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B-19-362 - 0295 BRIDGE STREET - Building Permitr f:+ ; CK e - The Commonwealth of Massachusetts Department of Public Safety Ulf Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling II (This Section For Official Use Only) (V 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) 2 9 5 'tc�a-e S-1—V-e-'C-4 SC A t-N/1 AA/--- F-W•W'Cb17 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 Buildingl;(. Repair❑ 1 Alteration ❑ 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 Engineering Peer Review required? Yes ❑ No�A Brief Description of Proposed Work: rdWC M d'1 V 1 O ee- owl G I h .= .e r C-eel m_ t 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): s 1 Proposed Use Group(s): SECTION:4:BUILDING HEIGHT AND AREA r Existing Proposed No.ef`Flooif Stories(include basement levels)&Area Per Floor(sq.ft.) S $sa3a S bb3a Lb ea(sq.ft.)and Total Height(ft.) qI loloU (ps 41lolo0 (ps LL SECTION 5:USE GROUP(Check as applicable) +Q sserr42jy A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business)9 E: Educational ❑ ., cto F-1 ❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I 'h►s'titonal 1-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile R: Residential R-1❑ R-2❑ R-3❑ R-4❑ Stora a S-1 S-2❑ U: Utility❑ Special Use❑and please describe below: ecial SECTION-6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public;2 Check if outside Flood Zone�j Indicate municipals A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required)Mor trench or specify:N,/4 permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable)k Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No Yes❑ No SECTION 8:CONTENT OF CERTIFICATE OF,OCCUPANCY ; Edition of Code: Use Group(s):S s,$.M Type of Construction: 1 Occupant Load per Floor: Does the building contain an Sprinkler System?: yes Special Stipulations: 4 At TC) Pt NNE 4M,r: The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Building Code (780 CMR) r , Building Permit Application to Construct,Repair,Renovate or Demolish any Building other than a One-or Two-Family Dwelling Code'and Other Requirements for Building Permits The Department of Public Safety has issued these building permit application forms so that municipalities across the state can move toward use of a single permit form and consistent permit application process. The MA State Building Code specifies the requirements of building permits and the applicant is advised to review and be familiar with these requirements in order to avoid some of the common permit application problems.Likewise the applicant should be aware that some municipalities require that the owner confirm, even prior to acceptance of the building permit application, that no outstanding property taxes,water fees, etc. exist.' Filing Instructions 1.Please contact the city or town where the work will be done to ensure that the city or town will accept this application form and if any additional information is required, and obtain the correct mailing address. After doing so, print the application, fill in completely and then submit to the local city or town where the work will be done. 2.All applications shall be considered complete and will be.reviewed if construction documents, specifications; fee, and other materials that may be required as indicated in the Building Permit Application are included with the application. 3.Please include a.check for the Building Permit fee. The fee may be calculated using the information to f be supplied in section 12 of the Building Permit Application. The check is to be made payable to the local city or town where the work will be done. . `; y L,J a } �lJi ♦ SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner m o b 9 5 6✓I CI Q 4 Gil_S a.�-C.►�r� , M.A,-. Name(Print) No.and Street City/Town Zip Property Owner Contact Information: C't,.✓��.r'o�-P IN1 r�t�s-r. °I'��b �i'193 311 - ✓ 1 v►� _ �Wru�bb. Title Telephone No.(business) Telephone No. (cell) _ e-mail address If applicable,the property owner hereby authorizes co✓ nn-- tt4n L-ea-t l�r tc q9 M OC.M S S+. LtQ✓A t✓t s}Cf�IM1�c . D IU S3 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) building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0.and skip 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 62✓ -P� o n S t y C+f O,0 Company Name /� A- n s� O t Y\t^.'C t�/ C�J` 04 5;61 Ot Name of Person Responsible for Con&uction License No. and Type if Applicable A fo oS c, t S to%.,v w MAc. b 1 of 1 Street Address City/Town State Zip a�!4 N 3 N b '�` -- D S��r►n t t�� al vie t..-�1 t a-P-t�m. �-r1 Telephone No. business Telephone No. cell e-mail address SECTION 11:WORKERS'COWENSATION 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? YesA No 0 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 $ 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 to the best of my knowledge and understanding. Nu pie L CA c✓at y / / ^--b ��L'_ t�✓o��c ryltn�rtr o- aol Please print and sign name Title Telephone No. y_Q tte 9 q Av cc.tn�t S�-. I­GonAt•�}--� M A," oI N 59 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: ame - Date Appendix 1 For the demoliti of structures the building permit applicant shall attest that utility an other service connection are properly addressed to ensure for public safety. Please fill in the informa 'on below and submit this appendix with the b ' ding permit application. The building ermit applicant attests under the pains an penalties of perjury that the following is true and acc ate. Property Location (Please indicate lock# and Lot#for loca ' ns for which a street address is not available) No. and Street City/To Zip Name of Building(if applicable) For the above described property the llowing ac 'on was.taken: Water Shut Off? Yes ❑ ❑ Provider not' 'ed and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes o ❑ Provider notifie and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Y No ❑ Provider notified d Release obtained? Yes.❑ No ❑ es ❑ No ❑ Provider notified an Release obtained? Yes ❑ No ❑ .Other (if applica e)- ° I . Yes ❑ No ❑ Provider notified and Re se obtained? Yes ❑ No ❑ Other (if applicable) ,