140 BRIDGE ST - BUILDING PERMIT APP T
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h The Commonwealth of Massachusetts
Department of Public Safety
y� 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:0 "0f-IV I Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street addre rs not available)'
/40 P'19ge S- Sale'm Q / 27(-)
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 all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑"TDemolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No G—
Is an Independent Structural Engineering Peer Review required? / Yes ❑ No [-
Brief Descriptign of Proposed Work: A 2 /JAl!2- I" �' D Nf nU �C Lf q Al-d
STAB 'll njtl eut- J7o02
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❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2 Cl I H: High Hazard H-1❑ H-2 O H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 ZI R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
" SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA Ill El IIA ❑ IIB ❑ IIIA ❑ 1118 ❑ IV ❑ VA ❑ VB ❑
SECTION.7:SITE INFORMATION(refer to 780 CMR-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:woe d
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ W, - &WVtV
Railroad right-of-way: Hazards to Air Navigation: \IA_I Iistt i u C...ni sic n Rovie�� Process:
cess:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
�y SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the buflding contain an Sprinkler System?: Special Stipulations:
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SECTION.9: PROPERTY OWNER AUTHORIZATION -
Name and Addrel Property Owner tJtht I
&40 V <_ mr 30 Charter SA . 6x 6393�
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: II
Ste,vt SMI f (43_134 tig7.� 61q liTo 6681 d-1 e,
Title Telephone No.(business) Telephone No. (cell) e-mail address
If ap licable, Ore property owner hereby authorizes
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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)
If building is less than35,000 cu.it of enclosed space and/or not under Construction.Control then check here O and skip Section 10.1
100.1 Registered Professional Responsible for Construction Control
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Name(Registrant) Telepho�ne No. e-mail address Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
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10.2GeneralContractor -
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Company Name
2Ar-ae( tNA(V1e92AQo e r. 03-F35fro
Name of Person Responsible for Construction License No. and Type if Applicable
S8 5,eeA,1ceie Ave J/ C-paIs-ew y a z/JS 11
Street Address City/Town State Zip
7 .79 C/ 33 = 9. A 1EA)AM044V0@ G'MAfL = o/I'I
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:9VOE KEYS'(:Obll ENSA"rION INSURANCE ALF'ItmVIT 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
Estimated Costs:(Labor ��II
Item and Materials) Total Construction Cost(from Item 6)_$ KJT_f 00
1. Building $ 1-$OP" OD Building Permit Fee=Totad 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 a able to
6.TotalCost $ �j O b (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:
- Name Date