58 BEAVER ST - BPA-15-167 RENOVATE 1ST FLOOR t-I 352�
W
IOL , ' Vft h Of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit){�MRol Por Ay RiNig other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
oO 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)
( 54, Be-,,Ver sdr Sr lerv/ Olci70
1 No.and Street City/Town Zip Code Name of Building(if applicable)
V ) - 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 WTRepair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition (Please fill out and submit Appendix 1)
�fl Fhal
ge of Use ❑ Change of Occupanry ❑ Other ❑ Specify:
building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No a
Independent Structural Engineering Peer Review required?pp nn e Yes ❑ No S
Brief Description of Proposed Work: lCO3geVA 'ah. dI' �.r5 f d/O Jt�3 fr;wtU✓a / a
f'1/tiSd { �+ ickiti Ne1,� Ne,/ o�i` <
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) E3
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 CROUP(Check as applicable) - -
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 H-- Hi h 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-1❑ R-2 R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U. Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6.,CONSTRUCTION TYPE(Check as applicable)
IAO IB ❑ IIA ❑ IIB ❑ IIIAO IIIB ❑ 1 IV ❑ 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❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NMI I_rstnr_c Comm„sion Revw,-Pnxc.s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 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:
rnr� ,-1L D 2jC2�j11S
SECTION 9: PROPERTY OWNER AUTHORIZATION '
Name and Address of Property Owner
Cs(e� LuTz 58 Zea ,/>4— 54le"i/ 6Ig70 e
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) e-mail addres
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix2): - -
if buildingis less than 35,0001cu.ft.of enclosed-space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction-Control -
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:W01zKERS'COA-IPENSA VION INSU RANCH AEPIbAVrt' 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 O No O
SECTION I2.CONSTRUCTION COSTS AND PERMIT.FEE:
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ approprtate municipal factor)_$
3.Plumbing $
d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (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 ail of the information contained in this
applintion is true and accu�rra/tte to t t of h es my knowledge.and understanding.
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Pleue tint and sign ram Title Telephone No. Date
_54/ow AA 6/976)
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date