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B-17-1176 - 0003A BUFFERY STREET - Building Permit l 7 >r athlofMassachutts,The Comn • Department of Public SafelA l 1 DEC -y P 4. 15 Massachusetts State Building Code(780 CMR) Q. Building Permit Applicattori for any;Building other than a Ctne-or Two-Fa'mily:Dwelling .on,., �.�;�• _ r ,,.�. �� . Secti For Official Use Only) Building Per it,Number: ;Date Applied.", 7Budding Official SECTION L-LOCATION A�,, e °, No.and Street City/Town.. " : Zip Code Name of Building(if applicable) Assessors Map# Block#and/or Lot # =e w�' `: `` � ,,SECTION2 PROPOSEDWORK� " t �z tk ; Edition of MA State Code used _ if New%Coitstruction check here D'ar check all that apply in the two rows below Existing Building Repair ETJ Alteration ❑ Addition❑ Demolition 0 (Please fill.out and.submit Appendix 2) (� Change of Use� ❑ Change of Occupancy ❑ Other'eD Specify: \� Are.building plans and/or construction documents beingsupplied as`part of this permit application? Yes� No ❑ Is an Independent Structural Engineering Peer R view requ�` d��? _, Yes ❑ No I�' Brief Description of Proposed Work: 7�� .? !lam tlD $4yd f .'SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION;OR CHANGE IN USE OR OCCUPANCYm �` ` Check here if an Existing Building Investigation and.Evaluation is enclosed(See 780 CNIR 34).Q - Existing Use Group(s): Proposed Use Groups): 4 SECTION 4:BUILDING HEIGHT AND AREA - iz , Existing �11 Proposed' No.of Moors/Shines(include basement levels)&Area Per Floor(sq:ft.) g E. _._ Total Area(sq.ft.)and'Total Height(ft) SECTION 5:USE GROUP(Check as.applicable) A: Assembly A-1❑ A-2❑' Nightclub D A-3 O , "A-4❑ A=5❑ 1 B: Business O E: Educational ❑ F: Tacto F=1❑ >2 D H: High Hazard -_ H-1❑ H-2❑ H-3 ❑ H4❑ H-5 Iz Institutional I-1❑ I-2❑ I-3❑ 1-4 0 a M: Mercantile D R: Residential =R-10 R-2 O A :R-3 D ,R 4 0 S: Storage S-1❑ S-2❑.=M : U: Utility;Cl I Special Use❑and please describe below:' Special Use Description: SECTION 6:CONSTRUCTION TYPE(Check as a liCable) s, wb 11310 HA.D �,'IIB ❑ ;.� � IIIA © IIIB�❑ LV ❑ VA�O�` VB D :"� 'Ns- . SECTION 7:SITE INFORMATION(refer to 780 CMR 105.3 for details on each item),, ti t Water Supply: Flood Zone Information: Sewae Disposal:gsposa: ,Trench Permit: ~Debris Removal: - ,4 trench rvs11 not be Licensed Disposal Site 13 Public 0` - -cheek if outside Flood Zone Indicate miunicipal �., ... � ` Private D or inden' Zone: ` '€ or on sites stem❑ required 6'or trench or.specrfy: y permit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: MA Historic Comulission Review Process: Not Applicable 1217, x is Structure within airport approach area? Is their review completed?1- 7 or.Consent to Build enclosed❑ -" g Yes 'or No`@�,i '` Yes p, 'No C� SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code- Use Group(s) Type of Construction: `- ' Does the building contain an Sprinkler System?: Special Stipulations - -, Design Occupant Load per Floor and Assembly space.�=� l SECTION 9; PROPERTY OWNER AUTHORIZATION71 Na a and ddrey of Property Owner Y Name(Print) No.and Street _ ty/)own f µ A;Zip Property.Q er contact Information: -76 Wife Title. _ Telephone No.(business) "F Tele hone No. cell e-mail address If applicable,the property.owner hereby authorizes: Nam ' .' Street Address`* r C ." `> . State` . Zip to apply for and act on the property owner's behalf,in all matters relative to work authorized by this building em-Litapphc4tion. SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 1) If a builduig.is less than 35,000 ca:ft"of enclosed space and/or not under Construction Control then check here 13 , . •„ a •- s• ... ,�� .' ,Otherwise€rovide construction control forms see section 107 m the code'as i uued. 10.1 Re istered Professional Res orisible for Construction Control(the piofessionatcoordiii ting document submittals) " Name(Re sty nt) T ep(i ne o. e-mail address Registration Number I Street Address City/Town ' State Zip Discipline Expiration Date - 10.2 General.Contractor Company Name Name of Person R onsible for C nstructi'on:, �i License No. and Type if Applicable Street Address A City/Town �� State Zip 77Y.36-0- co Telephone No.(business) Telephone No. cell " ` e-mail address SECTION 11:itiORKERS'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 appllcation."I+ailure to provide this affidavit will result in the denial of the issuance'of the building permit-i Is a si ned Affidavit submitted with this application? • Yes❑ No 0 ` SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE Istirnated Costs;(Labor `Item Total Construction Cost from Item 6)_$ • and Materials) F Cost( from Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2;Electrical" ;$ ' 'appropriate municipal factor)=$ P _. - 3.Plumbing $ * - _ Note:Minimum fee $ (contact municipality) 4.Mechanical (HVAC) 5.Mechanical; Other $ ' Enclose check' payable to 6.Total Cost $ l rjo+o° (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 , 1,application is true and accurate t stgfmy wledge understanding. �Z�W,7 Please print and Vgn name Titles Telephone No. Date Street * �ress City/Town State, Zip' Email Address � Municipal Inspector to fill out this section upon application approval: e t i A ame D t L