48 REAR BUTLER ST - BUILDING JACKET V '
Th(. Commonwealth of IMassachtisetts
qDepartment of Public Sa '
( '",•) ..\Ia++,li hu+ells�6nr liuilding C ("4m, 11
Building Vennit Application for any Building o •r than a to-I) amily Dwelling
(Ibis section Fur Official e Only)
Iitiddiul; I'crmit Nund'r'r' ._ _. Dolt•:\pplic`l: Building( t • '
SECTION 1: LOCA I[ON (Please indicate Illuck it and [.of 4 or to moons for it,
4zf. 1 f3vtle?� Sglwzq /wk 019v3
titrrvt Cit1' ;fmvn Ill,Codc ,V.voe
SECTION 2: N )I'O,SED I, RK
fdilion„1 .\IA S1.1to Ca It uwd . _. II New Gnrslnti t if rl •rt•❑or clmik.ill Ihaf•t t t .--.____. _ __.._. .._ __
11 F}' in the Iwo nnrs hvlrnv
Ftinlinf; Ifuildinf, Itelmirp :\hermimi Additiolt ❑ UonwliUun ❑ (I'Ioasc till uutaml+ubmit.\ppcndis l)
Chmq;eofUse ❑ ChangvofOrtupa_. ❑ Other p S,coif _
Are building plans and/orronslrui[Ion d,tumcnlsbcingsupplied•Ispartoflhisperntitapplicafiun? Its Nu p-/_-- - •
N mt IndopcnJcut titrudural Engincering Peer Reviety rySyuired? /� / Ycs ❑ No C"
Ifritd Ucsi ription of Pmpuscd {Pork:.__— UOU4f'� Iov-`16 k� e-,� S/h`(� J�9M` �iapyse MGui kC��rsc
=elFr�-�T—�(�`"
SECTION J:CONIVLE'rE THIS SLCI'ION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANCE IN USE OR OCCUPANCY
Chetk hen•it.in Esisting Ihtilding Investigation anti Evaluation is enclosed (See 7,40 CMR.11) ❑
F-\isling Use Group(s): _—_. _— lImpuved
sECrION 4: BUILDING MIGHT AND AREA
F.aisting Prupo+cd
No. of Floors/Stories(include bascnumt levofs)da Area Per Elver(sq. R.) .3
I'utal .\ma(sy. It.),utd fuLdHcight(ft.) /300 so, (gyp 3d�
SEC PION is USE GROUP(Check as a licable)
A: Assembly:\-1 ❑ A-_'❑ .Nightclub ❑ :\,1 ❑ :\-gyp :\-i❑ B: Business ❑
I p P_❑ If: III h H•u,trd It-[ Cl H-_❑ I I-3 p E: liduct11-3 C ❑
F: facto P. +
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ AI: Mercantile❑ I I•I❑ I I-i❑
R: Itesldenttal R-Ip 1?-2❑ R-\p R-A ❑
S: .ti forage S-I ❑ S-_'O U: Utility❑ S ecial Use❑and tte,ue&m nbe below
tipci ial Use
SECTION 6:CONSTRUCTION IYI'F. (Check ds a r licable)
LF. ❑ lit ❑ If.\ ❑ IIB ❑ I11:\ ❑ 1f111 ❑ IV ❑ VA ❑ I'll ❑
sl'.('rION 7: SITE LNFORMA HON(refer to 791)('.\IR 11 LU fur details un each item)
W,ner Suppl Flood Lune Information: Sewage Disposal: 1'rench Permit: Debris R.•uurval: -
Pubh, f� Ch"k it out.idv I-Leal Li ne Indit.nc nuntit ipal A tmn,111,ill not be I i,ro od Di+p,�+,d girt•❑
Prit.uv❑ �•r m,le iini% �,ih' _ � r� n atc+t.trm ❑ 'ryuiwd ❑,-r lrcnth or.f•rr 4%
Frnun i+rm It,+,rd ❑
j Hailruad right-of-,va lf.v.trde to Air \ac ig,ttion: •
\•,1 \f ),ht.ildr I I:wm tury i,ahm.urrolt d Ill' II
.uh .in•,i' I+ h•u'i IF irn „anl�lrlyd '
, r t , mrut t• Ifudd rn,Li+rd ❑ lr+ i7 •,r \'o 1,+ ❑ \ ❑ II
yICI1(1N ,4:( ON I IN I (IFl I I(111,1(•.\11: UCCII'.\N( Y
I Jilt, n , IC•,Jr 1- �r loayy�l IF „I t,•n,lui,to,n t`,Iuh.un l ,,.id l•rrll,. ,i-_
14 , . Ih, bn JJuq',., n6im.m `-I,r n�.11rr tit.trot' `-I•n rd ' lil•ul.�lnn+
i
Ill:(`I iON '): PROITI(I Y mvN1 It AU I,I-R- WN
o%%ovr v8 wq Z-
No. aml Strt-vt caY/ i-mvii
Prolvil), C011t.11t hiformation: T 317( -(
rvit-phone Nil (Ick-11)
I •It-pljtmv No. (Ilikslllit."S)
11 lVVjt,kjIlI tilt,Vrtiperl Y owner hort.-liv aitlhori/v.s
litrvet Adklrvss city/ I'Mi'll Slate ziv
Nanit! -r
'S tit lit 0 all Owl It .4 relatill'ill it irk vilthorized bY th 14 110 illi"d ,omittotit,-proverty ltvllvr '11, .
�THOL(Please fill Out'\Ppendix Q
SECTION to.CONS,FItUC`rlON CON
ill buildil-It,is le.4.4 th.1105,00R)Cu. ft.ul encI I, III-,,and or not under Construction Qn»nd then check here O and ski vSk-0i'll 11)11
Itesistered Professional Responsible for Construction Control
I'viephone No, C-11miladdreS3 Registration Numllvir
Nance 0tvl;i-str,OI0
Expiration Dole
Stale Zip Discipline
,;Ilevt Address city/rown
10.2 General Contractor
— I.
company Name
License No. and I y Pe IF Applicable
Name Of Person Responsible for Construction
12 0- 11 or P-I-tk�eA --
Street Address city/,rolvn SIdlu Zip
569
NO Ilm Iles.4) rov flione No. cell
e-mail address
A Workers'COMPels-tiulinsurancelce Affidavit from the M, UeValloent of 111UNITIll . ""t be Completed and
affidavit will result in the denial I'(the issuance of the building permit.
Is a mibmilled %vith thi.qjI,plication. Failure it)Provide fill-%,'signed Affidavit submitted with this-11221i" ll t' ll? yes 0 No C3
SECTION 12:CONSTRUCTION RuCTION COSTS AND PERMIT FEE
Eslilil,tetl Costs: (Labor total construction Cost(from Item6)
Item and Nilowrial.4)
I. Buildin S Wj 006 noil,ling Permit Ftv I Total Construction Cost x —(Imsert here
2. El"trical i appropriate riltilliciVal 1`00110 -5-
111111libillf" — S Note: \Iillillltllll fee . j 111tiLliCill0liti)
\l"11,1011,11 (JIV.\L) 5
IN. --
(Odwr) Alle to
i'll Cost I " 77-0,0 IV 111,1 write tliitk mkilm lit,fe
SLCFION tj: I LRE OF BUILDING VERM IT NkVPL ICAN r
11.011111 111111.111md tit 1hi4
Ile
Till-it it,mow�111111111k��
IF:i,lor III-imills-111,11 p,-Oiltivs of pt-ritirv. that 111 Of the Illf"I'l
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11tt,rillt; 111% 11,111C tIl-111W, I llCI`LbV ttV'I t inderstarldille,
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rill 11 pr 7q,
him /1�
rile
w )m
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%filimcip'li I 11'Petlir it, fill out this .e.tion OViO II)plicatimi ipproval: VI'lle I 1.,te
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