B-17-88 REPAIR SEAWALL The Commonwealth of Massaeuse
Department of Public �pp
Massachusetts State Building clWART 8 Al 8: 2j
Building Permit Application for any Building other than a One-or Two-Family Dwelling
is Section For Official Use
60 Building Permit Number. Date Applied: I Building Official:
SECTION 1 LOCATION(Please indicate Block 8 and Lot♦for locations for which a street address is not available)
CIc -2
No.and Street City/Town Zip Code Name of Budding(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here O or check all that apply in the two rows below
Existing Building O Repair[3 Alteration O I Addition 13 1 Demolition O (Please fill out and submit Appendix 1)
Change of Use O Change of Occupancy O 1 Other J1 specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes O No 0
Is an Independent Structural Engineering Peer Review requ �I Yes O No 13
`
Brief Description of Proposed Work:_/?1 a l,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 314) 0
Existing Use Group(s): Proposed Use Group(s):
SECTION*BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)A Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION S:USE GROUP Check as applicable)
A: Assembly A-1.0 A-20 Nightclub D A-3 O A4 O A-5 O B: Business O R Educational O
F. Fact F-10 F20 - H- High Hazard H-1 Cl. H-20 H3 0 H4 O H-5 O
1: Institutional 1-10. 1-2 O 1-3 O 140 M: Mercantile O R: Residential R-10 R-2 O R-3 Cl R-4 O
S: Storage S-1 O S-2 O U. Utility O Special Use D and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check'zs
IAD IBO IIA0 1180 11IA0 11180 1 IVO VAD VB0
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal
Water Supply: Flood Zone Information: Sewage Disposal A trench will not be Licensed Disposal Site O
Public O Check if outside Float Zone O Indicate municipal D required D or trench or specify:
Private D or indentify Zone: or on site system O permit is enclosed D
Railroad right-of-way: Hazards to Air Navigation: 4J! t lichgk.l'.nnn1i-1"N!n kev L-%%-Pry ts%:
Not Applicable D Is Structure within airport approach area? Is their review completed?
or Consent to Build enchsied D 1 Yes D or No D 1 Yes O No O
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Cede: User Group(%): Type of Consinution: (kcupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
2 1 - C.aL-I-1✓D VDF-�_u
2-j 17 MIAL45D TO N
SECTION 9 PROPERTY OWNER AUTHORIZATION
Name and Address of Proper O er
Dl 's �� ; 61� u/rs S� s IVa,
Name(Print)(Print) No.and Street City/Town Zip
Property Owner Contact Inioatnation:
—tT("/� .
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 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(Itbuilftwis lean fban3OW cu.It of enclosed space and or not under Construction Control then ebeek hent D and Section M
10.1 Rdx6hwW 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 GenaalContrnctor
me&'T� S�L7i�P tpl e (fit
Company
Name of Person Responsibje for Construction License No. and Type if Applicable
Street Address C ty/Town State Zip
Tele hone No. inenr Telephone No (cell e-maH amidress
SECTION ii:womig QC*jPX0=IMMOM APTIL)AVn*(NLG.L c.1S'Z.I 25C
A Workers'Compensation insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with'thb application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a si Affidavit submitted with this, Iicationt - Yes G No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) 'Pohl Construction Cost(from Item 6)�$
t.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)
S.Mechanical $` Enclose check payable to
6.Ti>ka1 Cult . $ / contact municipality)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 contaige d in this
application is true and accuratetothe best of my knowledge and understanding.
Please print and sign name `-� :L J� Title Tele 91�7� pate
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: �f ftp
Name Date