B-17-856 - 0401 BRIDGE STREET - Building Permit I
r
onwealth of Massachusetts
kT The Comm Depanent of Public Safety
Massachusetts State o
ngf
g Code 780 } Familyvelhng
-, Buil� other than aOne-or TW°" ii
f1 Building Permit Application for any� �Use Only)
•�X his Section For ;
(r r Official:
LO
Date'Applied:. Biulding able)
.Building Pernut Number:
SECTION 1:LOCATION(Please indicate Block
and Lot.#.for locations for,which a street address rsnot avail
of .
D Zip Code
" Name of Building(d a Pplicable)
No.and Street City/Town
SECTION2 PROPOSED WORK
, �. 1 in the two rows below
t f MA,State Code used r if New Construction check here O or check all that app y Appendix 1)
Edition o lease fill out and submit
Addition.❑ Demolition ❑ (P
Existing Building D Repair 0 Alteration D �'C
Other. ❑ Specify:. " No ❑
Change of Use ❑ 1 Change of Occupancy ❑ lic ition? Yes [3 "'
Are building plans and
construction documents being supplied as part of this permit app Yes ❑ No 0
Is an Independent Structural Engineering Peer Review required?
Brief Description of Proposed.Work: 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'.CMIZ 34) D'
Existing Use Group(s): Proposed Use Group(s):
SECTION 4-8LUDING HEIGHTfAN:D AREA; Ex stir Proposed
g
No,of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) ,
Total Area�(sq..ft.)and Total Height(ft.). ' r
SECTIONS:USE GROUP(Check as applicable)
A: Assembly A-1.0 A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business 0 E. Educational
R Fact Ti❑ F2❑ H-1❑ H72❑ H-3 0 H-4❑ H-5 O'
H: Hi Hazard... .:. .
L• Institutional I=1❑ I-2❑ I-3 0 I-4 D M. Mercantile Ct R: Residential, R 10 , R 2 0 R-3❑ R413
S; Storage S-10 S 2❑ U: Utility 0 Special Use 0 and please describe below:
-Special Use: a
SECTION 6:CONSTRUCTION TYPE(Check as ap licable) -' `
1A 1]
16 O IIA.0 1IB O IIIA ❑ HP 3 TV_0 VA 0. . ;. VB 0
SECTION 7:SITE INFORMATION.(refer'to 780 CMR 111.0 for details on each item)
Water Supply:, Flood Zone.Information: Sewage Disposal: s v 'Trench,Perm t: Debris Removal:
A trench will not be Licensed Disposal Site
Public D Check if outside Flood Zone 0 Indicate tnunidpal 0 1. p
on : required O'or trench or specify:,AYPrivate or,indentify`Z
permit is enclosed.0 -
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review ice:
Not Applicable O Is Structure within airport approach area? Is their review cntnpleted?
or Consent to Build enclosed 0: Yes O or No❑' . x
Yes 0, `� No Q
SECTION 8:CON£EN'r OF CERTIFRCATE OF pC_cuppNCY
[Ed:itiort of Code.,_.. Use Group(s), 'Type of Construction: occu ant
Pd pei'l~1oor:
the}ruildin contain an Sprinkler System? Special Stipulations:
IN
ORIZATIONSECTION 9 pgtOPERPYOWNII: AUTHame and Address of Property Owner
Zip
Name not — City/Town
�' ) No.and Street
Property Owner Contact Information:
- ` -- e-mail address
Title Telephone No.(business) Telephone No. (cell),
If applicable,the property owner hereby authorizes
1
Town State Zip
City/Town
Name Street Address ty/
to act on the roe owner's behalf,in all matters relative to work authorized.by
this building ernut application.
SECTION 10•CONSTRUCTION CONTROL(Please fill out Appendix 2),
o buildingis less than 35;000 cu.ft.of enclosed ace acid or not under Construction Control then check here O and ski Section 10.1
10.1 Registered Professional Res"onsible for ConstructiomControl
i Name(Registrant) Telephone No. e-mail address Registration Number-
Zip Discipline E
Street Address City/Town
State. i piration Date
10.2 Generalt Contractor
Company Mane MIA
40A5 ES
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
6X VIA
Tele hone No.(business) Telephone No. cell e-mail.address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 3 No O
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE ..
Estimated Costs:(Labor'
Item 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 (IVAC) $
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 BUILDINGPERMTr APPLICANT
By entering my,name below,I hereby attest un r the pains and penalties of perjury that all of the informatioZn d in this
application is bve and accurate to the best o y knowledge and tulderstanding.
y _
Please print and sign n -:Title
g9� lt1€j pol ��9 I E�r-A-A F MA Telephone No. Date
a,_ft -r
Street Address City/,Town. State Zip
1Viuniripalp�ctor to fill out this:section upon application approval:
Name
Date