0055 HIGHLAND AVENUE BPA-17-201 HIGHLAND HALL, S204 (c) LK cosg y
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
Q (This Section For Official Use Only)
N Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street qddress is not available)
U 5 VA-
No.and Street City/Town Zip Code Name of Building(if applicable
1
SECTION 2 PROPOSED WORK
Edition of MA State Code used
If New Construction check here❑or check all that apply in the two rows below
Existing BuildingV Repair❑ Alteration OIL I 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 JO No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No F1
Brief Description of Proposed Work: 4rrr,at5=ct:; �?t l'h.-1 l r.�"t �,c h 11At Huff u .4 f4_-nn
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.) 3C c.!t` �tX,o
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5 13B: Business)M E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-111 R-2❑ R-3❑ R-4❑
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 ❑ 7IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Disposal Site❑
Public�- Check if outside Flood Zone❑ Indicate municipal 93A trench will not be V3 or trench or specify:
d
Private❑ or indentify Zone: or on site system❑ permit required enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process.
Not Applicable 9 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No 19 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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Narqe pnAddress of Property Owner V
Name(Print) No.and S eet Ci Town State Zip Code
City/Town"/
Property Owner Contact Information:
Title Telephone No. Owner's Signature
If applicable,the property owner hereby authorizes
Name Street Address Ci Town
State to act on the ro er owner's behalf,in all matters relative to work authorized b this buildingermit application.
Zip Code
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)Of building is less than 35,000 cu.ft.of enclosed space
and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
N� jL�A_q__7,y
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Name(Registrant) Telephone No. Signature Registration Number
1046 Ave
Street AddJess City/Town State Zip Discipline Expiration Date
10.2 General Contractor
), �),
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Company Name
Name of Person Responsible fo Construction icense No. and Type
&3 6
Street Address t� City/Town State Zip Code
-10 k0177
Tele hone No. business Telephone No. cell ontractor's Signature
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 issuance of the building permit.
Is a signed Affidavit submitted with this application? YesO No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 7)_$ , L9V
1.Building $ 0 p
Building Permit Fee=Total Construction Cost x$12.00
2.Electrical $ 0 Q a (Insert here appropriate fee)_$
3.Plumbing $
4.Mechanical (HVAC) $ XC2. 00 Note:Minimum fee=$80.00($5,000.00 and under)
000.
5.Fire Protection $
6.Sheet Metal $ Enclose check payable to City of Lynn and write check
7.Total Cost $ O 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 t e best of k o ledg and understanding.
a rtob) X ��
Please Print and Sign Name Titl Telephone No. Date
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Street Address City/Town State Zip Code