B-17-307 - 0089 BRIDGE STREET - Building Permit The Commonwealth of Massachusetts ,
`,➢I Department of Public Safety 10)-1 APR 0 P 4- 1
Massachusetts
�J ( husetts 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: Buildmi g.Officiil:
(� SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for:which a street address is not available)
�•(Jv 9 Rc a e_ SV sale' roc, 0 /070
No.and Street City/Town Zip Code Name of Building(if applicable)
E
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 ❑ Addition❑ 1 Demolition M-(111'ease fill out and submit Appendix.1)
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 hY No ❑
Is an Independent Structural Engineering Peer Review required? f Yes ❑ No [I---
Brief Description of Proposed Work: re wise rL A ?At,,, / s bw/,/ t �'/�/G✓� +
1 �'a 1 W1 V
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
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) -
Py
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-1❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1 D H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 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 ❑ HA ❑ IIB ❑ ILIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal:
Public lti� Check if outside Flood Zone Indicate municipal
A trench w' not be Licensed Disposal Site
required or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way/ Hazards to Air Navigation: Ir\,I__listc ric_Cun mis,n.... y_Process:
Not Applicable 61/ Is Structure within airport appr ch area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No 3" Yes❑ No I�
Y r SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Constriction: Occupant Load per Floor:
DoNsAie building contain an Sprinkler System?: Special Stipulations:
NOT P. v mf't"� Sj i
V U
�3 cruet-�-e v y p v .
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
83 r3r� :¢ LUI - ry9 6rt fZS f. S^c. k nn ®/ 20
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Mgfc—TXrAk1 G jh0r-, - -
Title Telephone No.(business) Telephone No. (cell) e-mail address
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.lOc CONSTRUCTION CONTROL(Please fill out Appendix 2):
If buildin is less than 35,000 cu.ft:of enclosed space and or not under Construction Control then check here❑and ski 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 i
Compan�ny Name __yy� q U
Name of Person Responsible for ConstruVAon License No. and Type if Applicable
1 C-C4 Q_� el
Street Address City/Town State Zip
1-2 q79 -364- /00 Peter 60itCtrryj " coog cjJ+ Iye-
Tele hone No. business Tele hotfo No. cell e-mail address
SECTION 11:WORKF.:RS'CONIPEN5ATION INSURANCE AF.FIDAWE 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)=$
1.Building j4 $ U, U0 G•0 U Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
1.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to r� /A (_
6.Total Cost $ 10 (d 00. d d (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest and- the pains and penalties of perjury that all of the information contained in this
application is true and accurat t the st of owledge.and understanding.
1'n s
Please print nd sign name Title Telephone No. Date
(UU fat S a— 0cabA) ► _ olyGa
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date