40 BOSTON ST - BPA-12-189 SIGN: MINIT PRINT The Commonwealth of Massachusetts
Department of Public Safety
s:
klassachusctts Stale Building Code(780 CNIR)
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)
—R
No.and Street Citv/fown 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 Cl I Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of OCCupanCV ❑ Other ❑ SpecifV: _
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Peer Review required? Yes ❑ No B-
Brief Description of Proposed Work:
as n /7 P
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if tin Existing Building Investigation and Evaluation is enclosed (See 780 CNIR 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❑ F B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-I ❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB O IIA ❑ 116 ❑ ILIA ❑ Hill 0 1 IV ❑ 1 VA ❑ VIE ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zane Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site
IV
Private❑ or indenlify Zone: or on site system required ❑or trench or specify:.❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \I,n I i� r Con �.p�r.P"" .�.I,
Not Applicable❑ Is Structure within airport approach area? Is their review completed? `
or Consent to Build unclosed❑ Yes❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Hdilian of Code: Use Group(s)..- Type of Construction: _ Occupant Load per Hone_
Dues the building amain an Sprinkler System?: Special Stipulations:
t ,
SECTION 9: PROPERTY CR'I'Y OWNER AUTHORIZATION
�N:une and Address ut Property Owner AA �.1
�,'✓1 i 17 i L / "✓0h-/l y� OJOS�un d% �9�i+7 f ✓�4Sf
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
�tt ►vrRCr 1 a6w)e_U�!j LY14 M
Name Street Address ity/Town State Zip
to act on the property owner's behalf, in d] 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,OW cu.ft.of enclosed space and/or not tinder Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
" TZA,1,, + S2 71-z- &z1! 10/2 2 U
/Name(Registrant) - [— Tel phone No. a-mail adcltess Registration Number
Street Address Cl1) Town Stale Zip Discipline E piration Date
10.2 General Contractor
" T4kni al? Con v i
Company Name
Win- Tn4k-n4 I77
Name of Person Responsible for Construction License No. and Type if Applicable
,9/5- Vtfaong t1 n n-!s —may
Street Adddrress2 ity/Town State Zip
hr�No. business Telephone No. cell e-mail address
SECTION 11: bv_(wm-.15 COK111I NSA'IION INS R ANCN AAJ i ycwi l 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}'snuance of the building permit.
Is a 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 $ In 40Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4. 1lechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ 1
Enclose check payable to6.Total Cost $ ,O O (contact municipality)and write the number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICA
By entering my name below, I hereby attest under the pains and penalties Of pW
he information contained in this
application is true and accurate t the best of my knowledge and understandinPvY�rrr i� �� W/ - /7/1 h
Please print and sign name Title Telephone No. hte
Street Address City/Town Slate Zip
hunicipal Inspector to fill out this section upon application approval: 4to )3 1'
A he Date