mtaosfi 6 ,�� oo �Ia1C1�
Name(Print) No.and Street - City/Town ��,it' i'�`a -;>;r.., Zip
Property 0vner Contact Information:
°
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
A"Arlr-s 6N2?vf/N. Azo . SAD� Ul � a
Name Street Address City/Town 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)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check hem G 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
Company Name
Name of Person Responsible for Constru tion License No. and Type if Applicable
8� -r-2�ilcnlU� s 0
Street Address City/Town State Zip
Z o s'3i -
Telephone No. business Telephone No. cell e-mail address
SECTION 11:4VORKEI:3'CAAIPEN5Al'ION INSUItANC.T AFFIDAVfl' 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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE -
Item Estimated Costs:(Labor
and Materials) TotalConstruction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ - appropriate municipal factor)=$
3.Plumbing $
d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
ha nical Other $ Enclose check payable to
6.Tot)Cost $ ,j DU �m (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERhHT APPLICANT
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate the best of y knowledge and understanding.
i
"MN .Z_
nd sign na / Ti le Telephon No. Date
Sheet Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: M.LZI 313 I�. 10
Name Date. ..