6 BENTLEY ST - BPA-16-35 RENOVATE 3 UNIT BLDG K ► 13a f-20
4
The Commonwealth of Massachusetts
�4Department of Public Safety
1(f Massachusetts State Budding Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
M . (rbis.Section For Official Use Only) .
t Building Permit Number: Date Applied: Building_Official:
=BuildR
:LOCATION(Please indicate Block q and Lot ff for locations for which streeFaddresa is not available)
1 /ey S� S -ti � C2City/Town Zip Code Name of Building(d applicable)
SECTION 2•PROPOSED WORKte Code used S _ ff New Construction check here❑or check ad that apply in the two rows below
W Repair❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? YeOff No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No,[d'
Brief Description of Proposed Work.--a A/ec✓,/X S . 3 ti w /307"-" /
L.,'n./ar.✓S .e�.r rti���,�s vn io.,f e� Gx. � o
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) ❑
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 GROUP(Check as a plicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B. Business ❑ E: Educational ❑
F: Factory F-1❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 O H-4❑ H-5❑
1: Institutional I-1❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U. Utility❑ Spe ' and please describe below:
Special Use:
SECTION 6.CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ JIB ❑ 1 HIA ❑ 1I16 ❑ I 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:
Pub Check if outside Flood Zone❑ Indicate municip.- 0 A trench will not be Licensed Disposal !eir
Priva a or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: ;11��I listoric-Cignnussiun Ke��itng_I'roc"s:
Not Applicabla Is Structure within airport approach area? Is their review completed?
or Consent to Budd enclosed❑ Yes❑ or N,MT Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(sQ 4� Type of Construction: S-`y Occupant Load per Floor:
Does the building contain an Sprinkler System?: ..,,o Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION -
Name and Address of Property Owner / /J �c, ��7U .
(/1�G'/tiKM t/�9b✓I VL(i 1•7 / n�/ray �/�/'� �/
Name(Print)_-/VaL/ "-7n No.and Street City/Town Zip
Property Owner Contact Information:
,7-a� Sri 6/? 3�e_yam
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Str et 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 Appendiic2):
If buddingis less than 35,.000 cu.ft.of enclose dIs aceand or.not undIerConstruction Control then check here O and skip Section 10.1) -
10.1 Registered Professional Responsible for Construction Control
114
Name(Registran Telephone No. a-mail address Re stration Number
Street Address City/Town State Zip Discipline Expiration Date
- 10.2 General Contractor - - -
Company Name
f-fs !f<�v iL ��y ��{s o9fl�Y3 //ac- /y9z�y
Name of Person Responsible for Construction License No. and Type if Applicable ,
Street Addre City/Town State Zip
7,V Z- 97/3 7Fsl 7�_ 97/3 /l� /���� �hbf�ly,�r�'j
Telephone No'. business Telephone No. cell e-mail address
SECTION 11:WORKERS'CONIPF..NSAI'[ON INSURANCI:AEF'IDAVCY 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 a issuance of the building permit.
Is a signed Affidavit submitted with this application? Yeeg No ❑
- - SECTION 12:.CONSTRUCTION.COSTS.AND PERMIT TEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ //e? 190V Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical $ '/y00D appropriate municipal factor)_$
3.Plumbing $ OOd
4.Mechanical (HVAC) $ / a'd O Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ _ Enclose check payable to
6.Total Cost $ /$S a�' (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.
Please print and sign name Title Telephone N Dnte
3� G ,� 41r7 '_4 'I
Street Address City/Town, a/ Ofate Zip 1p
Municipal Inspector to fill out this section upon application approval:
Name Dal
w
�—+ '�''•('`'""'; .-_ . .wry.. .._ay.... ....
I -�-l--i---j-- I--r-�I- �_ �..._L_.}.._•--I-}- _.� l.. �I� I��+L ��QJ.�3'�Q7:�� --1-- --•-t•--�'i-'-i'--'_�����(�_� �. � .�._�...�.�,..
� t I
�! I
I
I 1
�_-r__}--_f__ 1.__.t_.f.-,�__1=_I ! 42.E .._..._._----�- -F-+----+-- --t---{--'----�-'---'-•.•.-•w...._ _ �-:-__•____'-__.�._i..�..i___-+......
I�l � .L� __y___..i__—.A___-1 .�. _.::..,�•�_._._.d._.J_.._...�{�! � •,T 1".^—i�—".'y-`.—f--• —y._��L_._I .�.,__—.._..�..�..�.. �_.�_.4.�.�...•_
1 ,
!
+---i- �--;--I- I ---{-.��._�..._. _..���1151a}-� �3/�+15�--�- 39dS��C12--i- --r �-- --1—T-T---w--�-�-+--{..•-•-*--
I
II FI _�,