PER APP RELOCATE GRILL RM BAR B17-58 The Commonwealth of Massachusetts
Deparhnent of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
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(This Section For Official Use
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and tot#for locations for which a street ad` ess isnot—available)
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No.and Street City/Town Zip Code Name of Building(if app'' able _
SECTION 2-PROPOSED WORK.
Edition of MA State Code use If Neto Cons6ction check here d or check all that apply in the two ro belo
Existing Buil . i pair Alteration Addition 0 Demolition ❑ (Please fill out and Submit AppeWix 1)
Change of Use- ❑ 1 Change of Occupancy O Other 13 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:
K v v. r ...
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) D
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.) AIYA
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4 O A-5❑ 1 B: Business E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional 1-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use:
SECTION&CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB M111, IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 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 one❑ Indicate municipal trench will not be Licensed Disposal Sit
required❑or trench or specify:
Private 13 or indentify Zone: or onsite system❑ permit is enclosed❑
Railroad right-of-way: Hazards Air Navigation: NIA I tistoric Commission Revica�_Process:
Not Applicable [s Structure within airport approach area? Is their revs completed?
or Consent to Build enclosed❑ Yes❑ o o❑_ 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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
/Name and Ad ress of Prope Owner /� M
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Name(Print) J No.and Street City/Town Zip
Property Owner Contac Inform ion:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If ap 11 b the property owner hereby authorizes
Warne Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Pleasefill out Appendix 2)
f buildingis less than 35,000 cu.ft.of enclosed s e and or not under Construction Control then check here El 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
10:2 General Contractor
Company N p
ame of Person Res onsible for Constructionll-- License No. and Type if Applicable
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Street Address Ci /Town State Zip
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Tele hone No. usiness Tele hone No. cell a-mail address
SECTION 11:WORKERS'CONVENSATION INSURANCE AF.F11)AVr1' M.G.L.c.152:§25C(Q)
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 0
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)_$ _ 000
1.Building $ 0 U Building Permit Fee=Total Construction Cost x,(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $ J
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ 2L a o v (contact municipality)and write check number here
SECTION A 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 he best of my knowledge and understanding. y�
f/�Cfta f yy/
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Ple��d g m, e.. Se Title G Telep
Date
Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
i° ` � ��y 3//1
Name Date