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B-19-527 - 0129 BRIDGE STREET - Building Permit The Commonwealth of Massachusetts Deparhnent of Public Safd nl, ,�g �, Massachusetts State Building Code(780�C1vIR IY Building Permit Application for any Building other thT a One-or Two-Fa i y Dwelling (This Section For Official Use Oiily) A Building Permit Number: Date Applied: Building Official: ' SECTION 1:LOCATION . No.and Street City/Town Zip Code Name of Building(if applicable) Asses&si&p# Block#and/or of # LO SECTION 2:PROPOSEDWORK 1 Edition of MA State Code used If New Construction check here❑or check all that apply m the two rows below � PPY� v Existing Building R" Repair❑ Alteration ❑ Addition❑ Demolition @'(Please fill out and submit Appendix 2) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ o/❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ M-0 ❑ Brief Description of Proposed Work:_. 5 C=C--lam 7`�sn- o � A/ e Cam( ' V we, cy (a(.© 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❑ 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❑ I-2❑ 1-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 EK R4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:.. Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMW105.3 for details on each item) Water Suppl Trench Permit: Debris Removal: Flood Zone Information: Sewage Disposal: Public Check if outside Flood Zone ��' �' _`"` A trench wi of be Licensed Disposal Site❑ Indicate municipal Private❑ or indentify Zone. or on site system❑ required . or trench or specify:�Str� permit is enclosed❑ Railroad right-of-way Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable 9V Is Structure within airport appr ach 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: J Use Group(s): Type of Construction: . Does the building contain an Sprinkler System?: 1V L? Special Stipulations: Design Occupant Load per Floor and Assembly space:. 512-(") RAlL;ED 110 G -G SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owne r ' COY C-�-C) '-y Name(Print) No. d treet City/Town Zip Property Owner Contact Information: ocv mzjc i9l 7!9, 4 Title Telephone No.(business) Telephone No. (cell) e-mail add ess If applicable,the property owner hereby authorizes: Name Street Address City/Town State Zip to apply for and act on the property owner's behalf,in all matters-felative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1) If a building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here E3. Otherwise provide construction control forms see section 107 in the code as r .aired. 10.1 Registered Professional Res onsible'for Construction Control(the pr6tessional coordinating document submittals] Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name G 5 Name of Person Responsible for Construction License No. and Type if Applicable —� 2 C�c c.ya-h/L f2�-►My�l� rw� --� . Street Address City/Town State Zip - KEYf�D -c,c.A- cow-, Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT 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)_$ �C, 1.Building $ a �v Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)=$ 3.Plumbing $ 4.Mechanical WAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ Q �p (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 erju t all of the information contained in this application is true and accurate to the best of my knowledge and and d' PI se p ' t and sign name Title Telepho a No. Date TL Street Address City/Town State Zip Email Address a Municipal Inspector to fill out this section upon application pp rovai: •-�. �r -�-- Name Date