B-17-684 - 0018 BROAD STREET - Building Permit 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 For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION
el Y ! 0t
No."and Street City/Town gZip Code Y Name of Build' (if applicable)
Assessors Map# Block#and/or Lot #
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 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 ❑ No ❑
Is an Independent Structural Engineering Yeer Re iew uired? II' es ❑ No ❑
Brief Descripti n of ro osed Wor '1 �o 7c {'l
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) 0
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 ❑ A-4❑ A-5 13, B: Business ❑ _ E: Educational ❑
F: Facto F-1 ❑ F2❑- H: High Hazard ' H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ -R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use Description:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB0 IIAEl 1I13O IIIA13 I1I130 1 IVO _ VAS VB0
SECTION 7:SITE.INFORMATION(refer to 780 CMR 105.3 for details on each item)
Water Supply: Flood Zone Informational Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal E3 A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or permit is enclosed❑t ' specify:
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 OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: y
Does the building contain an Sprinkler System?: Special Stipulations:
Design Occupant Load per Floor and Assembly space:
�� ,� %1 -a, _
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:'
�i�0 1 P' ^ / �V ���—� xt— °,.a i ti .3° �•a°S t CC.Qf(vJ` —/�
Title Telephone No!(business) Telephone No.'(cell) e-mail addresV
If applicable,the property owner hereby authorizes:
Name. , Street Address City/Town' State Zip
to apply for and.act on the property owners behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 1)
If a building is less than M,000 cu.ft.of enclosed space and/or not under Construction Control'then check here,0
Otherwiseprovide construction control forms.see section 107 in the code as r uired.- '
10.1 Re 'stered Professional Responsible for Construction-Control the rofeseional coordin ting document submittals)
Name(Registrant)- - Telephone No.- e-mail address Registration Number
Street Address City/Town' .State , Zip _ Discipline Expiration Date
102 General Contractor
Company Name
(ar
Name o ersori Responsible for db6truction License No. and Type if Applicable " t
Ovi
Street Address. _: .'. City/Town State Zip
Telephone No.(business) T61e Bone No.(cell) . ' ' e-mail address
SECTION 11:,.W0RKERS'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 13 •No E
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor ' rP77
Item'.. s Total Construction Cost(from Item 6)=$ Ate
t � _ � and Materials)
1.Building $ t E
<Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical _ $ appropriate municipal factor)=$ W
3.Plumbing $ °
4.Mechanical (HVAC) - $ Note:Minimum fee $ (contact municipality)
5.Mechanical (Other) ` $
Enclose check payable to
6.Total Cost a $' (contact municipality)and write check number,here
SECTION I35IGNATURE 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'accu• to-to the beSt of y k owledge and understanding. ,
Pleaseprmt and sign nam Titl " `' 'G Telephone No. ate
_ zu � re n n
tree Address City/Town" 'a; State Zip ' ` Email Address
Municipal Inspector to fill out this section upon application approval:. 9 3/
Name Date