13 MEADOW ST - BPA-16-1120 FOR 13, 13 1/2 & 15 logl ,f) /L;) pwPI'r,
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=� The Commonwealth of Massachusetts^' �_�l
Department of Public Safety O
Nlassachusetts State Building Code(780 CN1R)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
1 (This Section For Official Use Only)
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)
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L� No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
I Edition of NTA State Code used If New Construction check here❑ or check all that apply in the two rows below
L Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ I 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? Yes El No ❑
Brief Description of Proposed rk:? Oi-o-r /�"'
Wo
SECTION 3:CONIPLETE 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❑ .4-5❑ B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ 1 H: High Hazard H-1 ❑ -H-2❑ H-3 ❑ H-4❑ H-5 ❑
L• Institutional 1-1 ❑ 1-2❑ I-3❑ 1-4❑ 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 below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ - IIIB ❑ IVO VA ❑ VB ❑ -
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 Cl Indicate municipal❑
A trench will not be Licensed Disposal Site❑
required❑ or trench or specify: _
Private❑ or indentifv Zone: or on site system ❑ permit is enclosed ❑ '
Railroad right-of-way: Hazards to Air Navigation: %�% Historic 'ornieisssnn"t'vi,ew-,_ • ..
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 e _
Edition of Code: Use Group(s); Type of Construction: Occupant Load per Floor:
i
Does the building contain an Sprinkler System?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name andAddress of Property Owner, 3 _ J�r�-
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Name (Print) No.and Street City/Town Zip
d
Property Owner Contact Information:
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Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
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Name Street Address City/Town State Zip
to act on the prol2erty owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
[f 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
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
GOUIs /Z� ^5
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
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Telephone No. (business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COy1P ENSATION INSURANCE AFFIDAVIT 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 resat in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6) _$
1. Building $ *C Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ (3 j 0 O o •t7 appropriate municipal factor) _$
3. Plumbing $
.1. Mechanical ([-NAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check able to
P�Y�
6.Tolal Cost $ �� QO _ t7O (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 the st of my of dge and understanding. -
Pbe< print and s n name !� rule Telephone No. Date
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Street Address City/Town State Zip c�
Municipal Inspector to fill out this section upon application approval:
Name-" Date
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