PER APP 17-59 SMOKING BETTYS FIT OUT The Commonwealth of.
1 f- Department of Public ety
Massachusetts State Building Code(780 CMR
Building Permit Application for any Building otl�o}1l ANa2Uelkalkmily Dwelling
(This Section For Official Use Only)
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Building Permit Number: Date Applied: Building Official:
i SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
94 Lafayette Salem 0190
lm� 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❑ Alteration IX Addition❑ 1 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 Engineering Peer Review required? Yes ❑ No Q
Brief Description of Proposed Work:
Interior tenant build out of an existing restaurant&bar on the 1 st floor of an existing 2 story
buildinci. New work will include updating electrical, mechanical & sprinkler systems and new
finishes add new doors at front& side.
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): A2 Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 35180
Total Area(sq.ft.)and Total Height(ft.) 15540 30+/-
SECTION 5:USE GROUP(Check as applicabIe)
A. Assembly A-1❑ A-2 QI Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F. Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ I-2❑ 1-3❑ I4❑ M: 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 applicable)
IA [3 111 (3 IIA E3 IIB ❑ IIIA ❑ IIIBjp IV [3 1 VA VB 13
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:
A trench will not be Licensed Disposal Site❑
Public M� Check if outside Flood Zone l� Indicate municipal required or trench or specify:
Private 6 or indentify Zone: or on site system permit is nclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not ApplicableNo Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: 8 Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: TSpecial Stipulations:
I C_._c- V S {� tpeo V_:�- U t�-�'j s
1 31 QN L4.,e-yJ F=o (2- (� . )?tE2(fn i V S tq-iL_� CjD
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
RCG 17 Ivaloo St Somerville 01245
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Jim Gagnon 617-625-8315 617-512-2286 jgagnon@rcg-lic.com
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
lication-
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.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
Peter Pitman 978-744-0400 pfpitman@juno.com
Name(Re stran) Telep�one No. e-mail address Registration Number
Z ChvrC� 54- Sa2�., / &I
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Supreme Builders
Company Name
Scott Allison 069628
Name of Person Responsible for Construction License No. and Type if Applicable
58 Glad Valley Dr Billerica MA 01821
Street Address City/Town State Zip
781-x-6036 scott@supremebuilder.net
Telephone No.(business) Telephone No. celle-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FtE
Estimated Costs: (Labor -71
Item and Materials) Total Construction Cost(from Item 6)_$ a
1.Building $ q0jJQ D Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ VOD appropriate municipal factor)=$
3.Plumbing $ aoQ
4.Mechanical (HVAC) $ 6 6Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION :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 y knowledge and understanding. -
- pi� AlliSax ooniralw 7#1 _ 9Y3 66Sf
Please rint and sign name Title Telephone No. Date
51 Glad Valley Dr Billerica MA 01821
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date