0122 BOSTON ST - BPA-14-731 FINISH REPAIRS TO STORE The Commonwealth of Massachusetts
Department of Public Safety
' �r ➢U Massachusetts State Building Code(780 CMR)
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)
[off z rd/-y Y� SQL I:Qm —JZWj; (
No.and Street City/Town. Zip Code _ Name of Building(if applicable)
SECTION 2:PROPOSED WORK -
Edition of MA State Code used_ If New Construction check here❑or check a6 that apply in the two rows below
Existing Building Repair❑ 1 Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engmeerin Peer Review required? C Yes I N oOCrl.�r
Bri f Description of Proposed Work:
RG
C sGUC
SECTION 3:COMPLETE TFIIS 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): I 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.) y
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❑ H: Hi h Hazard H-1❑ H-2 ElH-3 ❑ H-4❑ 1-1-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4 O NL• Mercantile❑ R: Residential R-111 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 plicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑
A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-Way: Hazards to Air Navigation: V A I li t is�,uinnnunn 1 ypnm i r rs:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Yes O or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Cude: Use Group(s): Type of Construction:. Occupant Load per Floor:
Does lhu building contain an Sprinkler System?:_ Special Stipulations:
' G'�c.Q l Cl✓1 ��i. sEty-T 3t 3 I
4
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nam• add s Prope c—
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
Narne Street Address City/Town State Zip
to act on the property owner's behalf, mail matters relative to work authorized by this building permit a pplication.
- 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 O ind5kip Section 10.t
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
G e.0/E Kl
upany Name
lsr- C14)4.-c4 ez cam t o yl
Name of Perron Responsible for C nstruction License No. and Type if Applicable
Street Address City/Town State Zip
?E,zf- a d C��2ua �r r a C D I
Telephone' No. business Telephone No. cell e—mail—address
SECTION 11: INSURANCE AfFll)AVII, 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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE':
Item Estimated Costs:(Labor
Ill and Materials) Total Construction Cost(from Item 6)_$
1. Building $ ` Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=$ (contacts litipafity
5. N-lechanieal Other $ Enclose check payable to
6.Tot:il Cost $ l P•y
(/v—�+' (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
Municipal Inspector to fill out this section upon application approval: ZZ,
Name Date