33 UPHAM ST - BUILDING INSPECTION (/ The Commonwealth of Massachusetts
/ Department of Public Safety
s Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two- y D (ling
(This.S k tiom For Official Use Only)„
Building Permit Number: DateAppligd BuildingO,icial
SECTION 1:LOCATION.(Please indicate Block#and Lot#for locations for which a street ad res s is not e
-3;t, hA-en 5:4-lE Mkl- 01 y 7v '-3 sf-
No.an Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PRO
POSED WORK
Edition of MA State Code used If
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repaireu Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: tP! beSr-,e fr, tl
oits L
SECTION 3:COMPLETE THIS SECTION.IE EXISTING,BUILDING.UNDERGOING RENOVATION;ADDITION,OR
" CHANGE IN USEOR 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 Cl 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) 4
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTIONS:SITE INFORMATION (refei.to 780 CMR 111.0 for details on each item)'
Permit: Debris Removal;
Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
Private❑ or indentif Zone: or on sites stem❑ required ❑or trench or specify:
Y Y permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA HistoricCommission t:uview I'rcr�.rss:
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 OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
" SECTION 9:;PROPERTY OWNER AUTHORIZATION
Name and Address of Proper Owner J
df AM (/I ER � 33 �PN�I� - �� �'AIl=N( l�k 019fia
NYne(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
pi rrr.-el e_ ✓a��t 0/9!g'"
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 lOi,CONSTRUCTION CONTROL(Please fill,out Appenclik ;
[f buildin vs less thin 35000 cu.ft:of enclosed s'ace and'or riot under.Construe ion,Control•.[lien efieck fiere O'and'skip Section 10.1), 4
. 10.1 Registered ProfessionalRes orisibVe for Construction Control".
Name (Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor:
Company Name /7//7,0 Kp Z- ,/3l"
Name ofPerson Responsible for Constnrction License No. and Type if Applicable
31, C//t4.fe JT �GiPr�! I-01? -17N CT/�/
Street Address 704/ City/Town State Zip
y,& �� 37 yy�- ��- 6fiv,7
Telephone No. business Telephone No. cell e-mail address
-� SECTION 11:WORkL•R9 C.ONIPENSATION.INSURANCE AFFIDAVIT M.G.L.c.152:fl,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 ❑
SECTION>12;.CONSTRUCITON COSTS AND PERMIT FEE'
4
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ (yQ®CJ , (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERINIT APPLICANT;" C°
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 of my knowledge and understanding. ��� . ,30y 6§toJ
y�f 0w p A/er /�0 ery JJnr
Please print and sign name Title Telephone No. Date
treet Ad ess Cit f�Town State Zip
233y Lhvt fa lSC"er g lair 6Y 5/�
Municipal Inspector to fill out this section upon application approval:
. Name - Date