43 BUTLER ST - BPA-11-904 A
The Commonwealth of Massachusetts
Department of Public Safety
MatSadtusetts State Building Code(780 CM11R)
` 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)
z/3 au1ze-2 sr SAY-*-Al Oi970
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used Jh A-O Z00?f New Construction check here O or check all that apply in the t vo rows below
Existing Building❑ Repair❑ Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other Specify: c q-k
Are building plans and/or construction documents Laing supplied as part of this permit application? Yesg No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No o
Brief Description of Proposed Work:
peW10 EIOSTiyly VY22 f=k CAr jj2e / LIC Rt�iF ro REwta,rh t�K+� IQG/x•fGLy lt�
0 1o17CH G.7r s*�zy t/i7r-.Y ae ?27o-Y 129 c . sc'GN-7�sllf/fBA 5.- .
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 Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sal.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❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ • 1-1-5❑
1: Institutional I-1 ❑ 1-2❑ I-3❑ 1-4❑ Mi Mercantile ClR: Residential R-00 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as ap licable)
IA ❑ LB ❑ ❑A'❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Su ppyy: Flood Zone Information: Sewage DisQosaL
Trench Permit: Debris Removal:
Public Check if outside Flood Zone Indicate uumiripal
A trench riot be Licensed Disposal Site Er
required or trench orspecify:_
Private❑ or indentify Zone:. or on site system❑ permit is enclosed❑
Railroad.right-of-wa llazards to Air Navigation:Not Applicable f Is Structure within airport ap I` Ch area? Is their review completed?
or Consent to Build enclosed ❑ Yes❑-or No<H Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I�idition of Code: Use Group(s): . Tv pe of Construction:_ Occupant Load per Floor:
Does the building Contain an Sprinkler System?:_,__Special S'l i II I]lations: :
SECTION 9: PROPERTY OWNER AUI'I IOIUZAT ION
Name and Address of Properly Owner �.
O
;-he ��:a� y3 �r K� f�7 o
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
_ (9 to 1 &�j
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this buildin&permit application.
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 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control—IlDt -
tiUMNde .o M _WO. 5Ste— ,J'AISAll9"Al'~elet •tit /673L f
Name(Registrant) Telephone No. e-mail address Registr roil Number
G�eEcrT � I) f 0 � 014z 1 �— (;L7—Zof2
Street Address - ,City/Town State Zip Discipline Expiration Date
10.2 General Contractor
A44&&b r_'� Xx/c.
Company.Name --
.Dbc(v 1& 7 3L s
Name of Person Responsible for Construction License Nt. and Type if Applicable
//q 6;e&W-Oar, OC SuxltteD oRL l
Street Address City/Town State Zip
979 3Yo SSOZ 97s' 3�'0 _33yZ Q' (2 ReAo�7eS
Telephone No. business Telephone No. cell e-mail address
SECTION 11: tvCVIts H6'(0KHTNSAn0,A. ai'tn,>nyu 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+)d No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and N1aterials) Total Construction Cost(from Item 6)=$ 51 �(�•OJ
1. Building $ Building Permit Fee=Total Construction Cost x_L_? (Insert here
2. Electrical $ appropriate municipal factor)
3. Plumbing
1. h1cchanical (HVAC) $ Note: Minimum fee (contact municipality)
3. \lechanical Other S Enclose check payable to SR&"1"-"a.
R.Total Cost S j ,1 . 190 (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 knotrledge and understanding.
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please},tri��[and sign name Title - e c ,hone No. Date
Street Ad City/Torun ip
Municipal Inspector to fill out this section upon application approval: n /
Name Date
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