0155 WASHINGTON STREET - BPA-14-1179 ADRIATIC rWtV
The Commonwealth of Massachusetts
Department of Public Safety
Pj Massachusetts State Building Code(780 CNIR)
Building Permit Application for any Building other than a One-or Two-Family D e g
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for whit s eet address is not available)
IS� ,u dLD
No.am Street City/Town Zip Code Name of Building(if applicable)
SECTIONZ PROPOSED WORK
Edition of NIA State Code used_ If New Construction check here❑or check all that apply in[lie two rows below
Existing Building Lk Repairer Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix l)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction IIOCWneut5 being supplied as part of this permit application? Yes ❑ No Et
Is an Independent Structural Engm,—rin.Peer Review required? / Yes ❑ No &
Brief Description of Proposed Work: -1 l! r e_e_ (.(P P"Ar
A
o a-
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDWON,VG
CHANGE IN USE OR OCCUPANCY rn
so
Check here if an Existing Building Investigation and Evaluation N enclosed(See 780 CNIR 34) ❑ QQ <
Existing Use Gruup(s): Proposed Use Grou p(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-f❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-S❑ 1 B: Business Cl E: Educational ❑
F: Facto F-1 ❑ F2❑ H: F i h[lizard H-1 ❑ H-2❑:. ' H-3 ❑ H-4❑ H-S❑
1: Institutional I-1 0 1-2❑ 1-3❑ 1-4❑ NI: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ 11B0 1 ILIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone O Indicate uumicipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indenlify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: I Hazards to Air Navigation: %I_A Ili 1 nu l.... tii n I ',q,
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
nr Conseut to Build endoscd❑ Yes❑ or NO❑ Yes❑ No ❑
SEC'r[ON S:CON'rENT OF CEit'rIFIC,kTE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:. Occipant Load per Floor_
Does the building Contain an Sprinkler SystenP: _ Special Stipulations:.
�i..1 a��'1-r''�l. f � �V111C-C DEL-1VLTR,�fJ
SECTION 9: PROPERTY O6VNER AUTIIORIZA"rION
Name and Address of Property Owner F
x�2i'Wtc. 2SST-6-)l2_r) u (sS cJ�rvf ;a'GMN sr r��:sxc F2/� DAF
Name(Print) No.and Street City/Town Zip
Property Owner Contact Informs{ion:
UI.�o lCJvTIp 194_ fa3 _ IL75 �? ?z ✓iniC�a�,:�i'cr�la�ro lzn�fal✓.co
'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)
ff 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
101 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address _ Registration Number _
Street Address City/Town State Zip Discipline Expiration Date
1y0�.2 Gpelieral Contractor
Company Name,
Nanie,o`f;;Persoti-Responsible for Construction License No. and Type if Applicable
3EGpv1/�)c�t= s� c�vF2r= �a.� �2/ S l
Street A-ldresss City/Town State Zip
f3 _ 2� 2 56 -3 _ 5'A " c Cil�'eo/%grra�Lr G' Z. • , cc�i71
'fete loin e No`business Telephone No. cell e-mail address
SECTION 11:lVORK1-K1;'C0%1PFNSA I KIN INSURANCE AFPIDAVI 1' M.G.L.c.152.9 25C6
A Workers'Compensation Insurance Affidavit from the NIA 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) 'fatal Construction Cost(from Item 6)=$
1. Building $ "o O Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ '3, a 2 appropriate municipal factor)=5
3. Plumbing $
d. Mechanical (HVAC) S Note: Mininnurn fee=$ (contact municipality)
S. Mechanical Other $ O, ?O rJ
Enclose check payable to
6.Total Cost S (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 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.
Please print and sign name "title Telephone No. Date
Street Address City/Town ^ State Zip
Municipal Inspector to fill out this section upon application approval: '!
Name it