B-17-949 - 0122 BRIDGE STREET - Building Permit .53 CKs-r7
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Department of Publ ��L 2b
Z011 SEP 2 b A 2Massachusetts State Building ode(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(Thischon For Official Use Only) E .
1 Budding PerriutNumbers Date Applied $ Biulding Official`'
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SECTION 1 LOCATION(Please indicate Block#and Lot#for;`locatlons for which a sheet address is riot°available}
22 ridge 5F. atCm ,MR 0\q110- 3g29 SV. JOIrin's Church
No,and Streep City/Town Zip Code Name of Building(if applicable)
'. SI CTION 2 PRQPOSED WORK^,. . , .. .`. ._
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ reir Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ ge 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 ne
Brief Description of Proposed Work: re—r-00E
SECTION�3 COMPLETE THIS�SECTION�IF EXISTING�BUILL7,ING�UNUERGOING�RENOVATION,ADDITION;OR �,�^
� � ,:. .,` ;CHANGE iN FUSE OR,OC'�CUPANCY ��•�3 �� '; � '' ;' �_'
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) 0
Existing Use Group(s): Proposed Use Group(s):
5ECtION 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 I7SE GRO�UP.(Gheck as,applicatle} 1' s
Y ,�A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 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❑ I-4❑ M: Mercantile❑ R: Residential (• ' f R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use Vand please describe below:
Special Use chv(m7 I
` SEC"TION 6:CONS TRUCTION TYPE Check as a "licable
p
lA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7 STIE INFOItMAPiON(r`efer to"780 CMR 1110 for Aads on each item}h yz . . .<
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑
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❑ Yes❑ No ❑
SEC I ION 8 CONTE.IV T OFk CERTIFICATE OF OCCUPANCY r
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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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PROPERTY OtNNER AUTHORIZATION a `` rax`"
Wane and Address of Property Owner
daft% Morris Ul bridge 3V UAt _ VAR !� 01gio
Nanie(Print) No.an treet City/Town Zip
Property Owner Contact Information:
tiZty - - I&V 3�-51g t UKrcaMN5a1Cm� MCCA1 .
Title Telephone No.(business) Telephone No. (cell) e-mail address MN
If applicable,the property owner hereby authorizes
4KNO`sh �olAno "163 waver�� s�. fat& hamM!t c rlo z
Name Street Address City/T n State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10 CONSTRUCTIQN CONTROL Please fill auto gpendi a
(I£binl"dm is I(ss than 3 000 cu €t of enclosed spade and/pr npt ender Construction Control their shed here p�aetd slop Section Q1;
10j,Rekigtered Professional Res onsiblefor Cp dwC6riftv 1,, 4
Name(Registrant) Telephone No. e-mar' adl dress (OMJ Registration Number
165 ubtyehrttl 5t•. dlnarv% r 01,10 10t
Street Address City/Tdm State Zip Discipline Expiration Date
H er R 'RmrncA
Company Name
RADII R5 it ►�zzo� H i cl
Name of Person Responsible for Construction License No. and Type if Applicable
16 3 U�Yiverlu �F. ' c 0110 2.
Street Address City own State Zip
.3u$- 434$ - 3$O_ cct85 roofing&hr-rooFina corn
Telephone No.(business) Tele hone No. cell e-mail address
,.;SECTION 11 4l?ORKE"IL� cOl�'IFENsk1110N AUSTJ)ANC&li1aFIDA�IT�M G:L c 152.�§25G 6 � �'' _,�,,`` �-"
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the' suance of the building permit.
Is a signed Affidavit submitted with this application? Yes 1rNo ❑
y„ SECTION 12`C�NSTRI7CTIOlV,COSTS AND PERMIT�FEE;�y„��, �� , � W `� .� � .
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 00 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact muniiccipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost
$ 2 Z 600• W (contact municipality)and write check number here
32 - 1 C 3 Y4 6.
SECTION 13 RE-,OFBUILDINGPERMTT APPLICANT �x r ,
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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 print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out thtsssechon upon application pprovaL°
Name '.a Date