0062 WHARF STREET - BPA-15-43 $ss � �3LF3I
0 CA A , 0 GI,13 RECEIVED
PECTIONAt SERVICES
The Commonwealth of Massac usetts
Department of Public Safety
V Massachusetts State Building Code(780CM419 JAN 12 A 10: 59:
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 k and Lot N for locations for which a street address is not available)
Cps '\A, Q C 5� . PIA C)\S-10 �nn C-C)o`-'-
No.and Street City/Town Zip Code Name of Building(if applicable) .
I SECTION 2 PROPOSED WORK
Edition of NIA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repai Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix t)
I
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 required? Yes ❑ No ❑
Brief Description of Proposed Work:
�1 sS e �c
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 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❑ I B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ I H: High Hazard F1-1❑ H-2❑ H-3 ❑ HA❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION ME(Check as applicable)
IA ❑ Ill ❑ IIA ❑ IIB ❑ 1 111A ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppl Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
ublic V P Check if outside Flood Zone❑ Indicate mmoicipal A trench will not be- Licensed Disposal Site
Private❑ or indenti(y Zone: or on site system required❑or trench or specify:❑ permit is enclosed❑
Railroa
Nut d right-of-way- Hazards to Air Navigation: Vn I I. 1 n r •innm ..... I:o...,....I r,,,,,,�:
Applicable HazardsIs Structure within airport ap lah a trea? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or INNIP, Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:_ Occupant Load per Flour:.
Uaes the built iuy,contain.m Sprinkler System?: ._ Special Stipulations: __
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address ofProperty Owner
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Name(Print)—) No.and Street City/Town Zip
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Property Owner Contact In(onnation:
Title Telephone No.(business) Telephone No. (cell) e-mail address
Iff ap1plicable,the property owner hereby authorizes
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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 buildingis less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor -
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Company Mme
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Name of Person Responsible for Construction License No.
and Type if A plicable
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Street Address City/Town State Zip
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Telephone No. business Telephone No. cell e-mail address
SECTION 11:WURKEILS'CONIP6NSA110N INSURANCE AFPIDAVII' 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 ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) 'iota!Construction Cost(from Item 6)_$ fJ u MJ-0 0
1. Budding $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
d. NIechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
3. Mechanical Other Is Enclose check payable able to
6.Total Cost I $ 5 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, [hereby attest uud the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best o y wledge and understanding.
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Please print and sign name Title Telephone No. Date
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Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date