3 WITCH WAY - BPA (002) CITY OF S.UX2M, N'L-kss kCHUSETTS
BL ADLNG DEPART%MNT
` 130 WASHINGTON STREET,3"FLOOR
Tt L (978) 745459S
FAx(978) 710-9846
ICI\ BERLEY DRISCOLL
MAYOR THomAS ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/BU DING COJL�IISSIONER
APPLICATION FOR THE CONSTRUCTION;REPAUkRENOVATION,CHANGE IN U$E OR
OCCUPANCY,OR DEMOLITION OF ANY BUILDING OR STRUCTURE
This Seddon,tar ONklst Use Only
+ 8 Pennft,Proyeet- /
f PrI DaEss: Start End:
Canrnerltx
I
1.0 SITE INFORMATION
Loca*w Name: } h Building:
PMp"Address:
3 cdkkwG
Assessors MWModccoUParcat
�l cz� q�oRnuTloN
2.1 &wnw of Lermd
Name: rhucic,1 + 1 C d
Address
3 !�ti wa �eun m
W ,r � Aai97o
Telephone:
22 Om w w lases of bWlWna or s*ucw e
Name: Cd
Address:
Telephone:
3.0 AGENCY OR AUTHORITY AUTHORIZING CONSTRUCTION
Agency Name: Sc,rn
Address:
Agency Project Number
Pro(ed Manager Name: Tel:
4.0 PROFESSIONAL DESIGN SERVICES:.
4.1 Registered Architect
Name: Seal and Siignahm,-'
Address:
Fax
42 Regiisbred Protesslond Engineers: Wu=M&,at sM- s and..2"b appreagmt)
Name: - Seal mw Swwkw*
Addresm
Telephone: Fax
77.
.Ct_Responsibi�lY•. ���. .-. ,.
Noma S and 3tg iahuis' .
Address:
Teleplone:- Fax
Area of Responsibility:
Name: Seal and Signature `
Address:
HArea
of rebility:
5.0 DESIGN AND CONSTRUCTION UTIUZINO MGL C 112 SECTION 81R EXEMPTIONS
(See note below)
Contractor
Name: �II l 2 r
Address: 1, 3 `1q (J O s h(03 S`-
�4l�ulR1� h^� Da3��I
Area of responsibility: p 7t n/
'License Number. Date of 199tpiratkur
Telephone _ g g Fax: �;g �_•, 5 0
Contractor
Address: j3 5� WuS�llhy in S7c
Ha6'lour 144k
Area of responsibility: GU �� C z f 0 c¢{&c AC t7
License Number. O 0,q Date of Expiration: 8
F
ephone: 7��- �� / Fax 8 ( QYS0
ntractor
me:
Address:
Area of responsibility:
Ucense Number. Date of Expiration:
Telephone: Fax:_
Note: For portions of work utilizing exemptions of MGL c 112&81R complete the sectlon above.
Use additional sheets if necessary and attach to application.
6.0 PROFESSIONAL CONSTRUCTION SERVICES; `
8.1 General Contractor � 1M 0 �}f
Address: 13 7� W(4Shlag bn C4-
Telephone: �c — �_ Fax:
Responsible In Charge of Construction:
7.0 CONSTRUCTION DOCUMENTS -to be prepared by applicant
Item as Applicable
7.1 Plans (Note 1 this page) Submitted Incomoiete Not Required
if 7.1.1 Architectural i
7.1.2 Foundation
7.1.3 Structural
7.1.4 Fire Suppression
7.1.5 Fire Alarm
7.1.6 WAC
7.1.7 Electrical
7.2 Specifications
7.3 Structural Peer Review
7.4 Structural Tests & Inspections
Program
7.5 Fire Protection Narrative Report
7.6 Existing Building Survey
7.7 Workers Compensation Insurance
7.8 Other Documents (Specify)
(Energy Narratives, etc.)
Note 1 Areas of Design or Construction for which Plans are not complete at the time of
'4 this application must be identified herein. Work so identified must not be commenced until this
application has been amended and proposed construction has been approved by the
Department of Public Safety District Building Inspector having Jurisdiction.
8.0 COMPLETE THIS SECTION FOR NEW CONSTRUCTION ONLY
For Existing Buildings Proceed to Section 9.0
Num tortes above Number of Start
Grade G
Story Height Floor Area Per Floor
Total Building Height — To Area Above
above Grade/ l Grade ('(,
Total Bui depth bekyw. Total Building Area
Grade.
rief Description of Proposed Work:
8.2 USE GROUP AND CONSTRUCTION CLASSIFICATION.(New!Construction Only).
USE USE GROUP SUBmCATEGORY• CONSTRUCTION
(d ,aPP1e� ( as applicable CLASSIFICATION
A ,. Asswn A-1 A-2' I(3 A=4 1A
B Business 18
E Educational 2A
F Factory F-1 F-2 2B
H High Hazartl H-1 H-2 H-3 H-4 2C
I Institutional 1-1 1-2 1-3 3A
M Mercantile ' 3B
R Residential', R-1 LR-2 R-3 4
S Storage S-1 5A
U Utility 5B
Mx Mixed Use Specify:
Specify:
Sp Special Use
9.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
For new construction comolete s 7en
Addition ngRenovation Number of Stories atedChange in Use '
Demolition Existing
Approximate year of Area per floor(sf) Renovated
construction or renovation a
of existing building New• $ +
Brief Description of Proposed Work: RQ6hiilRXI S�I"`� ?U0d
!2 ' x �y ' 3 seg300n R"'rA, s x is p 7-. Deck t-0 f�' om
WirJuwS f-it be `J Ch`r y SiQ N Po.4d , Tr&s4 7b 6e �M�;
� t� to jlS Po' Ga V1 P�-'M r t
q f TUSE GROUP AND CONSTRUCTION.CLASSIFICATION(Existing'Bulidinge Only)'"
USE Grow e) EXISTINt3__ PROPOSED Change CONSTRUCTIOl0
Use. Hazard Use;, Hazard. Hazard CLAS3IFICAT10�1
("°t°s„b-catag°'» ; Group Index `Q;roup Index- IndeI " (J:b apgteaw )i
A Assembly 1A
B Business 1 B
E Educational , 2Ap
F Factory 2w ,
H High Hazard 2C'. ;
i Institutional. 3A '
M Mercantile 38
R Residential 4
S Storage SA
U Utility SB
Mx Mixed Use Hazard Index
Sp Special Use I I
Note: Include Hazard Index Modifier for Construction Type as applicable L_J
F
NSTRUCTION COSTS (See 780 CMR Appendix L)
Cost ' FeeCheck Number
at Construction 8 i Permit uldi
ng
(1)
3� qq7
10.0 AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR BU LDING
PERMIT(when applicable)
1. on behalf of the audwdzkV State
fAgency or Authority. hereby authorize. Do a"
for the building permit for project number,
i
f
Signature Oats
III
11.0 SIGNATURE OF BUILDING PERMIT APPLICANT
20S'jol bf pc)4
N,dkM
LJI c
g/o 7
Signfrev Oats
12. Certificate of Occupancy required on completion of project? _Yes No
inspector's Notes:
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SEP-21-2007 00:54AM1 FROM-NS RECYCLED FIBERS 0707449770 T-BTS P.D01/001 F-047
BAY STATE SURVEYING ASSOCIATES INC.
100 CUMMINGS CENTER, SUITE#316J, BEVERLY,MA_, 01915
NOTES:
LOCATION :_.a2AGr..'Sl1.C!!!755'.....«............_._.— 11 This is a mortgage inspection ctwey and not an
I,,g,,m nd awvey,therefore this plot Plan is for
SCALE : 1^ _ OATS :��!q�9�............. . mortgage Inspection proposes only.
B , 12 2 5 y P_G. 306 , _ z)This Ivey M bsaed on nmrey marks of othes.
REFERENCE : :..... ..,/_ 3)fivaml .rat ukW fences and tree lines do not
A v— necessarily,Indicate property lines.
�!...Q�`�!—141..... N yyhenera an offwd b 1'+ w[calk an lnmunent
..... mrvey is raemlmended to determine prop"
ec�n1 gyp,J lines.and my possible enaaoidments.
6)on""aiwYm m approximate,and are to be
The location of the bulldbtg1s)as shown,either used wily for the determinstlon of=mnl g.Not to
complied with the local zoning setbacks at the time of be used to eaab6eh prop"Ofles.
cons ruction or Is exempt hum violation enforcement action 6)In my protesdonal opinion the winding(s)are net
under Mass.G.L 1111e Vil Chapter 40A Section 7' located in the spooled flood hazard zone.as
donned by N.U.O.NIAPf �S�I D Z p I S �S�
La'T 9 4-
r
715
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OV M
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0
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