BPA-17-242 The Commonwealth of Massachusetts
Department of Public Safety&�PR —5 A S- I 9
Massachusetts State Building Code(780
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)
914 R� l M Al 6 q�v
No.and Str et City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
( Edition of MA State Code used_.jW°1 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: RBD rlA>(s
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural EngineerinPeer Reviiew required? Yes ❑ No GP'
Brief Description of Proposed Work: &S jV Dfij/ 'r 5`4 6 . Qysle< M`+a tr46Vf nwA- h6$*cftPK d
r s tel-t K' •/
M q Z 41 :c h
r r9iSfti-}!G
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.) s dS
Total Area(sq.ft.)and Total Height(ft.) r Ey 4
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRU ON TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
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❑
Public 11Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench ors specify:-
fY:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way Hazards to Air Navigation: NIA 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:266cl_Use Group(s):C— Type of Construction: 8 Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
pll px�L_E
rs `.
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
C i 7 C� o "t l t�
Name(Print) No.and Street Ci own Zip
Property Owner Contact Information: 5e, I a (c,titi. r1 e re-e Q c.r �— t o Q I�5 5` '" ` ` .-k
- `� I - c _ t,U _ J LC ?t c
Title Telephone No.(business) Telephone No. (cell) e-mail address /J
If applicable,the pro rty owner hereby authorizes
MCA-116;1)_<4k_ 1 m c 961
Namet Street Adess ity/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)
building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
4e<�v iS
7/9- 2-8'11 _wry
lite(Regis ant) Te,leP hone NQ� e-mail addr Registra 'on Number
6yht I&IL PL �l �e hex) —e_ lny7A
6
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
1/.5
Company Name
CZ A 22 A /D 7 711 Vit, -Sri-rdc-�,a
Name of Perwh Responsible for onstruction icense No. and Type if Applicable
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Street Address City/Town State Zip
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Telephone No.(business) Telephone No. cell e-mail a_aKds
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.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 iss ance of the building permit.
Is a signed Affidavit submitted with this application? Yes(7No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 7AI •00 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
6.Total Cost $ ?j� (contact municipality)and write check number ere
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I here y attest un pains and penalties of perjury that all of the information contained in this
application is true and accurate tr7e best ofowledge and understanding.
>t41 ue4tV i `1�L 47-1- /All 7 �7
Please p ' t and sign na a 1 Title Telephone No. Date
fl�ep �I M,9 t3/'f acs
Pz
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date