SOUTH SHORE AVE BAKERS IS - BUILDING INSPECTION 4- v
CITY OF S.u.E%4 UxsSACHUSETTS
& nnuvG DEPAR*r%MNT
I2 W%aMGTON STREET.3' FLOOR
TVL. (978) 745-9595
PAX(978) 740-98"
KEMBERLEY DRISCOLL
MAYOR THOMAS ST.F[ERRE
DIRECTOR OF PIBuc PROPERTY/BcmDjNG COJLNL lo.iER
APPLICATION FOR THE CONSTRucnaK RELsAIR;REMOVAjWK CHANGE IN USE OR
e OCCUPANCY.OR DEMOLITION OF ANY!BUILDING OR STRUCTURE
-Thl OMd*Use OnV
/i .: / J, /
B Pannf�Pr�t t .. _ ,
' Estinnts heojecc Da>ed: !j p' start — Fsd:
comments:
1.0 SITE INFORMATION
Loeadw Nw= `Lsl eundkW
Property Addreae ,��, v al Abbe Aw-
Assessors LbWBiodc atc tt S , LouPamak q Y +Y6
. .
QMf11 INFORMATION
2.1 Owner of Land 'aY
LNama l� Q
i°�`�' S Abbe �,r31, 50��4. ��s, Me. d 5`596
Te1ephOf1e v `7 63 63
2 Ownsr or Lessee of&dkMV or sbuc&m
Name:
Address:
Telephone:
3,0 AGENCY OR AUTHORITY AUTHORIZING CONSTRUCTION
Agency Name: e -
Address:
Agency Project Number.
Application for Permit to:
AA htYJ��
Location
Permit Granted
A roved
Inspector 'f Buildings
f�
i�
ro
to
S� _
I
- -- - - - . -
--- - - - - '
- -_ _ . __
_---I,
Io'` rd
for new consaucaon comolete
Addition EXIStNlg
Renovation v� Number of Stories Renovated ✓.:.
Change in Use New
Demolition Existing
Approximate year of Area per floor(sf) Renovated
construction or renovation-
of existing buMN -;Lmb New, 4
Brief Description of Proposed W/o�rk" p -
�ebUle� Aw�rP^nr ac�w (�� �GT�j �
i"�lU 2?Ai'�QVK' lWv �e.VVLa..�T..�vr� L'2wo^ Fr.. �CVKCSs�Jbh il2�
9.f. U8E GROUP AND CONSTRUCTION CLASSIFICATION(Eicisifng BuIdlpgs Qnlyj"`
ExISTINQ :PROPOSED hang
4` C e 'CONSTRUCTION
USE Group(s) CLASSIFICATIOjd
Use Hazard Use Hazard Herd !
t wticate8ayj.. Group Index group Index lndebt• {� apWte+b(i),;
A Assembly 1A z� {
B Business
E Educational.. 2A,' "
F Factory
H High Hazard 2C
1 Institutional- 3A
N Mercantile 3B
AldienUtiia.l
q
5A
59
Hazard Index
Note: Include Hazard Index Modifier for Construction Type as applicable U
9.0 CONSTRUCTION COSTS (See 780 CMR Appendix L)
Total Construction Cost Building Permit Fee Check Number
=(1) X $0.001
10.0 AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR BUILDING
PERMIT (when applicable)
1, on behalf of the aufhoncting State
Agency or Authority, hereby authorize, to apply
for the building permit for project number,
Signature Days
11.0 SIGNATURE OF BUILDING PERMIT APPLICANT
Name
Signature Date
12. Certificate of Occupancy required on completion of project' _Yes No
Inspectors Notes:
i CITY OF S.U.&M, T%LksSACHUSETTS
BL't mmrs DEP:URnmN''T
120 W.ASHtNGTON STREET,3m FLOOR
TEL. (978)745-9595
FAX(978) 740-9846
KIMBERLEY DRLSCOLL
MAYOR T HO&w ST.PmRRB
DIRECTOR OF PUBLIC PROPERTY/BU TIMING CONMUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
T OL
signature of permit applicant
���-/07
date
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