B-17-316 - 0211 BRIDGE STREET - Building Permit 7.7,
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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
(this,Section'FOT_OffiCial Use Only)
Building Permit Number: Date,Applied: Budding Officral _
p 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 ❑ 1 Addition❑ 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 Enginee ' eer Review required? Yes ❑ No
Brief Description of Proposed Work — � t/7C' 60 /� 7
4l,%
SECTION 3 COMPLETE THI1.S"SECTION•IF-EXISTING BUILDINGUUNDERGOING 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): T Proposed Use Group(s):
s SECTION 4c BUILDING HELGHT 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"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❑
1: Institutional 1-1❑ 1-2❑ 1-3❑ 1-4❑' 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;;CONSTRUCTI0IV--TYPE(Check as'appI— ble)
IA IB ❑ IIA ❑ IIB ❑, IIIA ❑ IIIB ❑ IV VA ❑ VB ❑
SECTION:.? SITE-INFORMATION(refer to Z80`CMR 111.0 for details om each;item)
' Trench Permit: Debris Removal:
Water Supply: Flood Zone Information:, f, Sewage Disposal:.
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 D
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 ❑
SECTION 8:CONTENT-DP CERTIFICATE OF OCCUPANCY
Edition of Codec Use Group(s): Type of Construction: Occupant Load per Floor
Does the building contain an Sprinkler System?: Special Stipulations:
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SECTION 9 PROPERTY OWNER AUTHORIZATION
Name acid Address of Property Owner
at� 111 si S <m Mit
Name(Print) No.and Street City/Town Zip
Property Owner Con ct Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Cs� �c=is
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 out Appendix 2)
If building id less than 35,000 cu.ft.-of enclosed s ace`and/or Trot under Construction Control then check here 0.and ski Section.101 ,.
10.1 Registered Professional Responsible for Construction Control
1�irDl'hS (Duia
Name z trant) Telephone No. e-mail address. ` Registration Number.
Street Address City/Town State Zip•- Discipline Expiration Date
10.2 General Contractor
ompany Name ,
Name of Person.Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
951 Jbs -a3Ro nu/A/f✓Sa MSPWer-1(M a.(
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 13
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 12 1,RW,00 - ' Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to
6.Total Cost $ �j O�tt� (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 knowledgw and understanding.
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Please p t ond sign name Title Telephone No. Date
Street Address City/Town State Zip
i
Muiucrpal Insp6etbr-to lll out thrs section upon application approval
__ ,Name Date