0155 WASHINGTON STREET - BPA-10-944 PASSAGE TO INDIA t e
The Commonwealth of Massachusetts
Department of Public Safety
tl1.uSdihusc1ISS1.It'Bit III ng Cudc(7Nl1 CN I R)
Building Permit Application for any Building other than aOne-or Two-Family Dwelling
(Ibis Section For Official Use Clnh)
Building Permit Nunder Date Applied: __— Building Official:
SECTION 1: LOCATION(Please indicate Block N and Lot if for locations for which a street address is not available)
_ WA5htA-I,- Yc.�,J 57 SAL wn�- --- 'N9,e,exGe tee
No. and Street City /I'm n Lip Code Name of Build int;(if apPI icablc) r, :x
S17CFION 2:PROPOSED WORK
Fdition of NIA State Code used If New Construction check here❑or check all that apply in the Iwo rows below -
Existing; Build in}; Repair❑ Alleratioo ❑ Addiliun❑ Demolition ❑ (Please fill out ood submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Othrr Specif}':�Z' .�K`7` Wt::` y- '} TAA
Are building plans and/or construction d+x'utIICltls being Supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering Peer Review requi`red�? - ` Yes ❑ No Zl- �
BrieF Description of Proposed Work S^{rr�tE.4- /v l�r..ae°Y- r ,tJO .4C' �- �/'f-✓lJ _ _
M41
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADD>V(5�V''.OR{;. M
CHANGE IN USE OR OCCUPANCY q, %'f�'`A''i `'�
Check here if an Existing Building Investigation and Evaluation is enclosed (See 760 CNIR,54) ❑
Existing Use Group(s): Proposed Use Grou p(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
1: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ 11-3❑ R4 ❑
S: Storage Sl ❑ S-2❑ U: Utility ❑ 1 Special Use❑and please describe below:
Special Use :
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ I13 ❑ IIIA0 111613 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: -
Pu hlic❑ Check if uutsidr Flood Zone❑ Indicate numicip,tl❑
A trench tv ill not be I.inmsed Disposal Site❑
required ❑or trends or specify:__________
Private El or indenlily Lone:_ or on site system ❑ pvrout is enclosed❑
Railroad right-of-way: hazards to Air Navigation:
:Nu[ Applicable❑ Is Slntclure within airport approach area? Is their ivvicw completed?
nr C.Ult]enl lu Build ORIOScd ❑ N os❑ or No❑ N its❑ :No ❑
SEC]ION B:CONTENT OF CI?RTIFICATE OI'OCCUPANCY
Eklilion kit Code: LSo Group(s). —— Ivpe at Construction: _ Occupant Lead per Floor.
DUOS the building;contain an Sprinkler St Stem?:__._._.__ Speci,d
s' f
SE('1'ION9: PROPERI'YOWNFRAUI'IIORI ZA"IION
Namc a/nnd++ A/d�dress of Propert, Owner —
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
I itle _— Telephone No. (business) Telephone No (cell) e-mail address
If applicable, the property owner hcrrbv authorizes
— Name Street Address — — —City/Town Slate Zip
to act on the pr,perh owner's behalf, mail matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less thin 35,0W cu.ft.of enclosed s,ace and or not under Construction Control then check here 0 and skip Section Ill.l
10.1 Registered Professional Responsible for Construction Control
� CaP000,5y/$ S
�_ob f`JA(CC e�5 9VY . O� - ' Noknwr4
Nano(Registrant) Telephone No e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No business Telephone No. cell a-mail address
SECTION 11: ( (.)Nint\SA_IR?\ 1\'-1Jl,'AN(_r Al I ,roll 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 a lication? Yes O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
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 $
a. \-lechanical (HVAC) !$ Note: \1inimum fee=$ (contactnumicipalih)
i. \luchanical Other $ Enclose Chrv'k payable to _
a.Total Cost S (arolan nwnicipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT -
By entering nn' name below, I hereby a0es[under the pains and penalties of perjury that all of the information contained in this
application is lrte and aCCurate to the best of my knowledge and understanding.
.9Q 62�;4 7
Please print and sign name _ Dille Tel phai No. I. Ile
tit rrcl Address Cih'/'Down Slate
Municipal Inspector to fill out this section upon application approval:
-- Name Da '
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