0001 LEE FORT TERRACE, COMM. BLDG. BPA-17-136The CoriT><ii' hwealth of`Massaehuse
Deponent of Public Safety
kfassachusetts=State Building Code(780 CMR)
r'Building Permit Application for any aui;#ingotherl than a One or TWo-Famrl}l wehing$;
r this Sec40 For Official Use Only) ...
1
Building Permit Number: Date Applied Building Offiaal.
sECTTON 1:LO"CATION,(Please rn4t,*id>i)`gck'#and Lot forlocatione for which a street addie"'a Ss itt)t a aUable)
Zi Code of popticoble)No.and Street City
SECTION Z PRdPOSEI3 WORK,.
Edition of MA State Code used If New Construction check here 0- 0' rcheck all that apply in fire two rows below
Existing Building Repair 0 Alteration 0 ; .Addition D Demolition D (Please fill out and sulimif A' odix.l)
Change of Use D Change of Occupancy , Other O Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No Q vT
is an Independent Structural Engineering Peer Rgview required?Yes . No c
Brief D ription of Pr posed Work:
e.
SECTION 3 COMPLETE THIS SEC'T'ION If EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,0R
rC)/
C,
CHANGE IN USE OR OCCUPANCY
7 O Check here if an Existing Building Investi !tion jind Evaluation is enclosed(See 780 CMR 34)
Existing Use Group(s) Proposed Use Group(s):
SECTION d-BUILDI G 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 asapplicable) ..
A: Assembly A-1 O A-20 Nightclub 0 A-3 0 A4 A-50 1 8: Business E: Educational
F: Facto F-1 D F2 0 H: High Hazard H-1 H-2 H-3 H4 0 H-5 0
I: Institutional 1-10 I-2 -1-3 O I4 O M: Mercantile R: Residential R-10 R-2 R-3 D R4
S: Storage S-1 S-20 U: Utility Special Use O and please describe below:
Special Use.
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA D IB IIA IIB IIIA O IUB O IV O 1 VA VB t7
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 O Check if outside Flood Zone O
A trench will not be Licensed Disposal Site O
Indicate municipal
required 13 or trench or specify:
Private or indentify Zone: or on site system permit is enclosed O
Railroad right-of-way: Hazards to Air Navigation: MA I lisoric Ccmnnivsiosn Review('necks:
Not Applicable Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed Yes or No O 1 Yes D 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:
c W 1a -7 l NOT) F X
C4_>&,L,4Eo AA p v . 3 11 1 t
y
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
90
4Le k S1 aE+j I i i Q (A N-MA 011-2-0
Name(Print) No.'anditreet
r
City/Town Zip
Pro My Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
l(appiicab e,the property owner hereby authorizes
e Alto t7'Lem
NaiveStregt Address City/Town State Zip
to act on the ro ;r oviner's tie a f;in ap utatters elalsvi twwork:authorized this bund n unit a !kation.
SECi30N.10:CUNSTR[1CTION CONTitd t(f'feasel Qut APperldix 2f
f buildut ,is less than 35;000 cu Et,of enck>sest s ''anti or not underrConstru46 Control then cheat here O and skip Section 101
10:1 Re 'stered PwfesslonA Rea onsible for'Conshvcfioit Control
Name(Registrar) T le o e No. a-mail address Registration Number
de-
Street Address' City/Town State Zip Discipline Expiration Date
104 General Co"ntrastor
Com any Namg
M EM10 Covera- s o q Ll L4
Name of Person Responsible for Construction License No. and Type if Applicable
3 4GC 12t`V0151de AAJ. JAIE
Street Addr.'ess City/Town State Zip
l Co
Telephone No.(business)Tele hone No. cella-mill address
SECTION 11:'WOxxt:l6'COMPENSATION LNSWR INCE AFFIVAM QVLG.L c.152.j 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 D No D
SECTION I2:.CONSTIIUCTION:COSTSAND'PERMIT FEE `
Estimated Costs:(Labor
tem
and Materials) Total Construction Cost(from Item 6)-$
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)
plc` Enclose check payable to
6.Total Cost q S o (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entermg my rune below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application i%s true and accurate to the best my knowledge and understanding.
nLQPZJQ - Lal A Okad' j
Ple print ind sign n me Title Telephone No.Date
WOW 0 re, U4
Street Address City/Town State ZiprII I .. I
Municipal Inspector to fill out this section upon application approval:
LA Dn
Name Date