4A ARNOLD DR - BPA-07-527 REMODEL KITCHEN i CITY OF SM EM, INLASSACHUSETTS
BumDLNG DEPARTuENT �1
` 130 WASHNGTON STREET.3' Ftooit _
TEL (978)735-9595 v
FAx(978)740-9946 ^��{ C(�
KI�1BF_RI.>r1C DRISC�/ / V
MAYOR �y "D(7 THomAsST.Pmm ��
DIRECTOR OF PLauc PROPERTY/BumoiNG Co.%masSIONER
APPLICATION FOR THE CONSTRUCTION;REPAUK RENOVATION,CHANGE IN USE OR
OCCUPANCY,OR DEMOLITION OF ANY BUILDING OR STRUCTURE
This Seddon.fbr Official Use Only
Bt�1d4yIPemYt,ProJeck_ Dstaa_ /
t3uiiding.Inspector'- - - •'
Eatiina6e P�ioNct Dates: Start: End:
Carnnsnts:
1.0 SITE INFORMATION
F Location NanwK l clt� . .4 -Vti Building:
Property Address, 9 A
ST1cw� t'lw �1�7G
Assessors MapJBlodc LoUPalr ek
24�QYyI ERSfiI WORMATION
2.1 Owner o1 Land
pOwwnw
t"1't(Ac - i� ►��
y q Arm O r.
`�7f�- 7y}^— Sea�
less.s of bu#d/nS or strucdrro
Name:
Address: T. 2 ' -15C-00ea061
Telephone:
3.0 AGENCY OR AUTHORITY AUTHORIZING CONSTRUCTION
Agency Name:
Address:
Agency Project Number.
Project Manager Name:
8.0 DESIGN AND CONSTRUCTION UTIU01I6 MGL C,112 SECTION 81R EXEMPTIONS
(See note below)
Contractor t J
Name: `
Address: ,f i5 SI
Area of responsibility: Cj 1 Go��cc c ��
ticense Number. , ` S o6 100 Date of ExpiraWM 3-1-07
Telephone: Fec�
Contractor
Address:
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fatc
Contractor
Name:
Address:
Area of responsibility:
License Number. Date of Expiration:
Telephone: Fax.
Note: for portions of work uti izinp exemptions of MGL c. I Q a 81 R complete the section above.
Use additional sheets if necessary and attach to application.
9.0 COMPLETE THIS SECTION FOR WORK IN EX14T1NG BUILDINGS ONLY
For new construction comnlete sectlo
Addition Existing
Renovation Number of Stories Renovated
Change in Use New F
Demolition Existing
Approximate year of Area per floor(sf) Renovated
construction or renovation. .1°l�5J
of existing building
Brief Description of Proposed Work
i
r
*-1 USE GROUP AND CONSTRUCTION CLASSIFICATION(Existlnp Buildings_Only)f
EXISTING— "PROPOSED Change CONSTRUCTION
USE Group(s) " in CLASSIFICATION
Use. Hazard Use_- Hazard.
Hazard
`tS
Group Index roup . Index .Index.• (+l as apgkabls)
A Assembly 1A a
B Business 1B
t
E Educational, ?A-
F Factory 2B"
H High Hazard " ~ 2e f
Institutional 3A
M Mercantile 3B
R Residential 4
S Storage 5A
U Utility 58
Mx Mixed Use Hazard Index
Sp Special Use
' Note: Include Hazard Index Modifier for Construction Type as applicable
r9.0 CONSTRUCTION COSTS(Sae 780 CMR Appendix L)
Total Constnu don Cast Building Permit Fee Check Number
x$0.00,
10.0 AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR BUILDING
PERMIT(when applicable)
on behalf at the audwdz np State
Agency or Autisorily, hereby authorize. JCt 122G( fiSh Ivy to apply
for the building permit for project number,
Signature Date
11.0 SIGNATURE OF BUILDING PERMIT APPLICANT
F
Name
Signature Date
12. Certificate of Occupancy required on completion of projeW _Yes 4_ No
Inspector's Notes:
l
Application for Permit to: ;
Ch. �s
Location
Permit Granted
/Vk/�/��
App ed
s
Inspector of Avildings
i