4 SPRUANCE - BUILDING INSPECTION -770
T i3 - H- 11 O `� (O l - RECEIVED
The Commonwealth of M c l assausetfs w
Department of Public Safety
1'Ia5S,1CIl I1Se(t5Stale Building Code(78BC, � JUN 25 P h 24
Building Permit Application for any Building other than a One-or Two-Family Divelling
(Phis Section For Official Use Only)
Building Permit Number. Dale Applied: Building Official:
SECTION 1: LOCATION(please indicate Block#and Lot#for locations for which a street address is nut available)
4- S to C—U fa-N c.E
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 here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ 1 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 ns part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review rer tired? Yes ❑ No ❑
Brief Description of Proposed Work: I et o ue � �tC C �Ap /3�a�� S �-wa 4.7-
�o CST®�i�r /3-.�/D.'.,.� s -XG
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 J:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. fr)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ I B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: High Hazard H-I❑ Fk2❑ F[-1 ❑ H--4❑ H-5❑
1: Institutional I-t ❑ 1-2❑ 1-3❑ I-4❑ NI: Mercantile❑ li: Residential R-I R-2❑ R-3❑ R-1❑
S: Storage S-1 ❑ S-2 Cl U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCION'IYPE(Check as a licable)
IA ❑ 1110 IIA ❑ HB ❑ 111A ❑ 11100 . IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 1I1.0 for details on each item)
Water Supply: Flood Zone Information: 'ewage Disposal:
'French Permit: Debris Removal:
Public Check if outside Flood Zone Indicate municipal A trenchwit�'ut be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required ®,or tr ench or specify:
permit is enclosed Cl
Railroad right-of-way; Hazards to Air Navigation: �L�IILy�r6;C„...q�i.-.6 in_(y w" l'n..r
Not Applicable( Is Structure within airport approa oea? Is(heir review c�mplete`d�?
or Consent to Build enclosed❑ Yes❑ or Nu( Yes❑ No ❑ /y ,
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Fdilinn of Code: Use Group(s): ____ Type of Couslruclion: Occupant Lard per Fl...
Does the buildingcontain an Sprinkler SyslciW .._—_—Spec 1,11 tit i pu l.0 ions:
SECTION 9: 1'ROPE•R'I'Y OWNER AU'1'IIORIZ.k'I'ION
Nome and Address of property Owner
coivyds :/7-�re" Z. A)'A e/970
More(print) No.and Street City/Town Zip
property Owner Contaetthrfoormatio'nL:
�j iy/r�•l.,w //,7,'!.s /r-••, - ��-- 77 YoSy .1 Pa l`'i's5�Ao7 �:'.,✓ .:.r
Title Telephone No. (business) Telephone Nu. (cell) a-mail addrds
If applicable,the property owner hereby authorizes
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 33,004)cu.ft.of enclosed space and/or not Under Construction Control then check here O andskip Section 10.1
10.1 Registered Pro fess4mdl Responsible for Construction Control
Name egistrant) Telephone No. e-mail address Registration Number
met Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
�+n r � CO NS/,• r/,- �/ L / C
Company Na�Te
�C< )/rn --5 . G ,nr os473y "ss
Name of Person Responsible for C nstruction License No. and Type if Applicable
!9 !rr //ey .0 SHIM /"4 0'/s70
Street Address > p City/Town State Zip
ZSk M9 (,GJO
'role hone No. buslnes9 Telephone No. cell e-mail address
SECTION 11:14'iJI:F@KS'CC)MII'I:N•ir\I'IUN INS_UR:\NC'K A FFIDAV1f M.G.L.c.152.§ 25C6
A 1Vorkers'Compensation Insurance Affidavit from the NIA 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 ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item EstlmatCll Costs:(Labor
and Materials) 'total Construction Cost(from Item 6) ='S 9K zLO,
L Building .S S",ZLD '•
Building permit Fee=Total Construction Cost x g (Insert here ,
2. Electrical S appropriate municipal factor)=S o
3. I'lumbing 'S
-1, Mechanical (11VAC) S Note: Mliniuuun fee=5 (Contact nnuh ici pali ty)
S. Mlechanical Other S Enclose check payable to
6, Total Cost y98 Z Z o (contact municipality)and write check number here /d/7
SECTION 13:SIGNATURE OF 13UILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information Contained in this
application is true and accurate to the best U oy knowledge and understanding.
Please print and sign name / ` Title Telephone No. Date
/9 .t'r//r- .S •L /i9�.y C/9�O
Street Address City/Town 7 State Zip
l""1
Municipal Inspector to fill out this.section upon application approval:
Name Dot,