10 BLANEY ST - BPA-14-1210 EXPAND HARBORWORK 6- Irl - t2
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts Shoe Building Code(780 CMR)
Building Permit Application for any Building other than a One-or•rwo-Family Dwelling
(This Section For Official Use Only)
Building Permit Number Date Applied: f Building Official:
SECTION 1:LOCATION(Please indicate Block N and Lot N for locations for which a street address is not available)
/9 B(Aricy S. S,g(r-r-t oi:270 -/W611
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK
Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration 13 1 Addition❑ Demolition O (Please fill out and submit Appendix t)
• Ghangeof-Use .0 Change of Occupancy -1 - --Other 13 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes 0' No ❑
Is an Independent Structural Engineering Peer Review required?'�l/- Yes ❑ No CIBrief Description of Proposed Work: L �fDNL HA+ wf C✓ry � 976r•11
FAQ PFI Vr FP IC', oe!rva At ii &C 0057' l
GZF.+Q7 CIZ015C a $Lr
MrSG t w02K ay'bL�itl Cfl�ir4y
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 applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ ll: Fli h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ Fl-5❑
1: Institutional I-I ❑ 1-2❑ 1-3❑ 1-4 R M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage Sl ❑ S2❑ U: Utility❑ Special Use O and please describe below:
Special Use.
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
11 ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ HIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CAIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
PttbllcX Check if outside Flood Zone❑ Indicate numicipnd❑ A trench will not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system required O or trench or specify:❑ permit is enclosed❑
Railroad right-of-way: hazards to Air Navigation; \I,\Ilii I rA—
w
Not Applicable26 Is Structure within airport approach area? Is their revieCompleted?
or Consent In Build enclosed ❑ Yes❑ or No Yes CI No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of,Code: Use Group(s); __.. Type Of Construction: Occupant Load per Flour:
DOes�the build int;contain an Sprinkler System?: ._ Special Stipulations:
SECTION 9: PROPER'rY OWNER AU'FIIORIZA,rION
Name and Address of Property Owner
--Tit) No.and Street City/'town Zip
Property Owner Contact Information:
k,�N1zrj WIrJ-j 973- - 56&5 Kwlnl�f� 5ra7t�11,prt
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable, the property owner hereby authorizes
-SEE Ae;�c
Nome Street Address City/Town State Zip
to act on the property owner's behalf,mail 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❑and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) 'rclephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
.10.2 General Contractor
Com7any Name
.40E-1 r11((.CrZ Cs - 109 3Zo L Urige2,ein
Name of Person Responsible for Construction Lisense No. and Te if A plicable
?yw� F9tj;' I Type
0174(01
Street Address City/Townhate Zip
1375 Ir? q7�- 777. 6v'& M&-t2 �cwN�rc�✓lA�i ,C l
Telephone No, business Telephone No. cell e-mailaddress
SECTION 11:W0I,'KFI,�S'CO\II'IcNSA'I ION INSURANCH A1110AVIT 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 the is�w ante of the building permit.
Is it signed Affidavit submitted with this application? Yes I"No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ Building Permit Fee=Total Construction Cost x—(Insert here
2. Electrical $ appropriate municipal factor)=5
3. Plumbing $
4. Mechanical (HVAC) $ Note: Mininuun fee=$ (contact municipality)
5. Mechanical Other $ Enclose checkan able to
P•Y•
6.Total Cost $ (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 No. Date
Street Address City/Town State Zip G
Municipal Inspector to fill out this section upon application approval:
Name Date