0010 BLANEY STREET - ADD ON TO PIER ( � j
-File Commonwealth of [Massachusetts
{ I,� Department of Public Safety
.Mas'.1t1111SON Stale Molding Code(7M)L MR)
y Building Permit Application for any Building other than a One-or'Two-Fancily D elling
(I his Sorlinn For Official Use Only)
- Building Perout Nuntbcr' _...- UatvApplied: Building Official' _
LUCA I ION(['lease indicate (flock Il and Lot p fur locations for which a street addr .s is not available)
BLS)- OI�CID.-
Ind Si n'et City ;I'ot.'o lip Cud, N.unr ut l)u ildiog lit applicable)
SECTION 2: I'ROPOSFD WORK
lidition of .\IA 5taly Code used It:New Construe Lion clwe I,ltcre urihetk,lll lilac apply inlh,lwo nncv below- _-
F�isting Building 0 Repair❑ :\Iteraliun ❑ Addilioo ❑ Dvowlilioo 0 (Please fill out and submit.\ppcndis l)
Chant;v ul L'se ❑ C lIangeof Ovcttp,tncy ❑ Other ❑ $prcily:-_
Arc'building plans a nd/or cons)rut lion doc'u own is being sit pplicti as part of Ibis permit application? )Ies ❑ No ❑ — - - -
Is an Independent Structural Engineering Peer Review required? Yv.v ❑ Nu ❑
Brief Duscription of Proposed Work.-__
�41' (C�l I n.j E r t,�iT�>�..)B�. C>r lip_P, 1 NJ TO_
SECTION 3:COMPLETE HUS SECI-ION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,Old
CHANGE IN USE OR OCCUPANCY
Check here it an Existing Building Investigation and Evaluation is enclosed (See 784)CNIR 14) ❑
T:xisling Use Cnntp(s); -- _ Proposed Use
0".
ECTION 4: BUILDING [[EIGHT AND AREA
Existing Proposed
loors/Star ics(i tic little bax'ntvnt let Ql.v)r Area Per Fluor(sq.it.)
'a(sq. ft.)and rot.d height(ft.)
SECHON 5:USE GROUP(Check as a licable)
bly:\-1 ❑ A-2❑ Nightclub ❑ :W ❑ A4C3 A-i❑ B: Business ❑ T:: T:Jucttiunal ❑
f-1 ❑ P'_❑ II: Hi h fiu.vd 11-1 ❑ 11-2❑ i l-1 ❑ I I-4❑ 1.1-5❑
tional 1-1 ❑ 1-2 0 1.1❑ 1.4❑ :;\I: Mercantile 0 R: Residential R-10 R-2❑ R-1❑ R-J 0e 5-1 ❑ ti•'_❑ U: Utilit ❑ SpecialUse urv:Use 1 ER Q a Kj-e
SECTION F:CONSTRUCTION TYPF. (Check as Applicable)
I.\ 0 lit ❑ Ii,\ ❑ IIB ❑ IBA ❑ 11113 0 IV ❑ V:\ ❑ V11 ❑
SL( I ION 7: SITE I.NFOR,MA I"ION(refer to-NO CMR 11I.t)fur details on each item)
Water Supply: Flood Lune htfu fill atiu n: Sewage Disposal: french 1',nnlI. Debris Ileum%al:
Public Check B ot, mdv I lo„d L„nr 0 hlJicat,municipal .\ Irvnth tell not be I icrn.ed Itisposal �itr
1'm.itc❑ „r mdenlil\' /ono5A�11 I. sue+t slcin O. r`'yuin•d�i,r Irvnth or sprrde _
A(L 1'rnnn is elf,I,wd ❑
Railroad ri hbof-wa
g Y Ilaianls to .\it,..V.ry igatiun:
Is':tru,Hirt, 1,Itbirt ' 1 Is lht,ir rrt�Ir,.,onq,l,led '
r l'nu.rut H, IIuiIJ rm L;srJ ❑ i \rs 0 „r\', Q4 1 .❑ \ , �7
i SF( I ION,Y: ON I L.141 OF ITIt III[('.\IIi OF OC("CP.\N('Y
i Jinni ,d C,,,1r ( l.r„npl.l It I,o,u(,•II0 It 11„11
u II,l It min .ni nn�.11ti 11�,� I rr t.trni' Imi i.i Il,u lewnn
��� �� Ile
ti LCIIUN I, PBOPl:Bl y O%VNf.R �\UI I(OI(IZ.%I]ON
\ nn, ind Ad Yossul Propvi \ Ottntr r��
-. -
(Print)t) No and Strut Cth'/ ruwn Zip
anti
I'n�prr1 Ow nor Contact Inlonnatiun:
I itle rvlvphone No. (business) Telephone NO. (icll)
c-nt,u at , n'ss
If applic,Ile, the property owner hcmbv authoria•s
._.--- --Name -Street Address --- -City/ ruwn----' State -- -Ziv--
to act on tit,-pro eat owner's behalf, in all mottos n•lative to work authorized by this buildin mnnit application
SECTION 10:CONSTRUCTION CONTROL(Please fill out Append(x 2)
If bu i Id in;is less than 15,0011 it', ft.ul endusnl s mu and/or nut under Constn,ct Ill n Control then check here❑and ski,Sre tit m lu.l
1 U.1 Registered Professiu nil Res ponsible for Construction C^oontrol
Name Rrgtstrant) �7'cle hone Nu, email address Registration Numbs fLN1V LtLr Jv �kLl4 11�.� �"tf•�L.d'Ci.�v�(- �—
fa titanium Date
<trcct Address City/Town Stale Zip Discipline Q,E� r
10.2 General Contractor
Company Name ZS IS
Nance of Person Responsible for Construction License No. and Type if Applicable
Strcet Address City/Town State Zip
( -1 09� �L, •- c-mail address
rvly ,hone No. business Tole,hone No. cull
SECTIONIl:o, v; rl: ,��w'tv.�Ipt\ I�zdla.\��-r .\Ilu,••,\11 M,G.L.c. 152. 2.5C6
11
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be Completed and
submitted with this application. Feilure to prode this affidavit will result in the denial of the issuance of the building permit.
Is a Sl&melt Alfidavit submviitted•with this application? Yes No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estiowted Costs: (Labor
Item ,unl Materials) Total Construction Cast(from Item 6) 'S—_--
I. Building 4 Building Permit Fur'Total Construction Cost x _(Insert here
,. EILtiIricai S appropriate municipal Ltctur) 'S
1. I'luntbinl; Contact numiCi ,alily
Mute; \liniuuun fee'S--( f )
1. \IrihaniCal (IIV:\C) S
i. \Ici hanii al Other) 5 l-itvluse Chv%k poyable h,
n. Gc,ll Cost > C( (Contact nuu,i,V,Iity)and write check rumba here
SECTION 13:SIGN,\TUI(E OF BUILDING PERMIT APPLic NT
tlsr lownlIg nw it. bvlu,v, I herndry attest tinder the pains and penallivs of perjury that•dl of tine inl-motion wot,iutrd it' this
a ppl ic.n it'll is true dud aauratQ to the best of nw kn,„%lodge dmd uadermanding.
I tale rrlophoov No 1),ov
. •,t rrrl \,hlrt•ss
Cilc, I'll„tn �Lite /tp
\lunicijmI In.pedor ht fill out this sediun upon application approval:
' . ..\ainv I ldr