140 WASHINGTON ST - BUILDING INSPECTION (5) C, sz�"
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One- well'
' ('this Section For Official Use Only)
Building Permit Number: Date Applied: - Building Offi¢i. .
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a.street address is not av e
I q 0 6A), Okck� O
No.and Street City/Town - Zip Code Name of BuE
applicable)
SECTION 2:PROPOSED WORK .
r
Edition of MA State Code used_ If New Construction check here❑or check all that ap two rows belowExisting Building❑ Repair A Alteration ❑ Addition❑ Demolifion ❑ (Please fill out it Appendix 1)
T_ 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 A
Is an Independent Structural Engineerin Peer Review required? - es ❑ No
Brief Description of Proposed Work - ..
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.)
SECTIONS:USE GROUP(Check as'applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business JR E. Educational ❑
F: Factory 1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 O E-3❑ R-4 El
S: Storage S-1❑ S 2❑ U. Utility P Special Use❑and please describe below:
Special Use: - - -
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB-❑ IV ❑ 'VA ❑ VB ❑
.SECTION 7 SITE INFORMATION(refer to 780 CMR ill.0 for details on each item)
Water Supply, Flood Zone Information: Sewage Disposal: Trench Permit: _ Debris Removal:
Public P Check if outside Flood Zone❑ Indicate municipal a A french will not be Licensed Disposal Site❑
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 19 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes ❑ or Nod I 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 PropertyOwner
tm�-PAL N< Oti/S
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
bu2me . 61�-422- a4on �i -yz3 - _ sGoldl �r Gr,14LyV9 PVAi3 ies he
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 thart35,000 cu,ft of enclosed space and/or not under Construe'on Control then check.here 17 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) - Telephone No. e-mail address. Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2GeneralCpntractor. - -
Company Name
a66 ag7
Name of PerscA Responsible fo4 Construction License No. and Type if Applicable
Street Address City/T&n State Zip
IlaA21- o,.a
kjd �� Arapp.-]-re$/2.E CAW'q4
Telephone No. business Telephone No. cell e-m
ail address
-' SECTION 11-WORKERS`.COAIPENSATIONINSCRANCL AFPIDAvIT M.G.L c.152, 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the-denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? - Yes O No O
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 7 jco Building Permit Fee=Total Construction Cost x—(Insert here
2.Electrical $ G. — appropriate municipal factor)_$ -
3.Plumbing $ -- —
4.Mechanical (HVAC) $ _ 0 Note:Minimum fee=$ (contact municipality).
5.Mechanical Other $ — o Enclose check payable to
6.Total Cost $ -coo. cX (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING 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
�a P�cation is true aaryr}d""accurate o fie best of my knowledge and understanding. .
TQaP�t,S. F3o �ibe�
Please print and s gn am�j n Title Telephone No. Date
4 ��rr` 9 �Q I`x= l°�i� 3 P trP�Y LIB G15/6
Street Address City Town State Zip
Municipal Inspector to fill out this section upon:application approval:'
Name :. Date.