97 BOSTON ST - BPA-12-879 ROOF A� The Commonwealth of Massachusetts
t j„W yI Department of Public Safety
f. ,,• fy' :\lass.uhusrllstil•defiuildingCnJc(791)C\IR)
Building Permit Application for any Building other than a O -ur TW am' mg
(this Section For Offici, Use Only) - —
Building Permit Number: _ Date Applied: ._ Building Of" al:
SECTION 1: LOCATION(Please indicate Block k and Lot k for locations for which a street address is n available)
9 °— - ------ -- -No.and Street City /Town Zip Code Nana•of Building(it appli(al+Ic)
SECTION 2:PROPOSED WORK
Pdiliun nl 51:1 State Cudc used If Nrty Construction chock here O or check all that apply in the Iwo rows below --
Eisling Building liepair❑ Alteration ❑ :Addition❑ Demolition ❑ (Please till out kind submit Appendix 1)
Change.of Use ❑ Changeof Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction d+K'untenls beingsupplfed as part of this permit application? Yes ❑ No ---__-
Is an Independent Structural Engineering Peer Review rcyuired? � � Yes ❑ No ❑
Brief Description of Proposed Work: rTAlAw �F It"''—mf
SECTION 3:COMPLETE THIS SUCTION 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 Clk ❑
Existing Use Group(s): Proposed Use Grou
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(se.(. ft.)
Turd Arm(sq. ft,)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-t ❑ A-2❑ Nightclub ❑ A-3 ❑ A4 ❑ A-i❑ 1 B: Business ❑ E: [educational ❑
F: Facto F-I ❑ F2❑ fl: Hi h Hazrd H-I ❑ H-2❑ 1-1-3 ❑ FI-4❑ 11-i❑
1: Institutional M ❑ 1-'_❑ 1-3❑ 14❑ hl: Ylercantile❑ R: Residential R-1❑ R-'_❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Spci ial Use
SECTION 6:CONSTRUCTION TYPE (Check is applicable)
IA ❑ Ill ❑ IAA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SEC'r1ON 7:SITE INFORMATION(refer to 780 CNIR 117.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: French Permit: Debris Runov al:
Public� Chei k if outside hood Zone ElIndicate municipal A [moth will not be I icrnsrd 17ispos tl5ilr
Private❑ or indcntily Zone: or oo site system❑ rcyuired O or tn•nch or specifc:
porno it is cnc Iosed❑ —. ..
Railroad right-of-way: [lizards it)Air Navigation:
.Xat Applic.ible❑ Is Stn ,ture within airport approach area. Is their rev icw ramplctcd.'
or Consent to Budd cnc lewd ❑ 1 cs❑ or.No❑ Yes❑ .No ❑
SEC"I[ON 8:COM ENT OF CER FIFICA'I'F OP OCCUPANCY
I:olitiun o I code." C se.Gr u1 (s): I\f o 0 1 C:0111lruction: 0"Alp nit Lood p r Floor
,ur
17 rs the fmllmgrontmo.ut 1;prinkltr4astvm' yl+t i.�l�tipul ozone:
--geu�`1i IVA
f ' r
SE(A ION 9: PROPI;It I OWNIIR AU I'IlORIZA'IION_ n
:Name mid Addms's ut Vroprrtl'()tram — —
Name(Print) No. and Street City/-I()wn _..—Lip --
Property Owner Contact information: r�
Title telephone No. (business) Telephone No. (cell) e-mail address
If,applicable, thee properly owner hereby authorizes
fin✓ �T �f1+ �L} —OL�1GG—
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this builklitir permit a „lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
1f Ipuildin•is less than 33,00l1 cu.ft.of enclosed s,ace and or not under Construction Control then check here O and skip Section 10.1
to.I li istered Professional Responsible for Construction Control
laf 14 (110far- Y4 Ila-�
n•(Registrant) Telephone Nu. c-mail address Registration Number
Street Address City/Tr wn State Zip Discipline Expiration Date
10.2 General Contractor
f., J Company Name
U�rL,a{� rt
.II csSL
Name of Person Responsible for Construction I�1 License No. and Type if Applicable
�AA�Yf 5 1 -rW--A '64 - ayg"5 B
Stt�trr�eeeet Adddr-e-ss City/To vn State Zip
role plu�No. business Telephone No. cell e-mail address
SECTION 11: ( (wi-1 N1,A f It IN IV,t F N 1 11 1 M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the NIA 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 perunit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estin apated Costs: (Labor
nd Nlaterials) Total Construction Cost(from Item 6)=S_
I. Building S Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical S .appropriate municipal factor)=$
3. plumbing S
F. :\Ic 'h::!cal (HVAC) S Note: \linimum fee='S__(contact municipality)
23. .\ crhanical Other S
Enclose check payable to
t,. total Cost 5 (contact nwnicipality)and write check number here
SECTION 13:SIGNA"I URE OF BUILDING PERMIT APPLICANT
Ilv entering my name below, I hereby attest under the pains and penalties of perjury that,dl of the information contained in this
application is true and accurate to the best of my knoMcdge,und understanding. -
I luue print and sign name ritic I-rlephone No. D.ptc
titrcet :Vaults Oily/r,-'Vo state /it,
Municipal Inspector to fill out this section upon application approval:
Name --------- — -- Date- —