125 WASHINGTON ST - PERMIT APP - 2ND FL 3a
All/ I The Commonwealth of Massachusetts V
Department of Public Safety
Massachusetts State Building Code(780 CMR)
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Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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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❑ 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 as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review requ} e�? n f C Y s ❑ No
Brief Descripptio of Proposed Work- RE-"`a�L 0l aL C f k��ti. S q�y�+� ��
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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 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❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ J-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage Sl ❑ S-2❑ U: Utility❑ Special Use❑and please describe below
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:it Perm :
Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑
Public 29 Check if outside Flood Zone Indicate municipal .A french will of he P
Private❑ or indentify Zone: or on site system❑ required or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable Pr Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No Q-� 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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) . Telephone No. (cell) e-mail address
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 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control / n
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Name(Re$�strant rA� Telephone No. e-mail address Registration Number
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Street Address Town State Zip Discipline Expiration Date
10.2 General Contractor
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Company Name1 /
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§ 25C(6)
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building Ego $ )X,o0 n 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 $ l a., oo m (contact municipality)and write check numbifr here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby att under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to th est o my knowledge and understanding.
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Please�1ri(tt and sign name Title Telephone Date
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Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: t/
Name Date