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63 BEAVER ST - BPA-16-669 RENO. 1ST FL 'P 33o CX, -7% 1 b Rem-IVED t SE#tV:�a The Commonwealth of Massachu e Department ofMp&%4t3 A. la- 39 W 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) Building Permit Number. Date Applied: Building Official: (, (�o SECTION I.LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) (� 3 13EAVE KST SA LEM Mom• No.and Street City/Town Zip Code Name of Building(if applicable) _ nA SECTION 2•PROPOSED WORK y Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Buihlingla" Repair 13 1 Alteration fa' Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: (( Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Imo. Is an Independent Structural Engineering Peer Review required? Yes ❑ No Q Ilbb Brief D criptiQQn of Propos5vl Work:. T K i;,NOV f3 T'E 1 r-LO E7 fi--F 1 . IC�LSVIL6 AS -5AMC_ �✓ uTY} 4 sMF}lC._ MvDiF;c,q^f�OS As NoT-t�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) O Existing Use Group(s): IProposed Use Group(s)- SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)k Area Per Floor(sq. ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-I❑ A-2 O Nightclub ❑ A-3 O A4❑ A-5 O 1 B: Business ❑ E: Educational ❑ F: Facto F-I O F2❑ - H: High Hazard H-1❑. H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional I-1❑ 1-2❑ 1-3 O hl❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 Gr R4❑ S: Storage S-I ❑ S-2❑ I U: Utility❑ 1 Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill O IIA ❑ IIB O IIIA ❑ !fill ❑ IV O TVAD 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 0' Check if outside Flood Zone❑ Indicate municipal 0, A trench will not be Licensed Disposaal Site El Private Cl or indentify Zone: or on site system❑ required❑or trench or specify:,e �'I C Z permit is enclosed❑ LJ'NN Railroad right-of-way: Hazards to Air Navigation: 1I_a I1kh"r Commissi...I I"",w"_r'nwr.5: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Budd enclosed❑ 1 Yes O or No❑ 1 Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code Use Group(s): Type of Constriction:� (kcupant Load per Floor: Dtxrs the building contain an Sprinkler System?: _J),Z_2 Specidl Stipulations: jcNQ Tio C?-C . SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner . Name(Print) No.and Street City/Town Zip Property Owner Contact Information: p LV /E P, 976. 74� 6 Zo Z_`� __ rA c t5,x o A*t Title Telephone No.(business) Telephone No. (cetl) e-mail address If applicable,the property owner hereby authorizes , 5 F4M >~ 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 Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control 711 DM AS /'IJDOty,4 �AM� j�le�.ToMlo° coo CS_ 0&07Sp Name(Registrant) Telephone No. e-mail address Registration Number IO-Z2--16 Street Address - City/Town SLite Zip Discipline Expiration Date 10.2 General Contractor l /1 UMf _S Company Name Saiv. P CS O� 07S0 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:WORKERS'CONIPENSAIION INSUIL AV171' M.G.L.c.152. 25C 6 A Workers'Compensation Insurmce Affidavit from the MA Department of Industrial Accidents must be completed and submitted with thisapplication. 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 0 No 2, N a E MV04oy SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Told Construction Cost(from Item 6)_$ 1. Building S'v0 IBuilding Permit Fee-Total Construction Cost x—(insert here 2. Electrical $ 4000 appropriate municipal factor)_$ 3.Plumbing $ 3SC70 . d.bfechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.hiecha nical Other $ Enclose check to 6.Total Cost $ municipality) payable 3 Q, DOD (contact municipali )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this application is true.red accurate to the best of my knowledge and understanding. 74ioM4iS Mc DoAIA 14 l��w�al���v � o 1vc2 R�8_ GZr�2G-t716 Pleue print and sign name Title Telephone No. Date �04�Cr i '�E �� . !3 EVEK�X M� O i `l I 5- Street Address City/Town State Zip / Municipal Inspector to fill out this section upon application approval: U111.1 YAW Name Dale , • 1 tufts<� 737��i 7��T OCO FS 'v fit J'1t}iN ,c� ��flM 0c�� 11�� '��` �S 0 12QS Go(3-/ 1- QQ0� �rV � eQ � a -S- o©off