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1 BOARDMAN ST UNIT 4 - BPA-16-878 WINDOWS S S caL 3 �P The Commonwealth of Massachusetts Department of Public Safety An f Massachusetts State Building Code(780 CMR) lT w Building Permit Application for any Building other than a One-or Two-Family Dwelling I (This Section For Official Use Only) `J 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) IlY! No.and Street City/Town Zip Code Name of Building(if applicable) — 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 Building❑ Repair❑ Alteration) ' I Addition❑ 1 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 ❑ No M5 Is an Independent Structural Engineering Peer Review required? Yes ❑ No Brief Description of Proposed Work: Ren QCL o D l VtNJ W tVl OGJ C 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.) 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 13A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ - H-3 ❑ H-4❑ H-5 111: Institutional I-1 ❑ 1-2 111-3❑ 1-4 C1M: Mercantile❑ R: Residential R-10 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 13 IIIB ❑ I W1 1 VA E3 VB E3 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❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required❑ or trench or specify: 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: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner ' GiPr� N4110 tiior �Qcxtrr��rah Sf `� 7� /� , WqW Name(Print) No.and Street City/Town Zip Property Owner Contact Information: () co hw e W —7()Vo Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes da l+ �'e,cu;ces IIS/j kfA Jr` SaIecx MA n1 T70 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 appticaiion. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If 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 rIS r .� Name egish t) r Teleph �e 1 o. e-mail address Regis alio Number at �aYP�, t& Oil�i76 _ 26be Street Address City/Town State Zip Discipline Exptratio Date 10.2 General Contractor Company Name 7vrL2�/ rr'rS — ©.� r1733 Name of Perso Responsible for Construction License No. and Type if Applicable I I N ke-m-N . {- l e kv-, M4- Loi q7d Stree�ess City/Town State Zip Tele hon No. (business) Telephone No. cell e-mail address 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 ust be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the is ante of the building permit. Is a signed Affidavit submitted with this application? Yes WNo ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor 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) 5.Mechanical (Other) $ Enclose check payable to 6.Total Cost $ O (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering lame below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application i tr e nd urate t the best of my knowledge and understanding. \ i Q ' L L � y _*Ito Please prim�S i$gn n3mer ���� Title Telephone No. Date �� e Street Addres O / City/Town Stat Zip MA olq1�) Municipal Inspector to fill out this section upon application approval: 1'++' �V ), NanVe Date