0122 BOSTON ST - BPA-16-1094 REPAIRS & REMODELING '-!M429-
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The Commonwealth of Massachusetts
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Massachusetts State Auddmg Code(780 CMR)
1 Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
1 Building Permit Number: Date Applied: Budding Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
/ 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❑ 1 Alteration ❑ 1 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 ❑
Is an Independent Structural Engineering Peer Review required? Ir Yes ❑ No ❑
Brief Description of Proposed Work:
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(R.)
SECTION 5:USE GROUP(Checkas applicable)
YNightclub
- -
A: Assembly A-1❑ A-2❑ Nib htclub ❑ A-3 ❑ A4 13A-5❑ B: Business ❑ E: Educational 13
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 13H-2❑ H-3 ❑ H-4 13H-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ Ft E3M: 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)
[A 13 111 IIA ❑ 111) [3 IIIA 13 IIIB ❑ 1 1V ❑ I VA VB C3
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❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \1�\,1 h t t ii.Gnnnucpi>i R, -w, i , e.,�:
Not Applicable❑ Is Structure within,airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 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:
�' 1 � ��3 S- -7007
SECTION 9: PROPERTY OWNER AUTHORIZATION ,
Name and Address of Prop rty Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: `
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Nirme Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding permit application.
SECTION 30:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If budding 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 Res onsible for Construction Control - -
• Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
/, - - - - -
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Compan Name
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Name of Perso,�j�esponsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
70
Tele hone No. business Telephone No. cell e-mail address
SECTION 11:4l'OItKERS'COnu'GN5,1'110N INSU101,"Ct.AFFIUAwrr 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❑ No 13
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ 000 — Budding 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 $ Qi) (contact municipality)and write check 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
applica ' is=, ccurato the b gf my knowledge and understanding.
Please print and sign naiS. Title Telephone No. Date
z(o �l N� Lo��u N� o i g ro1
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date