B-17-484 - 0098-0100 BRIDGE STREET - Building Permit �3
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CUR)
00 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)
o 1,90 3 rv� S lew` 01970
_({ No.and Street City/Town Zip Code Name of Building(if applicable)
(t ► SECTION:1 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 Addition4 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 9 No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
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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
Existin Proposed
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No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) 0-t �s I S15
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Total Area(sq.ft.)and Total Height(ft.) 1 �o la( cv"A
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ I 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❑ I-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(Cfieck as applicable) ;i
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ TV ❑ 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 Indicate municipal X A trench will not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable) Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No'9 Yes❑ No IT
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:
PROPERTYOWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City�/Town zip,
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
WILLAFIS 256' FAYZ ME- LYNJI-3 t-W 01q C)4
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 outAppendix 2
(If building is less than 35,000 cu.ft.of enclosed space and/or not undertonstruction.Control then check, here 13 and skip Section 10.1
10.1 Registered,Professional Resppnsiblie for Construction control7-
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Name(,Registrant) Telephone No. e-mail address Registration Number
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Street Address City/Town State zip Discipline Expiration Date
10.2 General Contractor
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Company Name
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Name of Person Responsible for Construction License No. and Type if Applicable
Lwj A) I-A 010(0+
Street Address City/Town State Zip
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Telephone No.(business) Telephone No.(cell) �J e-mail address
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-SECTION ll:-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.,152.:§2$C(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[3 No 0
SE&ION-11"CONSTRUCTION-COSTS AND PERMITFEE Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) $3 000
1.Building $20 000 Building Permit Fee=Total Construction Cost x—(Insert here
2.Electrical $ qb"000 appropriate municipal factor)
3.Plumbing $ 1 'y 0
L Note:Minimum fee=$
4.Mechanical (HVAC) $ qQ DO Q (contact municipality)
5.Mechanical (Other) $ Enclose check payable to Sjk-V-'6 6-
6.Total Cost $ p Qpp (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.
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Please prin and sign name V Title Telephone No. ate
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Street Address Cik/Town State zip
Municipal Inspector to fill out this section upon cation
appli approval:
Name Date