1 CENTRAL ST - BPA 'Pile Commonwealth of 1Massachusetts
Department of Public Safety
j' \lass.lchusclls fila le Ito ilding Code(790 CM If)
Building Permit Application for any Building other than a ()lte-or'llvo-Family Dwelling
(Ibis Section For Official Use Ouly)
Building I'cnnit Number :lpplicJ:
SECTION 1: LOCATION(Please indicate Block 9,md Lut p fur locations for which a street address is not available)
------------------------
—
No. am tilrret M1' •�A Cily/town /if)Code N.mle of Ruildin7:(if a(tplic,lhlc)
.•-i—
SWHON 2:PROPOSED WORK
F1lilion nl \IA 5611.C1111e rued It New Cnn.vlroc tion chock here❑orcheck all Ihm apple' in the hill torr bvloo,
lisistinl; Buildinge I Repair C3 Alteraliou ❑ AJditiom❑ Demolition ❑ (Please lilt out and submit Appendix 1)
Chanl;e ul Uw ❑ I Change of Occup,lncy ❑ 1Other ❑ Specify:._---
\m ind
Ig planar dud/or construction ,aunlenls being supplied Ispart of this permit application? 1'es ❑ No ❑ --- ---
Ibuild
s an Independent Sl nletural Engineering Peer Review required? Yes ❑ No ❑
llrict Description of Proposed Work:_--_ U_ lC i+r--Iw..�,___ f2o Meal-�rk fP.D(w r k,.' f o
SECTION 3:COMPLE"rE"rifts SECI•ION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Chcck hero if on Existing Building Investigation and Evaluation is enclosed (Sce,781)C\IR Sa) ❑
C-xisting Uw Group(s): _ Proposed Use
SECTION J: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(indude basement Iecels)h Area Per Fluor(sq. ft.)
Total Ami(sq. ft),old ralal Height(ft.)
SFCHON is USE GROUP(Check as a livable)
A: Assembly:\-I ❑ A-_2❑ Nightclub ❑ .\•1 ❑ A-I ❑ A-i❑ B: Business ❑ r:: Educational ❑
F: Facto F-1 ❑ F_'❑ f I: fli h flaza tt 11-1 ❑ H-2❑ H-1 ❑ I I- ❑ 11-30
I: Institutional I-I ❑ 1-2❑ 1.1❑ 1-a ❑ \t: Mercantile❑ It: Residential R-10 It•'_ R_.j❑ It-a ❑
S: ,ialStuUs S-I ❑ -S-2❑ U: Utility❑ Special Use❑,md please describe below:
tiperi.11 L're .
SFC`rION fe CONS rRUCrION IYPE (Check as a 1 livable)
I:\ ❑ 18 C3 IIA ❑ IIB ❑ ;IIA C3 IIIB ❑ IV ❑ \•,\ ❑ \'If ❑
-_ SIIC`IION 7: St I F:INFORMA IION(refer to 7,411 C.NiR I1I.0 fur details on each item)
Water Suppe Floud Cone Information: Sewage Disposal: rmnch Per I)ebna Rellln\'Ji:
Puldic Cluck it outnidc Ilood /_um ❑ Indiraty inuuirip,ll❑ A trench wdl not be lor,p"'th LicrnscJ Dispusll Gil.❑1'm.me❑ .r indcnlily /.no' ,.r on ate sl done ❑ ^'quir•d ❑orIronch
panto iv.n.In+rJ❑
It,li lruaJ right-4-way: 11.1/ards to Air..Nak igatiort: .
.\Iplic.ddr❑ I Is GIrm lire t,i thm.ufp ,jtAppro.n h.irre' � hlhru'rrtvrt.���mpla,vl'
j .r(S memo l., Mudd,n,hone(7 lrs ❑ r\1,❑ 1r.❑ \'n ❑
SFC l ION 1:CON I-L.V'IOF(I It 1'11:I('A 11:OF O( L'I'.\.\'OY
IJilu•n d(,alr lar l,n ni Ohl It •.. I l„uHnh Wart
1 { l\t np.ml I ,iJ Inr I Ir
building;„ nl a w,111 1pnn6lc r tit.Irm' Apr,i,d'-1ihnl,ilu oi.
L— St:CIIUN `k I'RUI'PIYIY(11VN P.li AU'I'l IOR ILA I[ON
' \ nuc lnJ .\ddrvss of I'nq+ rl�' lkcmr
{
Nance. (Vrint) _ - _..- No. and timet City/ ruwn f .
`Property ON, wrr`CCoilta,I Ittilorination
4tiV.o1.li> faddrc>s -----
IIIc reiephone No. (business) relephone No. (Cell)
II applir,lhic, the propertl'tllvncr hercbN-milhoritcs
--- --- ---- ---------Street Addrc.as - -- - -City/town- ---- Slate -- Zip
Name
to,,,t on the properly owner's behalf, in all matters relative to work authorized by this bidding lCrInit
SECTION tB:CONS1'RUC I'ION CONTROL(Please fill out Appendix 21
If blllldhl r is IC]V than i5A)W Cu. R.ill enllU9ed r+ace•old or not under CunstmCtion Control then check here D and eki l Section 1111
lift Registered Professional Responsible for Construction Control
-
Nawe(lic•l,iwrant) P 1'cic hone No. e-mailaddress Registration Number
titrect Address City/rown Stale Zip Discipline Expiration Dale
01.2 General Contractor
N IDI �'1(
Name of Person 4,sponsible for
instruction C License No. and type if Applicable
tilrcatgAddregssy }�/VI Ciry/"ruwn State Zip
rale shone No,illusiness Tele,hong No. cell e-mail address
SECTION 11:m �r11 1r :r l l'Mi l \,"A 111+\ 1\:1,11r..\.M 1 .v l 11""N l M.G.L.c. 151 25C 6
A Workers'Compensation Insurance Affidavit from the\(A Department of hnlustriul 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 si ned Affidavit SUbmitted with this application? Yes f] No ❑
SECTION 11 CONS'i'RUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and \latcrials) total Construction Cost(from Item 6) - 5--_---
I. Building 5 26C.ti0 Building Permit Fcr'Total Construction Cost a_Onsert here
'. Electrical 5 Ippropriate municipal factor) '3-
1-1 1-1 17,1111,11��e
ll+lumbing 5 Nota. Nholl rinn fee '5__—(contact nuu,ieipality)
L \ edmi,ical (I IvAQ 5
i. \Irrit.ulirai r 5 enclose Check pavoi le to
n. I'ot•d St 5 Q000 (an,taCt ❑uuliCipalit%)and lmle ncvck number lwfe
SECTION IJ:SIGNATURE OF BUILDING PERMIT APPLICANT
it r Iter it ` it 11111Cw
• c lie , I hbd
erey sueunder the pains and penalties of perjury Thal 111 of the info Cation n'nt,w 'd w This
.1pplireY Inu•.nu as ur.lte hl the hest of ,IN knr.t,Twig•,md understanding.
i �a ew
I'IM
I Ill,. L It•plln r N I,timer.rvr,pf rint�.l lI\^qcn nan,r
1^-z"t-ll�l �1 Cnr, rnt,n �I ltr /tl
\tunicipal luspeCtor to fill out this section upon .,pplication approval: g�ue[v
N.uno I l