SURF ST - BUILDING INSPECTION i CITY OF SAI.&M, iNLUSACHUSETTS
BUMONG DEPARTMENT
130 WASHINGTON STREET,310 FLOOR
v / TEL (978) 745-9S95
FAX(978) 740-9846
KI��ERLEY DRISCOLL
MAYOR THomAs ST.PtFRRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%L%MIONiFA
APPLICATION FOR THE COMMWCTION.REP'AM,RENOVATION, CHANGE IN USE OR
OCCUPANCY.OR oswumm OF ANY 9WLDING OR STRUCTURE
This Secdon,for OMMaI Uee Only
1Ellul Pa milt Project
Building inepsct .. •.
Eff"do Protect Datsa: start End:
Comments:
1A SITE INFORMATION
locatlonl Nam ;, o Building:
Property Address: Susf S
fecoen04 0+ .P/o,) -'SL, IOr6«yY S.T.s" /1vc. 7, zoo
2.q QWNMawi IWOR11"T1ON
2.1 Owner of Land
Name: &4 &� C e
Address: /S (3vooy �4v�
4000CXy , NN 6363F
Telephone: j,p 3 �{3U asP�
2.2 Owner or lessee of b0d/nS M s"ehrne
Name:
Address:
Telephone:
3.0 AGENCY OR AUTHORrrY AUTHORIZING CONSTRUCTION
Agency Nams: Alm
Address:
Agency Projed Number.
Project Manager Name: TeC
4.0 PROFESSIONAL DESIGN SEWCES:_
4.1 Registered Architects
Name: Seal and Signature
Address:
Few
4.2 Registered Protesslonsl Engineem MW adanonal SHssu Y necmMy and all a*to MOcallon)
Name N� Seal and Signaftm-
Addrese:.
Telephone: Fax
Af!eaF.of_Reapon§ibilitY
Nam Seal and StgnAw .
Address:
Telephone: Fax
Area of Responsibility:
Name: A11,4 Seal and Signature
Address:
LArea
tofresEponsibility
Fax:
5.0 DESIGN AND CONSTRUCTION UTILIZING MGL C 112 SECTION SIR EXEMPTIONS
(See note below)
Contractor
Name:
Address:
Area of responsibility:
'License Number Date of Expiration.
Telephone: Fax,
N "//�
Address:
Area of responsibilltir
License Number. Date of Expiration:
Telephone: Fa�c
Contractor
Name: N�g
Address:
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fax
Note: For portions of worts utilizing exemptions of MGL c. 112&SIR complete the section above.
Use additional sheets if necessary and attach to application.
6.0 PROFESSIONAL CONSTRUCTION SERVICES:
6.1 General Contractor
Address: �S lira dy dvG i3s.ks w lar oP
0/9;w
GD J- h6enxv
G 0 3 r!7 9 01010 C.w
Telephone: _ o0 4F 0l Fax: &/7- 2L3- 30
Responsible in Charge of Construction:
7.0 CONSTRUCTION DOCUMENTS -to be prepared by applicant
Item 4 as Applicable
7.1 Plans (Note 1 this page) Submitted Incomplete Not Required
17.1.1 Architectural ✓
7.1.2 Foundation
7.1.3 Structural
7.1.4 Fire Suppression v
7.1.5 Fire Alarm
7.1.6 WAC v
7.1.7 Electrical
7.2 Specifications
7.3 Structural Peer Review
7.4 Structural Tests & Inspections
Program
7.5 Fire Protection Narrative Report
7.6 Existing Building Survey
r.-
7.7 Workers Compensation Insurance
7.8 Other Documents (Specify)
(Energy Narratives, etc.)
Note 1 Areas of Design or Construction for which Plans are not complete at the time of
this application must be identified herein. Work so identified must not be commenced until this
application has been amended and proposed construction has been approved by the
Department of Public Safety District Building Inspector having Jurisdiction.
8.0 COMPLETE THIS SECTION FOR NEW CONSTRUCTION ONLY
For Existing Buildings Proceed to Section 8.0
Number of Stories above Number of Stories Below
Grade / Grade
Story Height 6 3„ Floor Area Per Floor /42-
Total Building Height Total Building Area Above
above Grade
Total Building depth below Total Building Area Below
Grade NA Grade
Brief Description of Proposed Work: s*le 0--e4- s�ooc/ STd�oy p S/�vc+'
/(�T u�.aen.b/y �m E'ss%e.>r S/�id Co• r�'IaT.Cer.,.��inn'4: C?l81x46�S�Z� A,*
elac7tica/i .✓o �/amb.;.nj. /2 X!G ov Cp..�,rTe /JiP.s L�rg� Sovaiulos),
qXV r'r s/.. .q••s w� 2x8 PT el,,e jo,sTs ov i6 " Co. TP�s Sot aZTac liR!
tpcc. Acot%nws. 2suy/� dcrw,✓ pl,7 pI4q c,vcT.�e Scab a77-41��•
8.2 USE GROUP AND CONSTRUCTION CLASSIFICATION (New Construction Only)
USE G F. USE GROUP SUI&CATEGORY CONSTRUCTION
(�as appligble) (4 as applicable) CLASSIFICATION
A , Assembly A-1 A-2 A-3' A-4 1A
B Business 1 B
E Educational 2A
F Factory F-1 F-2 2B
H High Hazard H-1 H-2 H-3 H-4 2C
1 institutional 1-1 1-2 1 1-3 3A
M Mercantile 3B
R Residential R-1 R-2 R-3 4
S Storage t/ S-1 S-2 5A .
U Utility 56
Mx Mixed Use Specify.
Specify:
Sp Special Use
9.0 COMPLETE THIS SECTION FOR WORK IN EXISIING BUILDINGS ONLY ��
For new construction o ete s an
Addition Existing
Renovation Number of Stories Renovated ,
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Briet Description of Proposed Work: i
i
%j USE GROUP AND CONSTRUCTION CLASSIFICATION(Exlsting,Buildings Only);t/
USE Group(*) EXISTING PROPOSED Chin 'CONSTRUCTION
Use Hazard Use _ Hazard Hazard CLASSIFICATION
UK"sui�l Group Index '$coup Index . Index• (4 a•avWlcaer.)
A Assembly 1A� �
r
B Business 1 B
E Educational 2A
F Factory 20'
H High Hazard 26
Institutional 3A
M Mercantile 38
R Residential 4
S Storage 5A
U Utility 513
Mx Mixed Use Hazard Index
undirlp
Sp Special Use
' Note: Include Hazard Index Modifier for Construction Type as applicable
9.0 CONSTRUCTION COSTS (See 780 CMR Appendix L)
Total Construction Cost Building Permit Fee Check Number
(1) _(1)x$0.001
46�03z
10.6 AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR BUILDING
PERMIT (when applicable)
on behalf of tits authorizing State
Agency or Authority, hereby authorize, to apply
for the building permit for project number,
Signature Date
11.0 SIGNATURE OF BUILDING PERMIT APPLICANT
Name
� 07
Signature O
12. Certificate of Occupancy required on completion of project? —Yes _V_1 No
Inspector's Notes:
17-6, 7
Application for Permit to:
m� /t'(4- 1A C�q--Akl
Location
Permit Granted
Appro
Inspector of Buildings
8
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