B-17-940 - 0030 UNION STREET - Building Permit E-11
Y The Commonwealth of Massac;
Department of Public Safety
Massachusetts State Building Code(78gR1(KP 22 A 04-1
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(Please indicate Block#and Lot#for locations for which a street address is not available)
'30 0A i0AJ .P� AA L®/YM/) A» a ( q-7 D
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
p 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 ❑ Addition❑ Demolition O (Please fill out and submit Appendix 1)
e-� Change of Use ❑ Change of Occupancy ❑ 1 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 lb,"'
Brief Description of Proposed Work: A-'AtMgL4 eQ'r-- sd Ur, !f b—p—/-/ rood f l �1
0 7lri. t/�lFs Cif-
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): 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❑ 1 B: Business ❑ E: Educational ❑
1F: Factory F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
Lk IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑ -
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
11
Railroad Applicable❑ Is Structure y e wis to air
Not Appthin port approach area? ����� G �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: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
Il°YI A i L TO C-t,L a
f
` SECTION 9: PROPERTY OWNER AUTHORIZATION _{
Name and Address of Property Owner {
Name(Print) No.and Street City/TownP Zip
Property Owner Contact Information:
1- -
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable;the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the properly 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 is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1)
10.1 Registered Professiono Responsible for Construction Control
ides a-ea < 0 Ire O r��a R
Name(Registrant) Telephone No. e-mail address to A e 'stration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor �" /I
pafv srt oLt Q[ aeoA 44 rA)& --
Company
�Name
1 II
_j l TVr►�J S�'r�"e�/ -
Name of Person Responsible for Construction License No. and Type if Applicable
ijtd - CAVA t-fq—, �� , DG4 Ad
Street Address City/Town State Zip
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11: vac Ij�t(: _;.: t i _f.SP Iy 1N5U1?ANi'I Af t �,�VC!'(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 ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
[tern Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ i 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 � lJr _ $- (contact r7 `ucipality)and write check number here_ -
SECTION 13:SIGNATURE OF BUILD;.-*G 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 est of my knowledge and understanding.
Please print i d sig1n name Title Telephone No. Date
6jf �'I �
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: `zt►^"! /
Name Date