278 DERBY ST - BUILDING JACKET The Commonwealth of Massachusetts
Department of Public Safety
I' .1,.P \laasaihu.eus titatr Building G�dr 1%80C\IR)-•rvrnth Editnm
City of Salem
Building Permit Application foran Building otherthanaI-ort-Famil Dwelling
(This Section For Official Use Only)
Budding Permit Number: Date Applied: Budding Inspector:
SECTION 1:LOCATION (Please indicate Block a and Lot M for locations for which a street address is not available)
2S w� S�le,n �er or S
No.and Street City /Town Lip Code Name of Building(if applicable)
V SECTION 2:PROPOSED WORK
If New Constriction check here❑or check all that apply in the two rows below
Existing Building Repair❑ Alteration ❑ I Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Other Specify: 2V\O e— Lca–
Are building plans andlur construction documents being supplied as part of this permit application? Yes 11110, No
Is an Independent Structural Engineering Peer Review
requir d? I Yes ❑ No
Brief U,gscriptiun roposed Work: e vv C d- l v U2
C of P.A &
�� 7 e- �' n
C48
�� � CO ✓�Lt/�\ % i
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUIL ING UNDEEMOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMA 3402.0) ❑
Existing Use Group(s): _3 Proposed Use Group(s): P
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: _57
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft)
SECTION 5:USE GROUP(Check as ap licable) I j I I
A: Assembly A-1 ❑ A-2r ❑ A-2nc O A-3 Ar A4❑ A-5❑ B: Business ❑ Wbelow:
F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑
1: Institutional I-I ❑ I-2 ❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please descSpecial Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA I8 ❑ IIA ❑ 118 ❑ IIIA ❑ 1118 ❑ IV ❑ VA
.% 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 it auL tdr Fl""d Lune Cl Indicate municipal❑
:\ trench tvdl not he Licensed C7i.pa.al Site❑
re9u,rcd O or trench �m spcafk:
('recite❑ or utJenuic Zone ur nn sde rr.tem ❑ permit is enclosed ❑ _
I Railroad right-of-wav: Hazards to Air Navigation: \I:\ Ih-6�n, t-� ... , .I"-, . Pn.,
\„t Apphad-la0 T btn�i lure tvthm aup, rt,ippru.tih arra' Is their rnnvn
e,ic„'cumpletrd'
,rrl i,n.rnt i,1Itod,l endi .rd ❑ 5rs❑ ..r\..❑ e, Cl \u ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
I:,itlnm ,l Cnlr _ .___ Lsc l,rupi,r ft pr..t l,in.truditn: I � lLiup.utt l�ed Pur FL�ur ____
: IL,r. the bu;Idu,p: ut Ltm.tn Gl,rutkler}t.lrm'. 'es �prcial Snpulah�mv _
f/ 'G
SECTION 9: PROPERTY OWNER AUTHORIZATION
Namea i id Address of Property Owner /
Cameo 0s!3oorj K f c
Name(Print) No.and Street Cih'/Town Zip
Priip�erly lh�r ngrr Contact Information: -f
79 0
Tide Telephone Nu.Ibusinessl Telephone No. (cell) e-mad address
If applicable,the properly owner hereby authorizes
Name Street Address City/Town Stale Zip
rip act on the tto pert%ow ner's behalf,m all matters relative to%vork•ulthonzed by this buildin• permit a p plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(it buildin•is Icss than 35,(MMJ cu.it.of enclosed space and/or not under Cunstniown Gmtrut then check here D and skip A•dion 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Reistrant) Tejr p one Nu.
e-mailaddress Re gist atiun Number
Gbl M�sMSf �iie-�S WKl1�o/� }ejt_O� 11
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
N. aof Prrsim p SI I soction a Noy a d Type if p icable
= hrontr
�s o�tSrr a 67-1 2—
S r Addre . . City/Town S to Zi
`�1d_ - A2-+
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COW ENSATION 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? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ 1I,,f 000 BuildinLEnclow
Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ �s0 dappropriate municipal factor)=$
3. Plumbing $ Zf E'l
4. Mechanical (HVAC) $ Oes Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ /r� 0eck payable to
6. Tidal Cost $ (9 and write c eck number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
He entering my name below, I hereby attest under the rams and penalties of perjury that all of the information omtained in this
application is true and accurate to the bes/t ''my/knowledge afid uncle atand�--
sles �l
('lease print and.�gn rid my rillr Telephone\n. ),Ile
Klrret Wdrea Cite/'gown SI,lt -1p
I
Municipal Inspector to fill out this section upon application approval: c
\ame I I•ple
l
Whitlock 681 Main Street Suite 331 Waltham, MA 02451
Architects 781.647.8008 whitlockarchitects.com
Construction Control Affidavit
Project Title Salem Beer Works
Project Location 278 Derby St., Salem,MA
Nature of Project Restaurant
In accordance with Section 116.0 Registered Architectural and Professional Services-
Construction Control of the Massachusetts State Building Code, I, William T. Whitlock, AIA,
Registration No. 8520,being a Registered Professional Architect,HEREBY CERTIFY that I
have prepared or directly supervised the preparation of all design plans, computations and
specifications concerning:
Entire Project X Architectural X Structural Mechanical
Fire Protection Electrical Other(specify)
To the best of my knowledge, information and belief, the above named project and that such
plans,computations and specifications meet the applicable provisions of the 780 CMR
Massachusetts State Building Code and all acceptable engineering practices and applicable laws
and ordinances for the proposed use and occupancy.
I will perform the necessary professional services and be present on the construction site on a
regular and periodic basis to determine that the work is proceeding in accordance with the
documents approved for the Building Permit as specified in section 116.2.2 for the portion of the
work where I am directly responsible:
1.Review,for conformance to the design concept,shop drawings,samples and other submittals which
are submitted by the contractor in accordance with the requirements of the construction documents.
2.Review and approval of the quality control procedures for all code required controlled materials.
3.Be present at intervals appropriate to the state of construction to become generally familiar with the
progress and quality of the work and to determine,in general,if the work is being performed in a
manner consistent with the construction documents.
Upon completion of the work I shall submit a Final Report indicating that the work has been
performed in accordant proved plans and 780 CMR.
�4g wA
d' SMT.
Signature and S M
Subscribed and sworn e) / Zo
Notary i _ My commission expires 5�P 7 zoic
.1 STEPHEN I 6NVYLESS
Notary Public,
commonwealth of Massachusetts
My commissinn FxoirPdsebtember 17 2015
C:\Users\Public\Documents\Beemorks Salem\Correspondence\Design Affidavitdoc I of 1 1/32011
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�. ;► r The Commonwealfti"of Massachusetts `' " .�`
///��� I " �� i' Department of Public Safety
I�� � - .\I.i..,�ihu.ctts tit.itr Buildin�;C��de(;30 C�IR)kcenth Lditiun
�h �y � City of Salem
J Buildin Permit A lication for an Buildin other than a 1- or 2-Famil Dwellin
�� �ThistirctiunFurl)fficialUseUnlv) �
I�uildinti Prnn�ll Number. D.ite Applird: 6 Building In.prctor. G
SECTIOfy' 1: LOCATION IPlease indicate Block N and Lot N for locations far which a street�address is not available)
278 D��t6Y ST SA���„1 v197o S•PtC� l3��-►� t,..o,M1k
x \u. and titrrrl Cih� /Town Zip Cude Name of Buildin}�(if.ipplicable)
- SECTION 2:PROPOSED WORK
If New Cun,truc[i�m check herr O or check all th�i[apply in the twu rows beluw
E�isting Buildi g❑ 2epair❑ Alteratiun ❑ Additiun ❑� Demulitiun ❑ (Please fill uut and submit Appendix i)
Chnnge uf Use ❑ Change uf Occupancy ❑ Other ❑ Specify:
Are building pl}ns and/ur cunstructiun ducuments being supplied as par[uf this permit application? Yes ❑ No L'3�
Is an Independe�it Structunl Engineering Peer Review�required? Yes ❑ Nu Q"
Brief Descriptiu�i uf Propo.+xrd Wurk: � � �
2'fil O!. OeC F�o a/L 0/L/�/M �G�`r �
� �— n /1ra�en . � . TRC.fI.. W�REtve .
x -- - � i��d.� �4�TS, .
SECTION 3:�I OMPLETE THIS SECTION IF EXISTtNG BUILDING UNDERGOING RENOVATION,ADDITION,OR ..,
�� ' CHANGE IN USE OR OCCUPANCY � ` ` - � � � �
Check here if an �� xisting Building Evaluation is endosed (See 780 CMR 3402.0) O '
Existing Use Gro p(s): Proposed Use Group(s): �•
Existing Hazard Endex 780 CMR 34:� Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
� Existing Proposed
Nu uf Floors/Stol�ries(indude basemen[levels)&Area Per Floor(sq. ft.) ��-
Total Area(si�. ft.j and Total Height(ft.)
� SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-ll❑ A-2r ❑ A-2nc❑ A3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2 ❑ H-3 ❑ H-4 ❑ H-5❑
� L• Institutional I-II ❑ 1-2 ❑ I-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2 ❑ - R-3❑ R-i ❑
S: Storage S I OI S-2❑ U: Utility❑ Special Use O and please describe beluw: �
Special U+e: I
� SECi1pN 6:CONSTRUCTION 7'YPE ICheck as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ ❑IB ❑ (V ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATtON lrefer to 780 CMR 1llA for details on each item)
Watei Supply: ' "��: Flobd�Zone Infomiation: Sewage DisposaL• � Tiench Peemit: � �DebrisRemoyal:�.
r��i,r�❑ Check il uut.ide Flu,id Zunr❑ Indic.�te municiF,,il ❑ \ Vench will nnt be Licrmrd Di.po.al tiitr ❑
Pric.itc❑ ��ih indcntif��Zunc: ���r iin sitr.�:.lem ❑ rcyuired �ur trcnth i�r.pc4i1��.: .
I- . . � permil i.cndu.rd ❑ ' -
- i Railroad riglit[-of-waV: Hazards to Air.Vavigation: \I:\ I li.li�ri�l�,�inmi..i��n It,��ir�� I'n,rr..:
\uF,\F�F�li�.iblc ❑ I.tilrurlurc�rithin airpnrt ,�F,F,rnach orr.i' h lhi�ir rucic�c c��inF,lctcd.'
' I ��r l�un.rnt tu Ruil�1 cnrl�ncd ❑ 1"c. � ��r.�1�❑ Ye. ❑ \�n ❑
� SECTION 8: CONTENT OF CERTIFICA�iE OF OCCUPANCY
� �� I_ iiu��n ��I C�� dc: _l.�,r Ci��uF,(.�: �cFi �1 Cun.tructinn: Uccup.�nl Luad pur Iliuir:
IIl �r.thc builiiin};.unt iin an tiF�rinAlcr ti��.lcin': >F.ci,il titiF ulatiuns� I
��'���i�'j �'J f.�EE�'1- �J7�J �pvu.�.�.�
� �� i
1
� �
SEC'f10N 9: PROPER'CY OWNER AUTHORIZATION � I
. . Vamc and Addrr>.��I P �pertv O�vnrr 27� �,�vl C�T S.g�„'l:�'N � � /'V} � �� 70 �.
Go PRo �i�� 0�u��,
Namr lNrint) Nu.and tilreel City/Tuwn ��P ��i
Prupert�•l)�cnrr C�ml,ict Inlurmaliun: I
GEo26� OSGoop -_ -=_
Title . Trlrphonr Nu. (business) Telephunr No. (crll) e-mail addnss ,'.
I(.ipplicable, thr prupert���nvnrr hrrrby aulhorizrs - � � i
Vamr titrert Addrrss � Citv/Tu�vn Slate Zip . . .,
tu act��n the �ru�rrlc���vner's brhalf, in all m,ittrn relaticr ta�vurk aulhurized bv this buildin � �ermit a ��lic.itiun.
�� � � � SEC'iION-�I0:CONSTRUCiION CONTROL IPlease fill out Appendix 21` ' ' � �
(If buildin•is Icss than 3i.UW cu. ft��f enclusxd s�aie and/��r not under Cunstrudion Contml then check here O and ski�Sediun IU.0
10.1 Re istered Professional Res onsible for Construction Control
Namr(Registrant) Telephone Na �e-m.il addrcss Registratiun Number ,
Strret Address CitV/Tuwn tita[e Zip Discipline 6xpiration Date
10.2 General Contractor
�� 1.. f 0
, C mpany Na e: � � . � j � � ., .. . . .. . ' .
' �1,An.t< `�� ,.�p2oT/�-
eifA l
���b�e
unstructiun �License No. and Typ pp
Nnrtje,y�f Per��L(,e+ un�S�xC L�iVN (`Ni9'� �� OZ ',
�,��3 ia-
�let AddrG3�� nA� - 3pp 3p $� City/�['ow� � State Zip6�T
_$� � ... o� al sco coac,9Sr^ N
Tele hone No. (business) Tele hone No. (cell) � rmail address
SECTION 11:WORKERS'COIvII'ENSATION 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 si ned Affidavit submitted with this a lication? Yes❑ No ❑ �
� SECTION 12:CONSTRUCTION COSTS AND PERMIT PEE
� Estimated Costs: (Labor
Item �nd Materials) Total Construction Cost(from Item 6) _$
, 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
�. 2. Electrical S appropriate municipal facror)_$ �
3. Plumbing $ �
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipalicy)
5. Mechanical (Othery $ Enclose check payable to
�� 6.Total Cust 5 Q O O �(wntact municipality)and write check number here
� SEC'TION 13:SIGNATURE OF BUILDWG PERMIT APPLICANT
� Bv enterinh my namr beluw, I hereby attes[ under the pains and penalties uf perjury that all uf the infurmatiun cuntained in this
applicatiun is trur and accunite_to the b�ie.t o1 my nvl dge ond underslandin�.
�q�C�q.. �rN�nOr� ,�p�t�.�!u�c�� s� Ng-n- �Ei .389-38►� y �
Plr.i.^F,rint .ind ni};n n.imr Tidr TcleEihune Vu. U,tte .
�y �IJICIao�S 3T D�J'NVtns r'f,B- _ o 'i
Ititrrrt A.i�irc.. Cih�iT�nvn � �tate Lip .
�1unicipal Inspector to till out tliis section upon application approval: � �
\ame �
Sa� � �1r S C�c�1� ��(�-�S«n
WALL OF KEG ROOM i
CEILINGS TO BE INSULATED (EXISTING AND NEW �
AND FIRE RATED 2 LAYERS PUMP STUDS) FINISHED WITH �
5/8" GWB EXISTING HOSE BIB ON NEW FOR PLYWOOD AND 1/4" PVC
SPRINKLERS TO REMAIN PLUMBING WALL DRAINS PANEL
'.l } � . � .t . d Y• � "Y
i.. +� '� .� ] ,
.� � ?,� y , v i !� ;.
.. . . .. .. . .
.
�
-. . . . . . ry �. w...�i � s• t.
�
. . .� • s ...q . . :.« • . y.
� PS O
2'-6y" 3'-2%"
W
EXISTING �
�Y KEG WASH � BREWER'S
� FLOOR � OFFICE TO Q
+ DRAIN r REMAIN �
FLOO
i D /� � �
` SMALL CURB � � Q
� � �
� DT ROOM RELOCA W Q �
r. SLOPE � � DOOR w �' n o
' W O D T R O O M NEW 48" 4„+�_ `7 m v cv
IS G NEW WALK-IN DO �— °' ��� � � � �
ST S) SULA H �I�I� J � Q �
M1 EXISTING I N E AND FI I HED I�I�I � Z vvi o
EGRESS ITH YWOOD D 1/4" W I
STAIR PV A L o 0 o p o � GALVANIZED w w
� � �II� TUBULAR � o
� N illl RAILING
Li\ a
3'-2J/s' 17'-1%e" � �^+/- ��I�� ` DEMO �
~ � I�I�I EXISTING WALL � �
FLOOR FINISH TO BE CEILINGS TO BE FIRE 3�_gy^ 4'-6" � � ��0�-�5��� N Q m�
POURED EPDXY WITH RATED 2 LAYERS 5/8"
�• �e f HIGH WEAR AND SLIP GWB IN STORAGE AREA. EGRESS � � I =�m�
RESISTANT FINISH EXISTING SPRINKLERS R O U T E \ �t��
� �a
TO REMAIN �- � � I � �3 n
� _ _ _ �
' I
' WALL FINISH 5/8" I ALL LIGHTING TO w
FIRE RATED GWB I HAVE SHIELDED -
� LAMPS �
Y �
� ALL SURFACES � a
WILL BE
WASHABLE � 3 : ,
r
' — P
— ---- ------ ------------------------------ -----------
�� The Conunonwealth of Massachusetts
. � �
L. �'� Depuhnent oF Public Safety
'A; !.. � .\I,iss.�r6usi•listitatclSuildingCuJc(78UC\IR)
�..,,..
Building Pcrmit Application for any Building other than a One-ur'1'wo-Faiuily Dwelling
1 ('I�hLc Sitilinn fnt O(fici,ll Use OnIV)
/ �l IluildingVcrmitNumbcr: --.---- D.�Ic:\pplicd: .---- UuildingOlficial: —.--- -_--__
q.,,l ti[CfION 1: LOCA'1'ION (I'Iease indicate liluck It and Lot p for Iocallons fur which a streef addresa is not available)
p� _�'��.---J�t��F—5 r--�/YI m�- 0 , �l Z �
Nu. and Strcet City/�I1nvn Zip C��dc —.—..N,�mc u(Building(if applirablu) --��---
� SGC'170N 2:PIiOPOSED WORK '
� IiJiiiun�d\I:\Slate Cude u.srJ._ If Ne�.•Cunstrurliun rheck I�ere 0 ur check oll thet a��pl�� in tl�r I�vu ru�v.s boluw ---
1, t'aislin�; IluildinF;❑ Rcpair❑ :\Itcr,iliun ❑ .\JJitiun O Ucnnditiun O (Plrosc lill uut anJ submit:\ppcndis I)
c�r /?Pn vG♦ Ex�5 iNG /�AGe
�V Cl��ingauf'l;.ae ❑ Ch�mgeufOrrupaney ❑ Othcr ❑ Sperify:__- �
�� Are builJing plans.md/ur eunslructiun d��'umenls 6cing su�plied.0 p,vt uf this pcnnit applieatiun? Ycs \u ❑ I,
Is�m InJependent Struiturxl Enginecring Pecr Revicw reyuimd? Ycs ❑ Nu ❑
liri.•f D��,criptiun��f Pn�pus..i IV�,rk:.�PEaIOrtAT�.v I7� �'1�/STLI��°_S�Q� FO.Q � AP�R_r.riP. TS
SECTION 3:COMPLETE THIS SECT[ON IF EXISTING BUILDING UNDERGOING RENOVA"f10N,AUDI'CION,OR
CHANCE IN USE OR OCCUPANCY �
Chcrk hrrr il an 8risting Bui�ding Investigation and Evaluation is•�ndused(See 7&)C111t.1�) O �
EsistingUseGruup(s): ___ P�uFwsedUSeGruup(s): __.___
SECTION 4:BUILDING HEIGtIY AND AREA
� Ecititing Prupa�ed
Nu.ul Flui�rs/Sturic�(indudc bascnunt Irvcl.+)2F:\ma Pcr Fluur(sy. ft.)
1'otal :\rca(sy. ft.).mJ Tutal liciglit(ft.)
� SECI'!ON 5:USE GROUP(Check es a licable)
�:\: Assembly A-1 ❑ A-2❑ Nightdub ❑ :1,1 ❑ A-I ❑ A•i❑ B: dusiness ❑ G Educational ❑
P: Pado F-I ❑ F2❑ � H: IIi h Haz,vd H-I ❑ H•2 O Ff.l ❑ li-�❑ I�I-i❑
1: Institutional 61 ❑ I-'_❑ I-�❑ I-1� bl: 1lercantile❑ R: Ruyidential R-I❑ R-2❑. R.1❑ Ii-I❑ .
5: Sturage S�1 ❑ S2❑ U: Ulility� Special Use 0 and please drscriba bcluw:
tipciial Usc .
SECI'ION fi:CONS�CRUCI'ION IYPE(Cheek a9 a licabl.)
IA ❑ Id ❑ IIA ❑ ilU ❑ III,\ ❑ I1111 ❑ IV ❑ V,\ ❑ VIl ❑
ti[CTION 7:SI'1'E INFOItAIA'I'ION��rcfer tu 7H0 C�IR lilA for details on each item)
w,,�ir tiuppiy: fluud Zone Information: Sewage Uisposal:
Trench PcrmiF. Ucbris Rcmuval:
Publii❑ Chcrk il oulsidr Ila�+d /_unc O Imlic,itc nwnirip.J ❑ :\ Ircnrh�eill nul bc I.ircnscd Ui.pus,d Sitc❑
Pric,Uc❑ �rr ini�i•nlilc Lnnc�. or��n ailc ccstom ❑ rryuirvd O nr trrnrh ��r.peril�': . .-- —. . . - -
. ___—__ . F�crmit is onrinseJ ❑ '
Itailru.�J righl•uf�way: IlaiarJc la :\ir Navihaliun: ,� . .:.�..i,.� , � ., �.�., . _ . ., . . . .
Xnf:\p�,lirat,lc❑ Istilrurlurrwilhin ,iirport.iE,F,rnarh,vi•a? Isthcirrc��ic�vramplriril' .
��rC��mrnlGrHuilJcnrlu+ad❑ lrs� uf.\'o❑ lbs❑ \'u ❑ � .
ti[C'I'ION 8:CUNII:N'f(>F l'I�.It�l'IPIC,\'I'G UP OCCUP:\NCY .
I[JiliounllaJr: ' _ ... ._ l'.rGruupl+l� .. . . . I\pr��IC��n�lruclian: lliiu�,,mll.nd�IporFl�,��r .
I�or.IhrbuilJin�;i��nl.�in.in>��rini.lrrtic.lrm'� ti��rci.ilSli�,nldti��iu: .
�
�� �����----�
� tiGCIIUN v: 1'ItOPI[R'IY UWNI(R AUl'IIUItIZA'1lUN ��--
N,mir,ind .\ddrass uf Pruprrh'U���ncr ----.,A ,," � • • —
_C�_o�l��� S Ezo p�— $��C�1_'UG��_14u�i''�L� o I 4 H:i
�V,unr(Prinl) No.and Strcct City/�1'uwn —___—__—.—_ __—'Lip
. Prnperly O�cnrr CunLict Infurmaliun: .
�WN�R _ '�_81:b3�.oS�S ----- —
� I�idc � T'elephune No.(business) Tclephanc Nu. (ccll) c-mail,idJress
II,ippliiabli�, Ihe pruperly uwner hercb)'aulhuriacs �
--P-A=T-R-�cac 0 0�__ Po��x L�_��_�A_Br'�_JL� n ''�_ o l%'�
- N.unc Strcet AdJress City/Tawn titatc Zip �
. lu,rct un the �ro�rrl uwner's bdialf, in all matters rrlativu!u wurk,�ulhurized b��thic buildin �ennit a >>lir�uiun
�SkCTtON (U:CONSTRUCTION CONI'ROL(Please fill out Appendix 2)
lf builJin�is Icxs than JS,UUI cu.ft uf endu.w•J s+ace�md ur nut imder Crn�stru.tion Control Ihen check hero O anJ eki Sectiun 111.1
1111 Re�ietered Professiona�Res onsible for Cunstcuction Cuntro(
iV.ime(Registrant) � Tclephone No. '"' c-ntail addre+s Rugistration Number
.. titrect AJdress City/Tuwn State Zip Discipline Espiritiun Date
10.2 Ceneral Conhxtor � I
OS(��0� 4�A�T►�C� � c.ors�aAc��nt� S��vic,r�S �� � J
C��mp:�nyName � . LICkW52D C09lI5TaVtT�CN sapER��tor G59 �bW3 F �/IO/3
PA i/dICX l9 �(� o�D I�t�u1F_ �mPaoVEM�N% CoNrRtubR• o "��a2ao .�.50 'p/zol3
�l,mii uf Persun Respunsible for Cunstruetiun . License No. nnd Type if Applicable
i'o �3ax I iI� M/�R�l.�N,�A� M� �l�i
Strcet Address � City/Town State Zip
q�1�. o �o v) —.— 0 s(�o�� S"ZJ� > c� vf-k��i✓.�✓�
�fcle�hune Nu. business Tele�hone No. ccll c•ntail address I
SEC'lIONIt•i�r�r.�.i,r.�rri��irr���;nu�t� i�u�.ur..�.vrr.�ri�u�,��'ii M.C.L.c.152 25C6
. .__.__.._._ ._ �- -- - -._._._...._ . . _. _ .
� A 6Vurkers'Cumpens�tiun Insurance Affidavit hom the MA Deparhnent uf fndustrial Accidents must be cumpicled and
submittcJ with Ihis applicatiun. Failure tu pruvide this��ffidavit wil!result in the denial uf the issuancc of the building permit.
� Is,�si�ned Affidavit submitMd with this a lication? Yes❑ No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimand Custs: (Labur
�md \Intcrials) Tutal Cunstructiun Cust(from ftem h)=5_
� 1. 13uilding 5 Building Pcrmit F�r=Tutal Cunstructiun Cust s_(Inscrt hcre
_'. Eli�tricol � 5 apprnpriatc municip.il factur)_�
t. Plumbing 5
J. \la�hanir,d (HV:\C) �5 N��te: ��linimum (c.=!S (.untact inuni.ip,ditY)
i. \Icch,mir.il Olhcr S
Fndasc rherk pa}',�b�c tu
n. folel Cost � y 6a�1� (cunta.t mwiiripalit��),ind serile ihi�ck number hrm ____._._ ! I
SEC�ION 13:SIGUATURE OF IIUILDINC PERh11T APPLICANT �
� I Bv cntering my nanu brin�v, I herebv,��Icst under Ihc p,iins and penaltic+ul perjury th.�t,dl af Ihc in unu,iliun �anteinrd i Ihis
' � � �p�,liratiun is true and aerur.�tc tu thc hi�e uf i � I.nm IrJgc.iml undcrstandiny,.
� D � D
Ai/'ic�— 1G002---... ------_ _ _ _��/{v���G--- '�$�'S'o_ ea�
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\lunicipal Inspcch�r to fiU uut thiy sc.tiun upon applicatinn app u�•aL• --._.. ...- __--- _- -.� . _. _-_ ._ -r�%/�--
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