19 BOSTON ST - BPA-15-454 REPLACE DAMAGED EXT. TRIM RECEIVED
INSPECT _ VICES
The Commonwealth of Massachusetts
Department of Public Safety 10I5 MAY 18 A
Fw
kfassachusetts State Building Code(780 CMR) Q 8
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
t� Budding Permit Number: Date Applied: Building Official:
U SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1/I� No.and Street City/Town Zip Code Name of Building(if applicable)
U ' 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 BIAlteration ❑ 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? Yes ❑ No BI--
Is an Independent Structural Engineering M Pee�� G}.�?.r Review required? n_— Yes ❑ No tg—
Brief Description of Proposed Work: &y.� s�5\4t
ExTwLt � �lt� non Scf�trL(�r
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 HEIGHTAND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor.(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION S.USE GROUP(Check as a plicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Huard H-1❑. H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional W❑ 1-2❑ 1-3 ClWt.14❑ : Mere ZZ Cl R: Residential R-113 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 a licable)
IA ❑ Ill IIA ❑ 11813 IIIA ❑ IIIB ❑ 1 IV 1 VA ❑ VB ❑
SECTION T SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Suppler Flood Zone Information: Sewage Disposal: Trench Permit* Debris Removal:
Licensed Dis os l Site
Public Check if outside Flood Zone❑ Indicate municipal A trench will not P
required❑or trenchch or specify:
Private❑ or indemify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: �In I listnrlr Cnnmis.ion R;�ier I'nir,q:
Not Applicable 01'� Is Structure within airport appyr ach area? Is their review completed?
or Consent to Budd enclosed❑ Yes❑ or No Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:. OLcopxnt Load per Floor:
Does the building contain as Sprinkler System?: Special Stipulations:
soar .�1z�
SECTION 9: PROPERTY OWNER AUTHORIZATION
` 7k&f
of Property Owner
1 'Sr u� G cs>.O Stu ti1 RO M t+ Q>
No.and Street City/Town Zip
ntact Information:
_ (_ oitk `141"o_ octt ()A+�r�dz2a�� �,,faTL.
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
(tiA-kT CIG (� co SAzCM VZA �J1.o1.��e.S(Z1Lc/�W- O(JI v
Name Street Address City/Town State - Zip
to act on the ro er owner's behalf,in all matters relative to work authorized b this buildingpermit a lication.
SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2)
If builJin is less thin 35.1
00 cu.f1.of enclose)s ace and or not under Construction Control then check here 0 and ski Section 10.1
10.1 Re istered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address R9scipfinExpiration
Street Address City/Town State Zip D
10.2 General Contractor
lA t �v�J�"�c Cc)LPcWl+�tzwU
Company Name
'Tkv-'VS M-}L bilukC
Name of Person Responsible for Construction License No. and Type if A
fn �� s Cn.-ou�4.st�n. �n.Street Address City/TownShep
a L@C"Lrh.L,CcM-�
Telephone No. business Telephone No. cell e-mail address
SECTION 11:4YOR PS'COfMPENSAI'ION INSURANCE AFF'11.MVIT M.G.L.e.152.a 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 issuance of the building permit.
Is a signed Affidavit submitted with this application? - Yes O No O
SECTION 11 CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ py
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ - appropriate municipal factor)_$
3.Plumbing $
d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $
6.Total Cost $ Enclose check payable to
I (contact 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 ost oDi—yTnowledge and understanding.
Ple:ue print and signpame Title Telephone No. Date
Street Address City/Town
State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date