B-19-306 - 0010 ANDREW STREET - Building Permit • �330� c���g3
X-he.Commonwealth of Massachusetts
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4 De artmen �.
p t of Public Safety
Massachusetts State Building Code(780 CMR)
Building,Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For'Ofhcial Use
,Burldmg T'ernut Number: Date Applied Building Official:
SECTION 1:LOCATION
_N.o..and Street City f.Town "" " Zip Code Name of Building(if applicable)
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Assessors Map#, Block#and/or Lot #
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 subri�it Appendix 2)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are 6ilding,plans and/or construction documents being supplied as part of this permit application? Yes'❑ No ❑ y
Is an Independent Structural Engineering PeeLFeview required? Yes ❑ No ❑
Brief aEp: tion of Proposed Work:
SECTION 3:COMPLETE E THIS SECTIQiV 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)• 0 • ,
Existing Use Group(s): Proposed Use Group(s):
` •SEMON.4:,BUILDING HEIGHT AND.AREA- e
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor"(sq.ft.) 4 A {
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❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional,I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 0, S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use Description:
z1 SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB0 IIA ❑ IIB ❑ 7 IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
ri SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 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❑
Private❑ or indentify Zone: or on site system O required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: , Hazards to Air Navigation: MA Historic•Connn fission Review?rocess:
�F Nit Applicable'❑ ' Is Structure witivri airport'approach area? { `°-rs their review completed?`--1 '
or Consent to Build enclosed❑ Yes❑ or No❑ R Yes 0. No ❑
SECTION 8:CONTENT OF CERTIFICATE OVOCCUPANCY -
Edition of Code: Use Group(s): Type of Construction:
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
9Mh%cA ZA�o \o Awor-foNhIst
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: lo
OXX ZA&Q0 171- AV- -VX=
Title Telephone No.(business) Telephone No. (cell) �e-maifllddress
If applicable,the roperty owner hereby,authorizes:
\L \Aoy( 3ID G.NAcA 1� ��✓-_V CM /vim
Name Street Address -",City/Town _ State -"Zip
to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION lOc CONSTRUCTION CONTROL(Please fill out,Appendix 1)
If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0.
Otherwise provide construction control forms see section 107.in the code as r; aired..
lo.l Re `stered Professional.Res onsible for Construction CoiiOol(the rofessioiW coordinatin document submittals)
Name(Registrant Tele hone No. e-mail address Registration Number
oA W wtiGV� /w� o k CIA o
Street Address City/Town State Zip Discipline Expn'ati Date
10.2 General Contractor
\-\c Gcy✓S-T Go
Company Name
\Zlims / ��1/L.�cC. bZl�lX• /`N�SS Ci�.,��P�q
Name of Person Responsible for Construction License No. and Type if Applicable
36 t^-k o\Q3i
Street Address City/Town State Zip
_-- '178 V/ _3y53 \.CsAxti Ljg�C-w Ao`.-G oM
Telephone No.(business) Telephone No.(cell) e-mail address -
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.1c.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 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE r.+
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)
4�pr
1.Building $ Building Permit Fee=Total Construction Cost x nser'oei'e I
2.Electrical $ appropriate municipal factor)_$
3.Plumbing
4.Mechanical (HVAC)
Note:Minimum fee=$ (contact munit pahty
$
5.Mechanical Other $ }
Enclose check payable to C6 -A-( �:,
6.Total Cost $ I (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 best of my know edge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip Email Address
Municipal Inspector to fill out this section upon application approval: we&�e
Name Date
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{ (978) 468-4275
CHECKED BY DATE
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PRODUCT 704-1(PADDED 11"EDGE) PRODUCT 706-1(PADDED 17-EDGE) C ,i >
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