0023 BEACH AVE U1- BPA-15-848 The Commonwealth of Massachusetts
r h4�jA�� Department of Public Safety
YY 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)
Wr 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)
. Q)
No.and Street City/Town Zip Code Name of Building(if applicable)
._ SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here O or check all that apply in the two rows below
Existing Building Repair❑ Alteration ❑ Additf�Demolition ❑ (Please fill out and submit Appendix l)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: 2e—
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 jX
Brief Description of Proposed Work:. -
144A, a 1F1�—fir 5 � t`
SECTION 3:COMPLETE TFIIS 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 CNIR 34) ❑
Existing Use Grou p(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 a licable
A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Bus)
iness ❑ E: Educational ❑
F: Facto F-1 O F2❑ H: Hi h Hazard H-1 O. H-2❑ H-3 ❑ H-4❑ H-5❑
t: Institutional I-1 ❑ I-2❑ 1-3❑ 14❑ NL• Ntercantile❑ R: Residential R-lO R-2 R•3❑ R-0❑
S: Storage S-I ❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ [6 O UA ❑ 110 ❑ IIIA ❑ IIIB ❑ 1 IV Cl 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site
require)❑or trench ors ecify: q
Private❑ or indentify Zone: or on site system❑ permit is enclose)❑ .ai
Railroad right-of-way: I1aLardS to tAi[NaV igatiOn: \I/\I L t ny Qgtnin55i n I .view I Not Applicable❑ Is Structure withinairportapproach area? Is their review completed?
or Consent to Build enclosed❑ Yes O'or No❑ Yes❑ No ❑SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Constniction:. Occupant Load per Flour:Dues the building containan Sprinkler System?:_ Special Stipulations:
MAAU -D '3121 Its
SECTION 9., PROPERTY OWNER AUTHORIZATION
Name and Address uj.Rroperty Owner
A 61g7C�
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to 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 2)
If building is less than 35,000 cu.ft.of enclosed space anJ or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control •�
Jc�dw 39
Name Rt mqt) Telephone NO. mail address , Registration Numb
Street Address City Tow - State Zip Discipline Expiration Date
10.2 General Contractor
CompanX>ime _
Name of Person Responsible for Co structiun_ Licen No. and Type if Applicable
o zS c i Gi
Street Address r City/Town State Zip
Telephone No. business Tele hone No. cell e-mail address
SECTION 11:%VORFEFS'COIIPENSAIION INSUItANCE 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 Pf No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Budding $ Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing S -
4. Mechanical (HVAC) S Note:Minimum fee=$ (contact mu ,lppallity))
5. Mechanical Other $ ( Enclose check payable to � /- CX J
6.Total Cost $ V (c (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
application is true and accurate to the best of my knowledge and understanding. �y�G3`Z
Please print and si lz Tit] a�ele hone No. Date
4F, rcR
Street Addre . ily/Town State Zip
Municipal Ins or to fill out this section upon application approval:
Name Date
� x/0 -Ppl-n • Ply �
ham.�rS
lot . 101
� � I
� l
I
30
5O..l C.
I
lyew �t�k a��o S�o��s
�K1A, 1,-+" rf-AR
St�.e �It�c,✓
e Y
-PO