56 PEABODY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
j �(p CFI 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 Onl
Bwlduig Permit Number Date Applied ' "^;" r Building'Offtctal ^ `'
SECTION 1:LOCATION (Please indicate Block#and,Lot#for locations for which a street address is,not available)
3(O PF�tt�l�`� .Sr�Tr Salc�n1 mA D19�0 5 f� �µ�oy �i. G,Nta�s
No.and Street City/Town Zip Code Name of Building(if applicable)
r. .. ._
- t '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❑ Alteration ❑ 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 ❑ No 2rd
Is an Independent Structural Engineering Peer Review required? Yes ❑ No fib
Brief Description of Proposed Work: 'TO RkMtUL-TOP EauSTtA;b/LJAC� _2rJF BVIO-1L OFLJW-15 AT 00m 76/fAl
tl1EE tiLy�t t�s� 21i3 AV, 940. o A&W unrtq cavrpl wozlo i'A.Zr,__
%y;Als�n r« f m;�Qv�Pert m6+rr-60—u y ?E AI r D,ent.,Dt, s
= CHNtNE�S�u0ks SfAc�D c,.rn/ O�f3Ee E[�SH�.r/6•S fSralS
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 ❑ 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-10 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 ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
`.1 1SECTION7:SITE INFORMATION (refer to 780 CMR 111.0 fordeteils on each item)'_
Water Suppl Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public Check if outride 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 Commission Review PrcK.ess:
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:OFOCCUPANCY: --
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9.1 PROPERTY OWNER AUTHORIZATION ,
Name and Address of Property Owner
5arvtt5 obP-44)
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
QWAP�(L jo0 _ _ vuo 5'08-552- '061,
Title Telephone No. (business) Telephone No. (cell) e-mail address
If appl'cable,the property owner hereby authorizes
Name Street Address City own State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
,- I SECTION 10 CONSTRUCTION CONTROL(Please fill out Appendik,
is less than 35,000 cu:ft of end'osei{s ace,and%or not`imder ConstructionContiolthen ch'eck'hete'O"and ski' Sechon 1031
10:1 Re 'ster` ion Control -`ed Professional Res onsible foi•.Constiiict a.F
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
'10.2 General,Contractoc . . . .
el;wnrts eay c'owom i-ofe s
Co �pany Name
YJy M �AJ - L S (O1d19
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
I.,SECTION11,, NORKER.S'.LOMPEKSATION.NSUP�ANCL AI!PiDAVIT 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❑ No ❑
i ;<`-SECTION 12r CONSTRUCTIOiV(COSTS AND PERMIT FEE . ,
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ Ulf,GU Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact munici ality)
5. Mechanical Other $ Enclose check payable to 66
6.Total Cost $ ,oa (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 infor
mation contained in this
application is true and accurate to the best of my knowledge and understanding.
Plea prjr�t and sign name Title TelephVNoDate
J S ( JkU11UTS'�Street Address City/Town Sta a
Municipal Inspector to:fill out thisisection upon application approval
Date.. -