0122 BOSTON ST - BPA-16-292 CORRECT CODE VIOLATIONS 3d�
f 10�A1 SER�i�Es
The Commonwealth of Massachusetts2q b
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Department of Public Safety ip16 aA 2
Massachusetts State Budding 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:
• r SECTION 1• OCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
(� No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2.PROPOSED WORK.
Edition of MA State Cod sed_ If New Construction check here❑or check all that apply in the two rows below
Existing Building Wi Repair❑ 1 Alteration ❑ 1 Addition❑ 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 ❑
Is an Independent Structural Engineerin Peer Review required? Yes ❑ No ❑
Br' f Descripti n of Proposed Work: l� crl _
6 (C
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 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❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 Cl 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check asap licable)
IA 1110 11A13 IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
required El or trench or specify:
Private Cl or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: :41!\I I„t oric.Connm si in Reoum
Not Applicable❑ is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Dues the building contain an Sprinkler System?: Special Stipulations:
M W 1 Lx-xD 23
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address ofPropery Owner
Name(Print)? /i tJ(• rrY r, No.and Street City/Town Zip
Property Owner Contact Inlfonnation:
z1i- Pl?b 3 a m fiAc U
Title Telephone No. (business) Telephone No. (cell) e-mail address
If licable, the property net hereby authorizes
/C /�Ltd./I eA a t� . % Jaz
Name 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)
f budding is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here O and skip Section 10.1
10.1 Re istered Professional Responsible for Construction Control
f1re A d u 7�1 ®add //�
une( e istrant11 T phoge No., e-mail: I r ss Registration Numb
�f /I t4 t LAl�(f j i'Td( 61\ LD ��
Street tAddress City/Town State Zip Discipline Exp' ation Date
10.2 General Contract or - - -
'Zo3hpany Name
anie of Per o Responsible for Constr tion License No. and Type if Applicable
�
bn 1 &L 4 `_/z) �LCJl //� jlj Gam./
Street Address City/Town ate Zip
Tele hone No.(businessf Telephone No. cell e-mail address
SECTION 11:WOKKER9'CORIPFNSA'I'ION INSUItANCF.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 this application. Failure to provide this affidavit will result in the denial of the issuance of the budding permit.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEET '
Item Estimated Costs:(Labor
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=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $IZ \ (contact municipality)and write check number here
SECTI N 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under th pains and penalties of perjury that all of the information contained in this
a plication is true and eSurate to the b to y I v i d u erstanding.
-7
Please pr' t id si n mm� f ,^ Title A /^ Tele ho e N
Street Address l' City/Town �V(Stt fate Zip p q
Municipal Inspector to fill out this section upon application approval: 4"*,- t, J 3/
Name Date