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B-19-260 - 0069 BRIDGE STREET - Building Permit The Commonwealth of Massachusetts Department 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 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) a .ScN o LgZa No.and Street City/Town Zip Code Name of Building(if applicable) �t 7" 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 p Repair❑ Alteration ❑ Addition� Demolition 1D (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building pans and/or construction documents being supplied as part of this permit application? Yes CY, No ❑ Is an Independent Structural Engineering Peer Review req 'red? Yes ❑ No k] Brief Description of Proposed Work: v� tsS 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): SECTION4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) `A "'kCT-0 Total Area(sq.ft.)and Total Height(ft.) SECTION 5:.USE GROUP(Check:as applicable) A: Assembly A"4 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: .Factory F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Ii:stitutional 1-1 ❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-113 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 ❑ TIIA ❑ IIB .0 IIIA 0. IIIB ❑ �IV V�[03 ,�VB SECTION 7:SITE,INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit: Debris Removal: Water Sup ly: Flood Zone Information: Sewage Disposal: Licensed Disposal Site Public�J Check if outside Flood Zone Indicate municipal A trench will not be P required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicablgb Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No 19Yes 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: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip t Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail a ess If applicable, the property owner hereby authorizes 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 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 E ©1 O S 12 Name of Person Responsible fo onstruction` License No. and Type if Applicable Street Address City/Town State Zip C_Cj_j__ Telephone No. business Telephone No. cell e-mail Vdress SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25G 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 9No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT AEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)=$ 1 aD 1.Building $ '0� Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ 90. appropriate municipal factor)—$ 3.Plumbing $ 0' 4.Mechanical (HVAC) $ Note:Minimum fee=$ 06 (contact municipality) 5.Mechanical. (Other) $ Enclose check payable to 6.Total Cost $ r 0'.&D. (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 knowledge and understanding. Please lint and sign name Title Telephone No. Date 3 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date Date