15 FAIRFIELD STREET - BUILDING JACKET 15 FAIRFIM D STREET
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The Commonwealth M as T usetts
Department of Public Safety A. 11; 13
➢V \Massachusetts State Building C815( 1 Rl
Building Permit Application for any Building other than a One-or Two-Family Dwelling
_(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1 57 / i9 gI p,4Z/ sT S2 /�W 6/970
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION PROPOSED WORK
Edition of NIA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building I Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change Of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes a No ❑
Is an Independent Structural Engineering F<eer Review required? Yes ❑ No
Brief Description of Proposed Work: e5t 19Zi Ex/1r e)>„<,Cr
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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): IProposed 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❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ - H: High Hazard H-1❑ H-2❑ H-3 ❑ 1714❑ H-5❑
1: Institutional M❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-l❑ R-2❑ R-3❑ R4❑
So Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
!A ❑ Ill I1A ❑ IIll ❑ 1 II1113 HIB ❑ I IV ❑ 1 VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Dis os l Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P '
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: %I�,l,i� i ig �;....... I •'w,"_t r".v":
Not Applicable❑ 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: Use Group(s):_ rype of Constriction: _ Occupant Load per Floor:
,Y
Does the building contain an Sprinkler System?: __ Special Slipulalions:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
�CN�/aa/me and
/�Address
�o�f Prooperty Owner I", - ,!/ ,,r, /p
Name(Print) - .�, No.and Street City/Town Zip
Property Owner Contact hnforination:r'„1, ?,rr
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
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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 buihlin is less than 35,000 cu.U.of enclosed s ace and or not under Constmction Control then check here O and ski Sec Hon 10.1
10.1
Re istered 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
r,t � (Dear r I/�ar.A-IS IZ1.0 C51 vvti
Company Name ��aa
Sra-/h& C5L l�
Name of Person Responsible for Construction License No. and Type if Applicable !�
Street Address City/Town State Zip
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Telephone No. business Telephone No. cell a-mail address
SECTION 11:W0RKFRS'C0N1PhNSAl10N INSURA:NCE.Af I IDAVIF M.G.L.c.152.S 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 it signed Affidavit submitted with this application? YeAK,No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE'
Item Esthnated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ d O v CD Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ C) appropriate municipal factor)=
3. Plumbing $ — oo U
4. Mechanical (HVAC) $ Note:Minimum fee $ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ v o U (contact municipality)ity)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 istrruueea�nd accurate to the t of my knowledge and understanding.
\ KoI�R1" CJJ T L OWNq-k �-� 4/ 11 lJt
Please print and sign name Title Telephone No. Da
_ 0/57�7
Street Address City/Town State ip
41
Municipal Inspector to fill out this section upon application approval: "�✓
Name Date
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All dimensions size designations ®i This is an original design and must Designed: 12A 1/2014
given are subject to verification on TECHNOLOGIES 0 not be released or copied unless Printed: 12/11/2014
job site and adjustment to fit job applicable fee has been paid or job
conditions. _ order placed.
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