13 1/2 MEADOW ST - BUILDING INSPECTION Sic
b The Commonwealth of Massachusetts
�r Department of Public Safety
_ Vy Massachusetts State Building Code(780 CNIR)
Z! 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: Building Official:
t SEC��TION 1:LOCATION (Please indicate Block#and Lot#for locations for which a street address is not available)
'7J/G�Gr.�CJlil S'-1- It r�1.
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 ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix"I)
Change of Use ❑ Change of Occupancy ❑ Other GYSpecif e r G L JL 7 —i
Are building plans and/or constriction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description� of Pr posed Work: Gd' L'� e"� � 0"-<�
�.U-�- V i
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 J
Existing Proposed 1
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❑ .4-5❑ B: Business ❑ E: Educational ❑
F: Factor F-1. Cl F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ FI-4❑ H-5❑
1: Institutional F1 ❑ 1-2❑ I-3❑ I-4❑ 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 Iietow:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA 13 VB ❑
SECTION 7: SITE INFORMATION (refer to 730 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public ❑ Check if outside Flood Zone❑ Indicate municipal IJA trench will not be P
required 13 or trench or specify:
Private❑ or indentify Zone: or on site system 11required
is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: iAIA hiistoric C�7rn�nissit>n Reye>v Pruycss:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed El Yes ❑ or No 13 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:
q� 3v G1 lr'rO G •C .
Cc 10
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owners g Gx 0 a j T
le'^ py!�r <lys SC1
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone o. (cell) e-mail address
If applicable, the property owner hereby authorizes
L*,J S6 '5'A`�r C3'4-c" �f/ A r t b rO cwt 5�- RDS-rte t r�s� O Z I f
Name Street Address City/Town State Zip
to act on the pro2erty 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 building is less than 36,000 cu,ft.of enclosed space and/or not under Construction Control then check here 0 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
Company Name
LOJK,S-k I kz.G-r'---r0 ( s - O
Name of Person Responsible for Construction License No. and Type if Applicable
q I rrmbj-oma s �, .,t- ,rr e�- 0-215-1
Street Address City/Town State Zip
oo.. L)pSe✓J0-d-S, .vI
Celephone No. (business) Telephone No. cell e-mail address
SECTION 11: WORKITS'COMPENSATION INSURANCE A'PFIDAVIT M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the NIA 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)_$
1. Budding $ <;5 a 00.OJ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
-I.Mechanical (HVAC) $ Note: Minimum fee=$ (contactnumicipality)
5. Mechanical (Other) $
Enclose check payable to
6.Total Cost $ S 000.0r7 (contact municipality)and write check number here
SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT
By entering m name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
applicado true and a .to to the best of my knowledge and understanding. tqy M-5 /
lease or
and si m name Title Telephone No. Date
�'A�tZ�-mac.-n,c�
Street Address ity/Lown /� Slate Zip
z/jf}-M�, ivy. S i r �G4 . —. - / 7�1" 'f O2/S 1
Municipal Inspector to fill out this section upon application approval: �` 'Zm-R %h.� k7
Name Da e
dice or Consumer Af[airs& Business,Regulation
OME,IMPROVEMENT CONTRACTOR
Registration "64a Typei
r ♦ Expi j - A 'STI '� ` Supplement Caid%-
►M BOARD U
N�rr
S, MiA 01906sh Undersecretary
n
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-058505 �� �
K ; Construction Supervisor k
LOUIS E FALZARANO
41 AMBROSE STREET _ u ;
REVERE MA 02151 y
/r ,
w Expiration:
Commissioner _ 0411112018 J