22 BECKET ST - BPA-13-245 ROOF RPR 1
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_ The Commonwealth of Massachusetts
•!�' Department of Public Safety
f.,.,7. \lassaehusclls State Building Curio(7811 C\i li)
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)
OLD Be,1s�-r S414, C) ) 9'70 3�r� Karr -
No, and Street Cit) /Town lip Code Name of Building(if,)pplicable)
SECTION 2: PROPOSED WORK _
Edition of MA Slate Code ust'd If New Construction check here❑or check all Iltat apply in the two rows below
Existing 13uildii ep; ;\Iteration ❑ Addition❑ I Demolition ❑ (Please fill out;md submit Appendix 1)
Change of Use ❑ 1 Changeof Occupancy ❑ Other❑.Specify:_
Are building plans and/or constnhction dtxuments being supplied as part of this permit application?, Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description Of Proposed Work:. `1=C2-t�.,9 �LA a �Q GIL p t' l-i o.rs
bo�r zpi yo F
5
SECTION 3:CONIPLETE'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 ChIR 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.),tad Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4 ❑ A-S❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ li-5❑
1: Institutional 1-1 ❑ I-2❑ 1-3❑ 14❑ 1 N4: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑,rnd please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 111 ❑ HA ❑ 118 ❑ IIIA ❑ Hill ❑ , IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit Debris Removal:
Water Supply: cloud Zone Information: Sewage Disposal: Liaroxsl Disposal Site❑
Public❑ Check i(outside Flood Zone❑ Ind A trench will not be I
Indicate municipal❑ required ❑or Irettch or specify:_
Private Cl Or indcntify zone:- gran site system ❑ permit is enclosed ❑
Navigation:
Railroad right-of-way: Ilaarrds to Air �I l ii.l.,� e•,ii---- �- . ..
Not Applicable❑ Is Slroclure within airport approarharea? Is their review comploled'
Or Consent hi Build cnclu,ed ❑ 1 es ❑ or:No❑ 1 es❑ No ❑
SECTION 8:CONTENT OF CERTIFICA'IT OF OCCUPANCY '
PJilinu of Code: _____.___ L'se Gnntp(s): 1\pc of Construction:
Doe, thr building contain en Sprinkler Svste In.':-__„. __Special Sti pu la l ions: ..
10077 r
SECTTON9t l'ROPER'rY OWN ER AU'1'I 10H IZATION ,
N,uue and Address of Pro rvrty Owner
N,une(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 herebv authorizes
-- Name Street Address City/Town State Zip .
to act on the property owner's behalf, mail matters relative to work authorized bV this building ermit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) -
If building is less than 33,000 cu. ft.of enclosed s pace and or not under Construction Control then check here O and ski Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-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 Licensee No. and Type if Applicable [],
—F-IA 6 P Y / i] _j
4 � _L.'D
Street Address City/Town State Zip
Tole phone No. business Telephone No. cell a-mail address
SECTION 11:1a-prherr;'rtnNfirr_V AtON_1V-,1J AN( FAI+11p,\V1I M.G.L.c.152.§ Z5C6
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 O
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
1. Building 5 6
Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)
V Plumbing $
4. Mechanical (HVAC) S Note: Nlinimum fee-S__(contact municipality)
5. 10ccliallical (Other) S Enclose check payable to 1 -
b.Total Cost S 9 ®® (contact municipality)and write ch ck number h ere
SECTION 13:SIGNA"rURE OF BUILDING PERMIT APPLIC/ NT
Ity entering my more below, I hereby attest under the pains and penalties of perjury that all the information runtained in this
application is true and accurate to the best of my knupvleJge anJ understanding.
Please print and sign name "Vitt Telephone No. Date
Street Address Citvi rU vn State /ip
Municipal Inspector to fill out this section upon application approval: -_ _ 1L--
Lmte VUate
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