B-17-399 - 0036-0038 BOSTON STREET - Building Permit �-- ` The Commonwealth of Massachusetts '
Department of Pu"MSMI*y) A la. 3 q
Massachusetts State Building Code(780 C R)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
1 (This Section For Official Use Only)
"Building.f Permit Number: Date Applied: Build ng.Offic4
SECTION 1:LOtA. IO Alease indicate Block#and Lot#for locations for which a str ttaddress not available)
i
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❑ 1 Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out quid submit Appendix 1)
Q 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 IT
Is an Independent Structural Engineering Peer Review required? 'Ioy)A-f I Yes ❑ No lid
Brief Description of Proposed Work: /C"w1. C— 1z ffi0,442glj2oC- CAA /-Moo '�qr' '
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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
QExisting Proposed
1
pp No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
'�� tV Total Area(sq.ft.)and Total Height(ft.)
® SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ 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❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑
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 ❑ 1V ❑ 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❑ A trench will not be Licensed Disposal Site❑Indicate municipal❑ required❑or trench or specify:
Private or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: t.r�,.l_list. ric_ ;,m,niysio�i Revic«_t'rocess:
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
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street 5 /"06 City/Town Zip
Property Owner Contact Information:
�� (..�%�C�=N�(�y-��"��°t�l '/sue -- - 'SC�G�G/�1%(/�1�` ��1��� f8 S✓�/ �Title Telephone Telephone No.(business) Telephone No. (cell) e-mat(address
If applicable,the property owner hereby authorizes
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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 building is less than 35,000 cu.ft:of enclosed space and/or not under Construction Control then check here❑and skio Section 10.1
10.1 Re istered Professional Responsible for Construction Control
Name(Registrant) Tel hone No. e-mail address, V;�i Re jr ion Number
4 cr
Street Address City/Town S Zi 5 Discipline xpiration Date
10.2 General Contractor
Cot tp, NaCZ
NameA Person Resp24,drze�,
'b a for Conrtr tion License No. and Type if Applicable
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Street Adc ress City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSMANCti AF.FIDAVU: 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❑ No ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE':.
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ 2S.504
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ -- (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 accu to to the b t of my owledge and understanding.
Please rint�`td sign name r Title q, Telephone o. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date