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318 DERBY STREET - BUILDING JACKET 318 DERBY STREET 9 C(ZO55 Certificate Number: B-16-1153 Permit Number: B-16-1153 Commonwealth of Massachusetts City of Salem Thisis to Certify that the ....................................................................................Building........................................................................... located at Building Type .................................I...............................318-C-2B DERBY STREET.................................................................. in the .....................................City.of Salem ....................................... Address ................................................. Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY Final ok tjs TURTLE ALLEY CHOCOLATES C/O HALLIE BAKER This Permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires ............................... Applicable........................ unless sooner suspended or revoked. Expiration Date Issued On: Monday, November 28, 2016 � O Commonwealth of Massachusetts City of Salem ti - 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 Return card to Building Division for Certificate of Occupancy , Permit No. B46.1153 ` PERMIT TO BUILD FEE PAID: $110.00 t DATE ISSUED: 10/11/2016 - This certifies that 318 DERBY ST NOMINEE TRUST GOLDBERG ANDREW`D has permission to erect, alter, or demolish,a.building,,_318=C72B DERBY STREET r. Map/Lot: 340485-855 as follows:, Other Building Permit LIMITED ALTERATIONS: ADDING A'BAY SINK; SOME DEMO,, FRAMING FOR SINK INSTALL @ TURTLE ALLEY CHOCOLATES Contractor Name: MARC J.SEARS DBA: WOOD LAB CUSTOM BUILDERS Contractor License No: CS-104405 f i}r l' /l Vjr 10/11/201$ Building Official /f`'t Date J may perm oneft shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within s mol after issuance.The Building Official may gra nmore extensions not to exceed six months each upon written request. All work authorized b this permit shall conform to the _-c'— y pe approved application-and the approved construction documents for which this permit has been gramed. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoningby-laws and codes." - Thispermit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public Inspection for the entire duration of the work untilthe completion of the same.. ^- 1 , The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. .. - H IC#: 182598 Persons contracting with unregistered contractors do not have access to the gustar*fund'(asset forth In MGL c.142A) . Restrictions: Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. Commonwealth of Massachusetts i Citv of Salem 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595-x5'641 _ T Return card to Building Division for Certificate of Occupancy ., Structure _CITY OF SALEM BUILDING .PERMIT= Excavation '*HERMIT TO BE POSTED IN THE WINDOW` , Footing INSPECTION RECORD t: Foundation - to Framing - Mechanical INSPECTION: ¢� Insulationj BY DATE Chimney/Smoke-Chamber t Final Plumbing(/GadE Rough:Plumbing Rough:G - " , Final - 111111121111111 Electrical r Service Rough Finalgo _. � . . to �l •, '. _ . Fire Department Preliminary w - Final a Health Department a.- Preliminary Final Commonwealth of Massachusetts a Citv of Salem 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 Return card to Building Division for Certificate of Occupancy Permit No. B-16-1153 PERMIT TO BUILD FEE PAID: $110.00 DATE ISSUED: 10/11/2016 This certifies that 318 DERBY ST NOMINEE TRUST GOLDBERG ANDREW D has permission to erect, alter, or demolish a building 31 8-C-2BDERBYSTREET Map/Lot: 340485-855 as follows: Other Building Permit LIMITED ALTERATIONS: ADDING A 3-BAY SINK; SOME DEMO, FRAMING FOR SINK INSTALL @ TURTLE ALLEY CHOCOLATES ` Contractor Name: MARC J. SEARS DBA: WOOD LAB CUSTOM BUILDERS Contractor License No: CS-104405 ` 10/11/2016 Building Official Date This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official may grant one or more extensions not to exceed six months each upon written request. 11��1\ All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officialsareprovided on this permit. HIC#: 182596 'Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A). Restrictions: Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. Commonwealth of Massachusetts r. a a City of Salem 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595x5641 Return card to Building Division for Certificate of Occupancy Structure CITY OF SALEM BUILDING PERMIT ° Excavation ��-PERMIT TO BE POSTED IN THE WINDOW Footing INSPECTION RECORD Foundation Framing Mechanical Insulation INSPECTION: BY DATE Chimney/Smoke Chamber Final / ZU ,f# h. Plumbin -/Gas Rough:PlumbinkkY ///O-%�J( !��✓1Z Rough:Ga Final V�41 IV Electrical Service Rough Final Fire Department Preliminary Final 0 Health Department Preliminary Final Certificate No: 133-14 Building Permit No.: 133-14 Commonwealth of Massachusetts City of Salem Building Electrical Mechanical Permits This is to Certify that the BUSINESS located at - ---- - - ---- Dwelling Type 318 DERBY STREET in the CITY OF SALEM Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY 31-8 DERBY STREET PETITE ETOLIE I This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ........... unless sooner suspended or revoked. Expiration Date ------------ Issued On:Tue Oct 1,2013 y . GeoTMS®2013 Des Launers Municipal Solutions,Inc. --------...........- "--- ..."" "" - "-"---------------" i 318 DERBY STREET 133-14 GIS# w Iz -10826' P COMMONWEALTH OF MASSACHUSETTS U , CITY OF SALEM Block � � «i�;5� , �` �?'�:�,.. ��m; e x f Categ'o'ry': TENANTFIT-OUTR, Perint# 133;14' ""'` BUILDING PERMIT Protect#_,.p lj�&7S=2014 000283; Est Cost a", ;$31,500 00p"`' Fee Charged:',¢ $35150 ,, Balance Due:`' $ oo, �„ yp, PERMISSIONIS HEREBY GRANTED TO: Const Class:E " :,b � a?:` Contractor: License: Expires: Use Croup: FITZPATRICK COMPANY CONSTRUCTIO SUPERVISOR-CS 10309 Lot Size(sq'°ft) 41, `Owner: SAA GROUP Zonmg 'k Nr °m"'�t".a. '�, Umts Gamed: �, ja"E ?Applicant: FITZPATRICK'COMPANY Units Lost:` E A,T: 318 DERBY STREET Dig.Safe#. :;?�3r'a 7`" ...,i('ia'� ' sakux'a:;. ISSUED ON. 08-Aug-2013 AMENDED ON: EXPIRES ON: 08-Feb-2014 TO PERFORM THE FOLLOWING WORK: TENANT FIT OUT FOR BABY BOUTIQUE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbing Building Underground: Underground: Underground: Excavation: Service: Meter: Footings: - Rough: Rough: Rough: Foundation: Final: Final: Final: Rough Frame: Fireplace/Chimney: D.P.W. Fire Health Insulation: Meter: Oil: 1 House# Smoke: Final: Treasury: Water: Alarm: Assessor - Sewer: Sprinklers: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: BUILDING REC-2014-000309 08-Aug-13 1561 $351.50 Call for Perml'. � Occupy GeoTMS®2013 Des Lauriers Municipal Solutions,Inc. - Certificate Number: B-16-1153 Permit Number: B-16-1153 Commonwealth of Massachusetts City of Salem This is to Certify that the ..............................................I.............I.............Building........................................................................... located at Building Type .................................................................318-C-2B DERBY STREET.................................................................. in the .....................................City_of Salem Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY Final ok tjs TURTLE ALLEY CHOCOLATES C/O HALLIE BAKER This Permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires ...............................Not Applicable unless sooner suspended or revoked. Expiration Date Issued On: Monday, November 28, 2016 5-0 The Commonwealth of Massachusetts Department of Public Safety Yu/' Massachusetts State Building Coale(780 CbIR) [Building Permit Application for any Building other than a One-or Two-F mil Dw g (This Section For Official Use Onl ) Building Permit Number. Date Applied: Building Official SECTION 1: LOCATION(Please indicate Block#and Lot It for locations for which a street address is not available) 31 S SA wR 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❑ 1 Repair❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix I) Change of Use ❑ Change of Occupancy ❑ Other 0 Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 0 — Is an hxlependent Structural Engineering Peer Review required?/y Yes ❑ No []-� Brief Description of Proposed Work: 10 ✓ICE-rpu t,�et., WwI�C t ✓C�A � CLe) , Kee )AA c� w 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 CNIR 34) ❑ Existing Use Group(s): LSM Proposed Use Group(s): LIA 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 aEElivable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A 4 ElA-5❑ 1 B: Business E: Educational O F: Facto F-1 ❑ F2 Cl IL High Hazard H.1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional [-I❑ I-2❑ [-3❑ 1-4❑ M: bfercantile 13 R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a livable) [A 1B ❑ IIA ❑ IIB 7,,tr, .... ❑ f[IB ❑ lV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMAfer to 780 CMR 111.0 for details on each item) Water Su I Flood Zone Information: ge Disposal: Trench Permit: Debris Removal: PP Y Public❑ Check if outside Flood Zone❑ te municipal❑ A trench will not be Licensed Disposal Site Private❑ or indentify Zone: site s required-Oor trench orspecify:permit is enclosed❑.. Railroad right-of-way: Hazarr Navigation: \I-\I liaoric is vnk5wn Rcvlr,r P',xt Not Applicable❑ Is Structure wrportapproacharea? Is their review completed? or Consent to Build cndased❑ r No❑ ❑ No ❑ SECTION8:CON-T CERTIFICATE OF OCCUPANCY EditonofdeUseGrow p(s) f Construction: Occupant Load per Floor:Dncs the building containa..Sprinkler System?: ecial Stipulations:_ SECTION 9: I'ItOPElt'fY OWNER AU'I'11O1(IZA'rION Name and' Address of Property Owner 1 I sa4 W Ov 3ay C,4" ( �uclws— R� i,, u R� ✓�I Name(Print) j No. and Street City/"rown Zip Property Owner Contact Information: Titte Telephone No. (business) Telephone No. (cell) e-mail address if 1pylicable, the prktperty owner hereby authorizes c�J`^ �V N—ante Street Address Cityity/Fl l State Zip to act on the property owner's behalf, in all matters relative to work authorized by_this building ermit a2plication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft of,,dosed s ace and or net under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Res onsible for Construction Control Nano(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Ll LCIO- C011lpany :idle' m-J1, S I o 2�0 C Name of Person Responsib a or Constructio License No. and Type if Applicable r - con- tr -42.1 Street Address Cf /Town S/ttaate / Zip Telephone No. business Telephone No. cell a-remit address SECTION 11:\b'i:A:Kt11:5'((:)a IPIr.NS;YI'ICw iNSUIMN(T rru�,IVIT M.C.L.c.152. 25Q 6 A Workers'Compensation ❑nsunnce Affidavit from the MA Department of Industrial Accidents st be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the iss ante of the building permit. Is a signed Affidavit submitted with this a lication? Yes No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item T and Materials) m m'Total Construction Cost(fro Ite 6)_$ 1. Building 5 Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical S Appropriate municipal factor)-$ 3. Plumbing $ O Note: Minimum fee=$ (contact municipality) 1. Mechanical (FIV AC) $ U i. Mechanical Other $ Enclose check payable to 6.Total Cost S r (contact municipality)and write check number here SECTION 13:S[GI TURE OF BUILDING PERMIT APPLICANT By entering illy ,,role below, I hereby nitcst wtd r to pains and penalties of perjury that all of the information contained in this //application its true and a�c}c�ur�ate,ttoottile bes n novledge and understanding. PI s nit red sign ame Title Telephone No. 11/c//� 4tr,\ddress � it /"row, State Zip / JIurJJiicipal Inspector to fill out this section upon application approval: Name DA[c Permit Number t, APPLICATION FOR PERMIT TO ERECT A SIGN NOTE:BUILDING PERMIT MUST BE OBTAINED BEFORE SIGN IS ERECTED �t Location, Ownership and Detail Must Be Correct, Complete,and Legible _ Salem, Massachusetts 9114ns ( To the Building Inspector: Data The undersigned hereby applies for a permit to}(Erect, ❑Alter, o Repair a sign on the following described buildings: DistrictStreet Address Zoning XUrban RenewalArea a Entrance Corridor 1 318 Derby St. Salem MA 01970 _ ❑Historic District o No - ' e Goldberg Properties Management ' e q Telephone 978-922-0800 1 'floor retell - e Turtle Alley chocolates 2 floor condos Address 42 Rogers St. Gloucester.MA 01930 3 floor Telephone 976-2e14000 4 floor E-mail 2halffe2fgmag.wn How many businesses are in the building? 5 lfa corporate body,name frontage of re nslble ajrjCef Halle A.Baker ' Seaport Sign Works Building linear feet Construction Sups license No Applicant's Space(if multi-tenant) 21 linear feet Address 16 Graf Rd.Unit 10 Newburyport MA 01950 Property linear feet Telephone 970e63-4444 E-mail garyaseaportal9morks.com (Sign Owner o Sign Erector a Other: :i Proposed Signs (If more than three signs we prcposed. atach addit[onal sheets) Sign 1 Si n 2 SI n 3 ci Surface o Surface o Surface )(Right Angle to Building o Right Angle to Building ❑Right Angle to Building ❑Free Standing o Free Standing ❑Free Standing o Awning ❑Awning c Awning ❑Portable(A-Frame) ❑Portable(A-Frame) >(Portable(A-Frame) ❑Other(specify) ❑Other(specify) wgndaw gWNm ❑Other(specify) Sign Materials Sign Materials Sign Materials lemkale viny:a late Avwd Wnyl I lesSc and a6minum Sign Dimensions Sign Dimensions Sign Dimensions 28'z35" 21/4'x 33f4' Sign Area Sign Area Sign Area sq It pleme sea diagram act it sq it Sign Height(if free standing) Sign Height(if free standing) Sign Height(if free standing) Estimated Cost of Net Work $ pl5aoa1ego Type Sign Area To Be Removed? I Sign Owne o Surface sq it Li yes ❑no ❑Right Angle to Building sq it ❑yes a no ❑Free Standing sq R ❑yes o no Sign refs Authorized Representative ❑Awning sq it o yes ❑no n ❑Other(specify) sq it ❑yes ❑no P erty Owner IT 11 7 Planning I&Community Development Department Historical Commission 7 t� Building Inspector aea4yto rev City of Salem Sign Permit Application Worksheet NA �E11'v`rx ice`; 22-Sep-ls 1016 OCT 13 P 4- 56 1 Turtle Alley Chocolates 318 Derb Street Zoning(res/non-res) B5 Entrance Corridor(YIN) N Lot frontage n/a feet Building or tenant frontage 25 feet #of businesses on site Bldng dirt from street center <100 feet Multiplier 1 maximum area permitted 25.00 sq ft total proposed sign area 9.59 sq ft sign 1 Sign length 26.00 inches height 35.00 inches sign 2 Sign length 47.00 inches height 6.00 inches sign 3 length 41.00 inches height 4.63 inches sign 4 length 0.00 inches height 0.00 inches sign 5 length 0.00 inches hei 9ht 0.00 inches maximum area permitted 0.00 sq ft(per side) maximum#of signs permitted 0 signs maximum height permitted 0.00 ft tall sign 1 proposed sign area 0.00 sq ft length 0.00 inches height 0.00 inches proposed sign height 0.00 ft(approx) sign 2 proposed sign area 0.00 sq It length 0.00 inches height 0.00 inches proposed sign height ft Application meets guidelines set forth in the Salem Sign Ordinance Yes Recommend approval Yes Commonwealth of Massachusetts ` City of Salem { ` - 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 Return card to Building Division for Certificate of Occupancy - Permit AID: $0.00 6-1190 PERMIT TO BUILD DATE ISSUED: 10/18/2018 This certifies that 318 DERBY ST NOMINEE TRUST GOLDBERG ANDREW D has permission to erect, alter, or demolish a building—_,,,.318-C72B,DERBY STREET Map/Lot: 340485-855 as follows: Signs SIGN PERMITtAS APPROVED FOR: TURTLE ALLEY CHOCOLATES Contractor Name: Contractor License No: d 10/18/2016 Building Official Date . This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced wititin six months after issuance.The Building Official may grant one or more extensions not to exceed six months each upon written request. i All work authorized by this permit shall conform to the approved application a—nd the approved oonstfuctlon documents for which this permit has been granted. I . t All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in.a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. t The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials a provided on this permit. H IC#: - "Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth In MGL e.142A). Restrictions: / Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. 318 DERBY STREET 259-14 COMMONWEALTH OF MASSACHUSETTS CITY OF SALEM GIs#: _ 10826 = � Map Block: SIGN PERMIT Lat: Permit: =.Sign Category: SIGN° = ' Permit# '259 14 PERMISSION IS HEREBY GRANTED TO: Project# JS 2014 000637` s Est. Cost: $310.00 -�? 491y, _ ..,„, Contractor: License: Expires: Charged:TO a' � t1 Markarian Sign Co. Fee C Balance Due:$ 00 ' 7 Owner: NICOLE ABLITT Applicant: NICOLEABLITT DigSafe#,, o-'A'N -:,," :!AT: 318 DERBY STREET UseGroup a g ConstClass '; ISSUED ON: 23-Sep-2013 AMENDED ON: EXPIRES ON: 23-Mar-2014 TO PERFORM THE FOLLOWING WORK: SIGN PERMIT AS APPROVED FOR(PETITE ETOILE CORPORATION) THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: j a(: ;t GeoTMS®2013 Des Lauriers Municipal Solutions,Inc. ermit Number 1 .co APPLICATION FOR PERMIT TO ERECT A SIGN A fit♦' PC4ccr NOTE:BUILDING PERMIT MUST BE OBTAINED BEFORE SIGN IS ERECTED af Location, Ownership and Detail Must Be Correct, Complete, and Legible Ilk Salem, Massachusetts Date To the Building Inspector: The undersigned hereby applies for a permit to ❑Erect, ❑Alter, ❑Repair a sign on the following described buildings: ■ rban Renewal Area ❑Entrance Corridor (� ❑Historic District ❑None e of Buildingi Telephone t' floor l, • • ` L„ , 2 floor 3 floor Address ) Jar/ Telephone 4 floor E-maiF �f 'Cv 7 E V How many businesses are in the building? Frontage If a corporate body,name of res onsible officer Building linear feet prlpd�ICpaa Cor strtxtion btip's license L _ J Applicant's Space(if multi-tenant) linear feet Address Sr, �A � Property linear feet Mail Sign Permit to Telephone ,2 E-mail Pr 'eAAt4G*A'C'* Sign Owner ❑Sign Erector ❑Other. Sign 1 sligIn 2 Sign 3 ❑Surface ❑Surface ❑Surface ?Right Angle to Building ❑Right Angle to Building ❑ Free Angle to Building (o Free Standing ❑Free Standing o Awning landing ❑Awning r ❑Awning e(A-Frame) ❑Portable(A-Frame) ❑Portable(A-Frame) ❑Other❑Portable e 9ther(specify) 1—'�15�11��_ E ❑Other(specify) -rLZK Sign Materials � C Sign Materials Sign Materials 41 N Sign Dim Sign„H Sign Dimensions Sign Dimensions Sign Area Sign Area Sign Area .�j s ft s ft s ft Sign Height(if free standing) Sign Height(if free standing) Sign Height(if free standing) Estimated Cost of Net Work 10 Signatures Existing Siqns Type Sign Area To Be Removed? Sign Owne ❑Surface sq ft ❑yes ❑no Right Angle to Building sq ft ❑yes o no ❑Free Standing sq ft ❑yes ❑no EignOr r ditepresentative ❑Awning sq ft ❑yes ❑no❑Other(specify) sq ft ❑yes ❑no rty O er a ng&Community evelopment Department Historical Commission -------------- Building Insp F' 08124/10 rev '. 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 Section For Official Use Only) 'n Building Permit Number: Date Applied: Building Official: U, SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) ID No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2•PROPOSED WORK fl Edition of MA State Code used If New onstruction check here❑or check all that apply in the two rows below �( Existing Building❑ Repair❑ Alteration Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) 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 Engineerin Peer Review require ? �( Yes ❑ No ❑ I Brief Description of Proposed Work: ✓ni O' �l�'/!'<Cjr C l �IvNT Nk D z. J r`N U� + 1N 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 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 ❑ A-4❑ AS❑ B: Business E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage Sl❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IBD IL4. ❑ HB ❑ IIIA ❑ RIB ❑ IVO 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 EV A trench will not be Licensed Disposal Site❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ 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 their review completed? or Consent to Build enclosed❑ 1 Yes O or No❑ I 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: q-1D V j7Z>g"1 G �10`IZ M ,X -�D p over) SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner ��s- 42, P-w62,5 930 Name(Print) No.and Street City/Town Zip Property Owner Contact Information: X8.7 8691 r751 2► evrotll• cow l Title Telephone No.(business) Telephone No. (cell) J e-mail dress 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) (If building is less than 35,000 ca.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 102 General Contractor WOC)d (tib c.v6� uZ[J4e,4 Company Name IUIr.�"i. Name of Person Responsible or Construction License No. and Type if Applicable S "Ven4e4�J Rd E55 eV DA7 n � 21 Street Address City/Town State Zip Telephone No.(business) Telephone No.(cell) a-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVTT 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 0 No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ I,G oO 1.Building $ r -Oio Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ $DOD 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ [b 00Z) (contact municipality)and write check number here SECTION 11.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 th est of my knowledge and understanding. CDS o.Vuv- i1 _Soy_ �i68� �� 16 Please rint and sign name Titi Telephone No. Date c .kcve ZJ Y1ol X55Mc z1110 gi Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date The Commonwealth of Massachusetts �•' Department of Public Safety Massachusetts State Building Code (780 CMR) ssb r ��a Building Permit Application to Construct,Repair,Renovate or Demolish any Building other than a One-or Two-Family Dwelling Code and Other Requirements for Building Permits The Department of Public Safety has issued these building permit application forms so that municipalities across the state can move toward use of a single permit form and consistent permit application process. The MA State Building Code specifies the requirements of building permits and the applicant is advised to review and be familiar with these requirements in order to avoid some of the common permit application problems. Likewise the applicant should be aware that some municipalities require that the owner confirm, even prior to acceptance of the building permit application, that no outstanding property taxes, water fees, etc.exist. Filing Instructions 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be reviewed if construction documents, specifications, fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a check for the Building Permit fee. The fee may be calculated using the information to be supplied in section 12 of the Building Permit Application. The check is to be made payable to the local city or town where the work will be done.