B-17-442 - 0162 BRIDGE STREET - Building Permit cps
e -
The Commonwealth of Massachusetts `
Department of Public SaffR Massachusetts State Building Code(780 C ` A32
3
Building Permit Application for any Building other than a One-or Two-Family Dwelling
`V (This.Section For Official Use Only)
Budding Permit Number: Date Applied: Building Official:
SECtION•1LOCATION(Please indYcette Block#and Lot#'forlacatiiins for which a'streeGaddress is not available)
16 6 (11%: g e Sk S!%k?W\ W0,70
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 01.
Alteration ❑ Addition❑ Demolition (Please`fie46ut and subinit-Apperidix l)
Change-of Usk , ❑ 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
Brief Description of Proposed Work: S r%
Atli 4 ow 1l " o- ea+ Pedot 4Aouirr
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): t`
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: Factory F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-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)
[A ❑ IB ❑ [IA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 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❑ A trench will 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: NIA I hStoric Commission Review I'nxcss:
.........___.._.__.._.-_.....__..__._._.._._....._.___.....__._.----.._.__.__....___.
Not Applicable ] Is Structure within airport approach area? Is their review completed?
or Consent to Buihi e;n losed❑ Yes❑ or No;O ~ Yes❑ 11 No ❑ '
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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
f+ M [i.�'�dnS la 11'w4rt, Dr 04h&erk l0 9�3
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
John Cgr-%i K C V-Sro_ Q(7
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
TTC romm cor,4mC}*-�5 G\ I Pa' S91Py-w, M4. oI o
Name Street Address. City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this buildin ` ermit application.',.
SECTION.10•CONSTRUCTION CONTROL(Please fill out Appendix 2).
If budt ig is less than 35,000 cu.ft:of enclosed s ace and or.not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsibleeffor Construction Control
Name
(Registrant) T�ephone No. e-mail address Registration Number
�
1 • o%rw+ 1!!L% of 4 7a las
Street Address City/Town State Zip Discipline Expiration Date
10:2 General Contractor ,
Company Name
Cat..; re C$—QgS$9s
None of Person Responsible for Construction License No. and Type if Applicable
G,. I A tay^Lf SA SIR err r-%C 6 70
Street Address City/Town . State Zip
Ara g17
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WOIaKEits'ct.)nu-'ENSA'i ION INSU RANCH:VFFILMWf M.G.L,c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
1.iViechanical (HVAC) $ Note:Nlininwm fee=$ (contact municipality)
S. Mechanical Other $ Enclose check payable to
6.Total Cost $ Se) OA6 (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.
jotit� Cc�;Me a+..ner
Please pr' and sign name Title Telephone No. Date
I Ga 6r%•de-r .r 11. 541 fINC, ! t4
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: wEe+�7 `►q" ��L'
Name Date