1 SPRUANCE - BUILDING INSPECTION L
7 -70 c(c 10l7 5` *7F)
'0- l u -11`68
�° ( Z RECEIVED
The Commonwealth of Massae lusetEs
Department of Public Safety �� JUN 25 P h 24
�J MLtssachuselts Stale Building Code(730 Ci
Building Permit Application for any Building other than a One-or"rwo-Family Dwelling
(Chis Section For Official Use Only)
Building Permit Number: Dale Applied: Building Official: -
SECTION 1:LOCATION(Please indicate Black k and Lot✓♦for locations for which a street address is not available)
l nJh C .nl AIJ C'-Cr_
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check Isere O or check all that apply in the two rotve helow
Existing, Building❑ Repair❑ Alteration ❑ 1 Addition❑ I Demolition O (Please fill out and submit Appendix 1)
Change of Use ❑ Clt,mge Of Occupancy ❑ Other ❑ Specify:
__ .. Are'Building plans and/orconslnnctiun documents being supplied as l•:,rt of:his porn titnpplicatior.? Yes ❑ No ❑ —
Is an Independent Structural Engineering Peer Review re�nurtiDtrd? Yes Cl No ❑
,7 Brief Description of Proposed Work: Re�.�-+O-e- 9` Zn: e-C C 4Az 4T
SECTION 3:CONIPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,Olt
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 730 CMR 34) ❑
Existing Use Group(s): Proposed Use Grou p(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Storios(include basement levels)rq Area Per Floor(sq. ft.)
Total r\rea(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-I ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
P: Facto F-t❑ F2❑ It: High Ilazard II-1❑ FI-2❑ . t! ❑ H-4❑ 1-1-5❑
1: Institutional 1-1 ❑ !-2❑ 1-3❑ 1-4❑ SNI: Mercantile❑ It: Residential R-1 R-2❑ R-3❑ RA❑
s: Storage S-I ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION(:CONSTRUCTION TYPE(Check as a licable)
[A 13 113 IL\ ❑ IIB (3 IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 730 CNIR I11.0 for details on each item)
Water-supply. Mond Zone Information: 'ewage Disposal:
Trench Permit: Debris Removal:
Publi[ Check if outside Rood `Lane Indicato municipal
A trench wit of be Licensed Disposal Site
regained or trench or specify:
Private❑ or iurlcmify"Lone: or on site system Cl permit is enclosed❑
Railroad right-of-w.ay:/ ILizards to Air Navigation:
Not Applicable PS Is Structure within airport apprua mea? Is their review completed/?
or Consent to Build enclosed❑ Yes❑ o ( Yes❑ No ❑ /fir
SECHON 3:(-ONI'EN'r OF CL'R'TIPIC\'1'E OF OCCUPANCY
Edition of Cule. Use Group(+): .____--_ I'vpo of Constriction: ---- Occupant Load per Floor:
Uu��s the building contain an tipriuklcr tiystem�. ..___tipcCial tilipulations: __--- -.-_.--
SECTION 9: I'ROPER'1'Y OVVNIilt AU'r[IORIZA't'ION
Name and Address of Property Owner
10'e4-, VS /—I-vy " I /yl A 70
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
�ivrr�•1.. �a.��>'' -S Tz-•-', 1 77-r"loSy J Pa t'i'a5 Ay7' '✓.
'title Telephone No. (business) 'relephone No. (cell) a-nail addres9
If applicable, the propertyowner herebyauthorizes
3tNN. 'rh P"�f WB9"�N
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this bis ild ing Perin it a PPIication.
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 Constriction Control then check here Mind skip Section 10.1
10:1 Registered Pro fessjonal Res onsible for Construction Control
Nan ( egistrant) — Telephone No. a-mail address Registration Number
reet Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor �
r+n r �o�Sf� �o�ro ✓ LG C
Company NNa,me ` /_
Name of Person Responsible four C/i)nstruction License No. and Type if Applicable
!9 't-r ilev at /1114 O'/17e'
Street Address City/Town/ State Zip
7—T ZG38 sA .� /j_c•i,rry0e!5 v' T NTT .
'rele hone No. business Telephone No. cell c-mail address
SECTION 11:VVc.naa:r.S'CO,nVhi\SnfneN NStJVA_NCfIrrllr\Vff M.G.L.c.152.9 25C6
A Workers'Compensation Insurance Affidavit from the NIA Department of Industrial Accidents Hurst be completed and
submitted with thisapplication. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this a lication? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) 'fatal Construction Cost(from[tem 6)-.$
1. Building S 8'?,iD '•
building Permit Fee-Total Construction Cost x 9 (Insert here
2. Electrical S appropriate municipal factor) 78
=S o•
�
1. Plumbing .S
1. Mechanical (HVAC) :5 Note:Minimum fee=5 (contact municipality)
5. Mcclanic l Other t5 Enefase check payable to
6.Total Cost
$ y98' L t o.'� (contact 11 11-C polity)and write check number here--la-L7
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby,utest under the pains and penalties of perjury that all of the information contained in this
,application is true and accurate to the best, my knowledge and understanding.
�.s a1 r 979--gra_ z6XZ y
Please print and sign name / Title Telephone No. Date
/? it'r//iX S'�C S�.n �r _O/9 O
Street :\ddressCity/gown State Zip
i\iunicipal Inspector to fill out this section upon application approval:
Name I arc