37 BOARDMAN ST - BPA-15-1087 RENOVATE 2 FAMILY The Commonwealth oV &S
I W
Department o�'�r�, a�etyO Massachusetts State Building Code(780 Chl(i)
_ Building Permit Application for any Building Igri na[9ng�o AlLmilyDwelling
(This Section For Official Use Onl )
In Budding Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
(D 37 I OArc"
L No.and Street City/Town Zip Code Name of Building(if applicable)
1 - SECTION 2 PROPOSED WORK
Edition of MA Slate Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building h! I Repair❑ 1 Alteration ❑ 1 Addition O 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No'6=
Is an Independent Structural Engineerin Peer Review equtred? Yes ❑ No'd.
Brief Description of Proposed Work.,_ h t o� 2 1 a�I
a 2
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Cheek here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O
Existing UseGroup(s): Proposed-Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)i&Area Per Fluor(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-1❑ F2❑ I H: High Hazard H-1 O. H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional I-1 O 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2® R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA IB ❑ ❑A ❑ IIB ❑ IIIA ❑ I118 ❑ 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:
Licensed Disposal Public al Check if outside Flood Zone❑ Indicate municipal❑ p s
Site us ❑d A trench will not be
required O or trench or specify:
Private❑ or indentify,Zone or on site system❑' permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: ki-\I li_tort, wa.I'nxrvs:
Not Applicable❑ Is Structure within airport approach area? Is their review completed? _._
or Consent to Budd enclosed❑ Yes❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Gnnip(s):' 'Type of Construction:. Occupant Load per Flour:
Does the building contain an Sprinkler System?:_ Special Stipulations:
Mgti�� Xol&
SECTION 9: PROPERTY OWNER AUTHORIZATION
Na ue and Address of Property Owner
e �i�� 171L✓f3v s� SA Lm Of`3�q
Name(Print) No.and Str t City/Town Zip y
Property Owner Contact Information: I
7 O�cgS— `% SbZ2'72t
Title Telephone No.(business) Telephone No. (cell) e-mail address
I(f�applicable,the property owner hereby authorizes
y1�11;(�aC Tn[H Cot Z;LUC�$t"R1LJ� 1/1) /-}AMIy'�N /1'Y.i OI 9
Mune Street 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 Appendix 2)
If building is less thin 35,000 cu.ft.of enclosed space 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. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2/General Contractor -
l7iF-'pIZ6
Company Name
(^al'ATL!-c- �N C 1.1 C-S
Name of Person Responsible for Construction Lilcense No. and Type if Applicable
&I $Lll?"L�eF2Y Lf� FFAM 14n;l /10-� 1
IV.
Address ����// �✓ City/Town 1 / State --`Zip
IV.4X nf-c- 9�-JJl- J $��/ ��P/7 CA (� V•Q..✓I ZcTr, fVQf--
Tele hone No. business Telephone No. cell a-mail address
SECTION 11:VVORFE:RS'COAIPEN.SA PION INSURANCE AFFIDAVIT M.G.L.c.152§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with thisapplication. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes El No O
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 61_$ S b/ OOD
1. Building $ 3 <00 Building Permit Fee-Total Construction Cost.x_(Insert here
2.Electrical $ Q M - appropriate municipal factor)-S
3. Plumbing $
d.Mechanical (HVAC) $ Note:Minimum fee $ (contact.municipality)
5.Mechanical Other $ Enclose check a able to
PY
6.Total Cost S j�Qo (cnnti t municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 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 i knowleu and understanding.
a£T)Y_6C -f2i n1 LI 4
Please print and sign name Title Telephone No. Date
GL N . 1, ✓1
`� o 1&M �1ta1/i lL f P N 95Z
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval- Zh
Name Date