B-17-416 - 0104 BRIDGE STREET - Building Permit DEMO 57P
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
_ n (This Section For Official Use Only)
c.Vx 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)
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❑ Alteration ❑ Addition❑ 1 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 ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ No Ell"
Brief Description of Proposed Work: �T*h-N4r� or �rtim R
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.)
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 1-1❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 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 ❑ ILIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public,< Check if outside Flood Zone al Indicate municip
A trench will not be Licensed Disposal Site 0
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA IListoric Commission Kevicw I'nx:css:
...................._................_............_............._.._._.._.._...-.... -._........'...... ...
,.- . 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 b idd ng contain an Sprinkler System?: Special Stipulations:
�I P'1eL, `TO Er .e' 4
s
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
CvaceAoAS L.0 26Y 6 1g1?0
Name(Print) No.and Street City/Town Zip
Property
Owner Contact Information:
;Le
Title _T Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Nune 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 Wil" .is less than35,000 cu.ft:of enclosed s ace and or,not under ConstructionC.ontrol th.in check here O 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
T TC G evwr-c,i L c t\ rq C n
Company Name
L e+M 1r't
None of Person Responsible for Construction License No. and Type if Applicable
C a 1 a,., "'NCB .r Sc;\P-. P\4 GI B 70
Street Address City/Town . State Zip
Telephone No. business Telephone No. cell e-mail address T
SECTION 11:WORKERS'(ONIYF..NSA1'IOiN INSURANCE AFFIDAVlT 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 O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE.
Rem Estimated Costs:(Labor
and Mateys) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $Itappropriate municipal factor)_$
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 accurate o the best of my.knowledge and understanding.
W a$gr �-S
Please print and sign na Title Telephone No. Date
_
,_ f lr2&Lg ,p Ind
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date