0010 PRESCOTT STREET U2, BPA-17-139 C>0 s
r4!
The Commonwealth of Massachusetts
Department of Public Safety 20 11 KAR -3 A 4� 0
Massachusetts State Building Code(780 CMR)
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)
C� No.and Street City/w Zip Code Name of Building(if applicable)
SECTION 2.PROPOSED WORK.
_n Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
�y Existing Buiidin Repa' Alteration ❑ 1 Addition❑ I Demolition (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ I Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
ld
Is an Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work: Nn1k A"01
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) E3
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(jq.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❑ B: Business ❑ E. Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H;j❑ H-5❑
I: Institutional 1-1❑ I-2❑ 1-3❑ 14❑ M. Mercantile❑ JR. Residential R-113 R-2 Cr R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility[31 Special Use❑and please describe below:
Special User
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 111 IIA 13 IIB ❑ IIIA 13 11111 E3 IV C3 1 VA 13 VB C3
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:it
h Permit.Water Supply: Flood Zone Information: Sewage Disposal• Licensed Disposal Site
Public It Check if outside Flood Zone Indicate municipal A trench w knot be P
Private❑ or indent' Zone: or on sites stem❑ required or trench or specify:
dy y permit is enclosed❑
Railroad right-of-w : Hazards to Air Navigation: IA I Iistoric_Cuminksion Revi�.sy 11roce,s:
Not Applicable V Is Structure within airport a_pTach area? Is their review comple d?
or Consent to Build enclosed❑ Yes❑ or No qV 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:
SECTION 9. PROPERTY OWNER AUTHORIZATION t
Name and Address of Property Owner
-AA-1Ve 160
Name(Ppa6 No.and 9treet City/Town Zip
Property Owner Contact Information:
1�7 CIPAI
Title Telephone No.(business) lephone No. (cell) e-rhailQdoss
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.(Ptease ftll out Appendix 2j:
f buikliIn is less than 35,000 cu.&of encbsed s and or not under Construction Control'thm check here 0 and skip Section 10.1
10.1 Re redProfessional Responsible for ConstrucH64 Control
7.,.
Name(Registrant) Telephone No. e-madiffre4 Registration Number
ZeWI4.vG/-)Rt jk-;'do of -'Ln C,s 1-9-/R
Street Address City/Tovkd State Zip Discipline Expiration Date
10.2 General Contractor
Company Name /
rz .c/oN CS"
Name of P =son Responsible for CUstruction License No. and Type if Applicable
It* �e8/,a,c>G Aye ty ��•O�Pa�D y M4 C?/ ? o
Street Address q �y City/To� State Zip
Telephone No.(business) Telephone No. cell e- ' a ress
SECTION 11.1 Olt FhS'MMPEN.AITION WSURANC.B AFFilMU 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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No
SECTION 12.CONSTRUCTION.COSTS.AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ r4,1, 6 -," Building Permit Fee-Total Construction Cost x_(Insert here
Z Electrical $ zS-ee appropriate municipal factor)-$
3.Plumbing $ /-S-400
p
4.Mechanical (HVAC) $ Note:Minimum fee-$ (contact municipality)
5.Mechanical Other $ Enclose check payable to 4i� gginn
6.Total Cost $ 00 .� (contact munki ali )and write 69ck 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 is true and accurate to the best of my knowl ge.and understanding.
L✓il/ �7� 9 � t l7
Please print and sign r9ne Title Telephone No. Date
Street Address Cityown State Zip
Municipal Inspector to fill out this section upon application approval: ��t?
Name Date