0026 NEW DERBY STREET - B-13-843 TAVERN ON THE SQ The Commonwealth of Massachusetts
# Department of Public Safety
Massachusetts State Building Code(780 CMR)
") Building Permit Application for any Building other than a One or Two-Family Dwelling
(This-SectionFocOfficial Use Only),,,.,..'m Building Permit Number Date Applied Building Ofhual
SECTION 1:LOCATION.(Pleme indicate'Block#,and Lot#for locations for which.a'street address is not available)
ts�esr. arc i a r �--
No.and Street 5:25Ci /To n Zip Code Name of Building(if appy ble)
SECTION 2:PROPOSED WORK, >,'kr
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 ❑ Addition❑ 1 Demolition '❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy Cl Other ❑ Specify: O
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 42
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING_UNDERGOING RENOVATION,ADDITION,.OR, -
�."
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(Checkers applicable):.
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use 0 and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE.(Check as,applicable) • .'� -IA El IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CM. 111.0 for details on each item)i,
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench 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 P,view Process:
Not Applicable❑ Is Structure within airport approach.area? Is their review completed?
or Consent to Build enclosed❑ Yes 0 or No❑ Yes ❑ No ❑
SECTION&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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s
- aSECTION go-PROPERTY 04VIVER AUTFIORIZATION '" ?• �`�;,:,., , "
Na4153 � �i � 1
me and Address of PropertyOwner _D -
/2 t/4.�n.,-h;wl .2 o t�v ,fay .C>/fl��+�t -
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.
., Q CONTROL(Please fill out Appendix 2)1: a
•' If buildin' vs less than 35,000 cuIOft of encl,ssed CONSTRUCTION
an%orNot der Construction;Contcol then check here'O andski` Section 10.1)": • '
101 Registered Professional Responsible for Construction Control". •'„. ` _ a- •"
Name Regime- stern Tee r�1Vo. e-mail addres Registration Number
LIA
Street Address Ci �wn �State
Zip Discipline Expiration Date
"10.2GeneialContractor"'w. `' _ `
F �.•ems -.
Company Name Alye i p '
�z6
Name of Person Resp ible for Construction License No. and Type if Applicable
3 Q.s VA.1Z;�
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
` ..;� - SECTION11:WORKERS`COMPENSATION INSUPANCE:AFFIDA�IT M:G.L.c.152:' ;2$C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑'
` *; • ' 'SECTION 12_-'CONSTRUCTION COSTS AND PERMIT PEE"
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ Oa 0tl Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ O,� 9 °� appropriate municipal factor)=$
3. Plumbing $
Note:Minimum fee=$ (contact mt ty)'
4. Mechanical (IIVAC) $ — � �J �\
5. Mechanical Other $ Enclose check payable to � J\
6.Total Cost $ K Yoe (contact municipality)and write check number here
SECTION,13;SIGNATURE-OPBUICDING%PERMIT APPLICANT- "r!'• ,„ _
By entering my name below,I hereby attest u99er the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the b y knowledge and understanding.
Please print an sign name Title e No. Date
(�,St*atezip
Street Address City/Town
Municipal Inspector to fill out this section upon application approval
_ .... .
„_ , _,..Naine:r -- Date 1...�..