38 HARBOR ST - BUILDING INSPECTION Z C
, 3 3 C� r.G
The Commonwealth of MA999€fi&setts ERVICES
VIOW Department of Public Safety Massachusetts State Building Code(7jej§&MC 10 A
[— Building Permit Application for any Building other than a One-or Two-Family Dwelling
Ln (This Section For Official Use Only).,\1 gp fa Al- w 1 m It
^ l sfOA.
1 Building Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for whicha street address is not available)
lFEdition
`/gietreetCity/Town Zip Code Name of Building(if applicable)
SECTION 2.PROPOSED WORKMA State Code used S If New Construction check here❑or check all that apply in the two rows below
I Existing Building Repair❑ Alterations I Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy 2f 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ NoA
Is an Independent Structural Engineering Peer Review requved? Yes 13No o
Brief Description of Proposed Work: �Fi1i✓c?1 "/LL�G�L
Ar
C'oP aF Gl/aP� Rte{ /i�lit/
ilA/� YAC/ L/i7.e Z Y.KOWSA�/ 1 4901401AI-4 QiF7iIA
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): Cl I Proposed Use Group(,- A/L/
F-!C L/j�'TS q 5rA
y, SECTION 4:BUILDING HEIGHT AND-AREA
t02;1�i'&V&r15 Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) dL 1 _ 4
Total Area(sq.ft.)and Total Height(ft.) - 43-5111 .(9JJYr
SECTIONS: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❑ 1 H: High Hazard H-1 ❑ H-2❑ -H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ 1-2❑ 1-3❑ FI❑ M: 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 C3 Ill E3 IIA 13 fill 1 IIIA ❑ HIM C3 I IV ❑ 1 VA C3 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 O IndicatemuniCI.pal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required E3or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA I_li_storic Commission_Kcvicw I'ruc_csn_:
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 Coale: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
St✓r7v-C' T� Civ lt_Ocrc-S C,:_'�L . ( Z j 1�1
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
41:,1A/3 A,f'.ngP� i9 NC1�7✓/a�Sl' t0� CICd14412w VA ?329
Name(Print) No.and Street City/Town Zi
Property Owner Contact Information: d-�03- 521 2600 -96061,V41)5;ONCya-0,111 L. 004
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
c 2r/F5 L r�iliTCNE7� Mr 3_26
SGf�L>titilE�2 sr ✓'✓�9rYCNr3 .✓LfA Oil f!�
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 application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) -
If buddingis less than 35,000 cu.ft.of enclosed space and?or not under Construction Control then check hem O and skip Section 10.1
10.1 Registered Professional Responsible 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
-rzlc /i
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
�7 s s7 " /i VcNe237 Zn7 lZZ4 ca 1 4
Street Address City/Town State Zips
973 /o�
Telephone No. business Telephone No. celle-mail address
SECTION 11:WORKEKS'COMPL'NSA'I ICIN INSURANCE AFFIDAVIT M.G.L.c.152 9 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 O
.. SECTION I2.CONSTRUCTIONCOSTS AND PERMIT FEE
Item -
Estimated Costs:(Labor - 0 0Q Of
and Materials) Total Construction Cos[(from Item 6)_$
1.Building $
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $ 0a'n ,
d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 11 0 c00+0" (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
application is true and accurate to th best of my owledge.anti understanding.
124;F_ 976 /lf- /0?b5 J7,1) 2215
P ease print and sign name Title Telephone No. Date
.= c L �<r-._019
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: -'+""' /3
Name Date