0015 SUMMIT AVE, 667-1A BERTRAM TERRACE, B-13-662 i y The Commonwealth of Massachusetts
�J tr Department of Public Safety
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:
SECTION 1:LOCATION(Please indicate Block#and Lot#.for locations for which a street address is not available)
N0.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❑'or check all that apply in the two rows below
Existing Building❑ Repair Alteration ❑ 1 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 Ml� No ❑ ,
Is an Independent Structural Engineering Peer Review required? Yes ❑ No B�
Brief Description of Proposed Wor
co !nr12� m �h art n� Ong
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.R)and Total Height(ft.) - 'R
'r SECTION 5:USE GROUP(Check as.applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 7 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ -H-5❑
I: Institutional 1-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 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) -
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
j 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❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTIONS: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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Ad ress of Property Ownerp
i 2�✓��J //vn
Name(Print) _ No.and Street City/T wn Zip
Property Owner Contact Information: 6?40,7
Title Telephone No. (business) Telephone No. (cell) mail address
If applicable,the property owner hereby authorizes
Name 4reet Add res 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 D and skip Section 101
10.1 Registered Professional Responsible oonsible for Construction Control
LhI�Slnio 6° melgl-k 4�2-Pl- 417'77r �ih :o�ri ,i�.r1 i
NaJ��Jll�ggfy�tr t ifaZ -503Z
/ h No. e-mail dress Registration N umb
o�l
l3
Street Address City/Town State Zip Discipline Expiration Date
10..'22../Genera/l Contractor /}
�
oy}pany Name
'gd D. //3 Fe q ff/C
Name of Person Responsible for� Construction License No. and Type if Applicable
(&7se G1 tf7G y� //f�Lf�v vr7
S eetr t Address City/Town State /Zip
Telephone No. business Telephone No. cell e-mail addr 6s
SECTION.11:WORKERS'COMPENSATION INSURANCE AFFIDAVff M.G.L.c.152.§ 25C6
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 tpguance of the building permit.
Is a signed Affidavit submitted with this application? Yes OK No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ CI'ZS' Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ - appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HV AC) $ Note:Minimum fee=$ v`7 (contact municipality)
5.Mechanical Other $ Enclose check payable to Ike-0 CJY �L' 1"
6.Total Cost $ 8 e Z (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 Tele e No. .Date
Street Address City/Town Sta Zip
Municipal Inspector to fill out this section upon application approval:
. Nam Date.