10-12 WISTERIA ST - BPA The Commonwealth of Massachusetts
J Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwel in
(This Section F ' ial Use Only)
Building Permit Number; Date Applied: S Building Official:
\v SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is n
oravailable)
10-12A Vj1Srulg S Sr (aA,MA 019Z
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 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 r��yq�ired? Yes ❑ No IId'
Brief Description of Proposed Work: ld)SrAL A1Qk� �1n 51�11�(g
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) ❑ i
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(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ I 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❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 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❑ 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 Review Process:
Not Applicable❑ Is Structure within airport approach area? Is thew review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ 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 Proper Owner
i2oher+ i3 f ay9 Cum s /A gkeoem, o I4NS-
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
011 ne!
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 a6 matters relative to work authorized by this building ermft application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
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
10.1 Registered Professional Responsible for Construction Control
Sreaen kclNGr� 7$I . 33 S333 S9[eso4werncotsr'tata). 7 5 4`l CONa e c e trant T Iephone No. e-mail ad ress Registration Number
t�e�Ia ST �ZM t fo �g 01906
Street Address City/Town State Zip Discipline Exp�e
10.2 General Contractor
HASWO C 00971 rLXTIOA)
Company Name
STeoen VAlbrAtl r;n30-
Name of Person Responsible for Construction License No. and Type if Applicable
u kuxatl S I SayfJoS #A o I q06
Street Address City/Town State Zip
791 A33,5333 _$3k_/z33 SgcaS @ E4Sie�f1C(A97rXPo() A)01
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor 6 0
and Materials) Total Construction Cost(from Item 6)_$ /I It075
1.Building $ 7S'0 V Building Permit Fee=Total Construction Cost x_(Insert here
2 Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 1 1(07 S- ®L (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
application is true and accurate to the best of l d and understanding.
Please r' t and sign name Title Telephone No. Date
y S G�OS 4 A 0140
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date