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BPA 17-75 Zl �/C> c F�-(e,�1 / The Commonwealth of Massachusetts Department of Public Safety 1 Massachusetts State Building Code(780 CMR) L � 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: t A r SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available WAh--03 ST' 6441-1M A n 1 q 70 > No.and Street City/Town Zip Code Name of Building(if applicAle) -': SECTION Z 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 ❑ 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 Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: 6)Cf e 40✓— wU/'(K X&23 o'✓tti Z O f Qin LCK A dP 5 UeAP,4,ae- A/ Sr,4L-JA2Q-m/ A7r 5^01-96-- SECTION 1.9 i-.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 ❑ 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❑ I-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 ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 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❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑or trench or specify: 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❑ Yes❑ or No❑ 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: M -to C, .C_ 7 2 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner I WAr&& s t— SA�"�1 MAX1h`►'►L. ©► kHVMt5 SAS, MA 0/91 ca Name(Print) No.and Street City/Town Zip Property Owner Contact Information: v O NA 1, �A R L-oW Fo W4 L 1. N-40 PlevSTfe- Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes PATfOCU, M o S 6 4e© oSF,,00D CoN7-AAC;i&NG P060A 10l, MAIMLF_k AP MA D f9 'Ar Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this building t application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) building is less than 35AM cu.ft.of enclosed space and/or not under Construction Control then check here O and sldp Section 10.1 10.1 Registered Professional Responsible for Construction Control P,46kick /h y�-�-0� / 3i(- z 7-- Name(Registrant) Telephone No. e-mail address Registration Number 10o bad �rr118Ke�n nS� ° 9y� Street Address City/Town State Zip Discipline Exp' ti Date U r /z 1 10.2 General Contractor Company Name fid/G - /3 *Z.7- n RA !R 'CK OS600P C51. Cs- 0 9/6 't3 Name of Person Responsible for Construction License No. and Type if Applicable X M! PIT- Street I -Street Address City/Town State Zip '7 74, ' p„ / v _ _ �cz i�Y circ aSG'mooCo� �►��S_4C O n Telephone No.(business/ Telephone No. celle-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.152.§25C A Workers'Compensation Insurance Affidavit from the MA Deparhnent of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the 1 uance of the building permit. Is a signed Affidavit submitted with this application? Yes No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Item and Materials) Total Construction Cost(from Item 6)_$ 170, Om 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ //10 0 p p (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereby a under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the of owledge and unders anding. y, fi 0,/007 oWN6 1 pr'RIu� OS6WP 056mP P.410-7116 � CPV7,V1e1-,n6— Ple e print and sign nameTitle ^ Telephone No. Date pp^� ^/ Street Address City/Town State Zip ( oZ Municipal Inspector to fill out this section upon application approval: Name Date