93-95 CANAL STREET BPA-17-195 i
U) The Commonwealth of Massachusetts
0— Department of Public Safety
� 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: 2 Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
C� 93-11 Q10 T7
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2-PROPOSED WORK.
Edition of MA State C e used If New,Construction check here❑or chec
.kAfi 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 ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
AA
,
AA
Gam ' oYZ-
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): C'004 1 Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 2
Total Area(sq.ft.)and Total Height(ft.) c7 2�
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ 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❑
I: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 111 ❑ IIA ❑ IIB O IIIA ❑ IIIB ❑ 1V. ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply Ole
Flood Zone Information: Sewage Disposal A trench will not be Licensed Disposal Site 01
Public� Check if outside Flood Z e❑ Indicate municipal required❑or trench or specify:_,
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of--way: Hazards to Air Navigation: jA 1 iistoric Cunnni�siat Re�'ig��.a'roicas:
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: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
7 S'R'� . �7 7 3
L�-a
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner �•/�,
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
ll //
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the roperty 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 rmit application.
SECTION I&CONSTRUCTION CONTROL(Please fill out Appendix2j:
f budding is less than 35,000 cu.ft.of enclosed s ce and or not under Construction Control then check here D and skip Section 10.1
10.1 Re tared Professional Responsible ffoorConstructiori Control
ZICP Ca ,lc t2a IF.22-
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
r�p u cs - 06�7 S �
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address c� City/Town State Z*
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Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:4V)RKERS'COMPENS TION WSURANQ AFFIL)AVff' M.G.I:.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 0 No 0
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ 79>C"
1.Building $ U20 Building Permit Fee-Total Construction Cost x_(Insert here
2 Electrical $ appropriate municipal factor)a$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee-$ (contact municipality)
S.Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my none below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and ac rate to the best of my knowledge and understanding.
Z-42-C)
P ase p ' t sig nun _ TTitle elephone No. Date
Ad _City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date