28-28 1-2 BROAD ST - BUILDING INSPECTION f iWWW
The Commonwealth of Massachusetts
Department of Public Safety
:11.15S,IC h usCll s Shlh'Building ARIL'(780 CNII?)
Building Permit Application for any Building other than a One-or Two-Family Dwelling ,
(Phis Section For Official Use Onl%)
Building Permit Number: Date Applied: Building Official:
SECFION 1: LOCATION fleas�indite Block#an Lot #for locations for which a street address is not available)
NO.and Street City/Totem Zip COde Name of Building;(it-applicable)
SECHON 2:PROPOSED WORK
Edition of NIA\State Code used If Now Construction check here❑or check all that apply in the two rutrs below
Emsling building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (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 Ihis permit application? Yes ❑ No CIK
Is an Independent Structural Engineering�Pr-e�erReview required? Yes ❑ No IS'
Brief Description of Proposed Work: PA&&irt F2eak S'TAi its
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 7811 CMR 3A) ❑
Existing Use Group(s): Proposed Use Grou p(s):
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(inCludC 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❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H--f❑ 11-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ 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 applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: French Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required ❑or lrem h of specify:_
Private❑ or indenti(}' Zone: or on site system❑ permit is CnC IOSCd❑
liailroad right-of-way: hazards to Air Navigation:
Not Applicable❑ Is Structure within airport approach area?- Is Iheir rev iety completed?
or Consent to Build enClOscd ❑ Yes❑ or No❑ Yes❑ No ❑
SECTION B:CON ENT OF CERTIFICATE 01:OCCUPANCY
Edition of Cade: L So Gruup(s), I\pe of ConslruCtinn, OCCupant Load per Moor:
Does the building contain an Sprinkler Sc stem?:_____ __Special Stipulations:
SECIION 9: PROPERTY OIYNER AU 111ORIZAIION
N,unc.red \d.4- ss ut I l .I,ct'h' C error 1 1 1
Name(Print) No.and Street City/Town Zip
Prot rty OwnCr Ctmjky;j1111urnl.uir'II:
'I ide Telephone No. (business) Iclephone No. (cell) G - "VXV ,�
If applicable, the property owner herebv all 111 orizes
- Name Street address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work-authorized by this built in r omit a„licrtion. -
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less th:m 35,1100 cu.ft.of enclosed s,ace end or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. c-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
fZ a 6 A4 J. LA e-au—e r yr
Name of Person Responsible for Construction License No. and Type if Applicable
) - 13 H " (-c_7 So /e:., ` a9-) 0
Street Address City/Town State Zip
Telephone No, business Telephone No. cell a-nail address
SECTION 11: lcl u:r.lntti'l lmlrr`sn LION lN<_IJI,'A.NCJ Al Pll 1,,%11 M.G.L.c.152.§ 25C6
A Workers"Compensation Insurance Affidavit from the 1,1A 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 O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) .Total Construction Cost(from Item 6)_$ 9a 5.0O
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)_$
1. Plumbing S
a. Xlechanical (HVAC) S Note: Nlinimmril fee=$ (contact nu v''ipalih'
3. \lechanical Other S F.nduse check pavable to
6. Total Cost $ I?a r b (contact municipality)and write check m nber here---___—_
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering me name below, I herebv allest under the pains and penalties of perjury that all of the infurn ltion contained in this
appIica tion is true Inrd atcitrote to the bcsl of y kit ob led gc and understanding.
Please print and sign name ` Title Ie il,I'M No, Date
tilrcet Address Cl IN town tale i A /
Municipal Inspector to fill out this section upon application approval: _ __— ____w.3�J�
Name Date