3 CENTRAL ST - BPA) ^/ The Commonwealth of Massac&616�t ED
Department of PublicSafet�/J� - ER VICES
:NLtssdr husell.s Stale Building Code(71i�VC�N� G` ��
Building Permit Application for any Building other than aOne-or T' o-1�m' elling
(Phis Section For Official Use C ----
Building;permit Number: Date Applied: Building Official:
srcriON 1: LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
J 'A " q
No. and Street Cit}l /town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of NIA Slate Code used If New Construction check here❑or check all that appl} in the two rows below Existing Building Repair❑ I Alteration 42r'-I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or constmclion documents being supplied as part of this permit application? Yes ❑ No IV
Is an Independent Struchtrat Engineering Pver Review required? + Yes ❑ No Gil"
Brief Description of Proposed Work:-_is Ax-,- t,,;r-SA" 3 O�fay ✓�tt�w--S __
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 CNIR 14) ❑
Existing Use Group(s): IProposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Fluot:s/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❑ H: High Hazard H-1 ❑ H-2❑ 11-4 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-1❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-1 ❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable) -
[A ❑ IB ❑ HA 0 IIB ❑ ILIA ❑ IIIB ❑ 1 IV O 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 A trench.tvil trench or not be Licensed Disposal Site
Pl Check if outside Hood 7_onre Indinde numicipal
ired or
Private❑ or indrntifv Zuno.- nr on site ScStcttt ❑ requ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: �i t 1 it 1�,. norm
Not Applicable PT Is Structure within airport ap+roach area? Is their review completed'
or Consent to Build onclosod❑ Yes❑ nr:No Yes❑ No ❑
SECTION&CONTENT'OF CERTIFICATE OF OCCUPANCY
Edi lion of Code: L'se Guru p(s). __ ____ IN'pt.of Ck mst rust ion: ______ 0,L❑pan t Load per Hoor -
Dons Ihr building contain an Sprinkler Svslrm?._ ND---Sprr ial Stipulations:.__.__— _
SE(7I'ION 9: PROPYRIN O1VNFR AU'II IORIZA'IION ,
F---
ITiupvrtl'Owner
No i n, Street Cit}'/Town Zip
Inlonnaliuni S-
Title Ielephune No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town Stale 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 thin 3i,000 cu.ft.of enclosed space and or not under Construction Control then check here O and skip Secto1.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town Stale Zip Discipline Expiration Date
10.2 General Contractor
mpany Nat p
�GllDlo c� t7til+mac. C s1 .�1� 10 1q j-5
Nara f Person Responsible for Construction License No. and T pe if Applicable
eti 6or\1 "tacy,ru —& kcw tlk _S ]
�Street
Address
, City/Town State Zip
Telephone No. business Telephone No. cell a-nail address -
SECTION 11:ttt)I;f.l R4 c l.1\II'f V,A I If 1N V-1JKANC1 ;M 1 11+AI I I M.G.L.c.152.9 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure it,provide this affidavit wilt 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 b) _$
1. Building $ a Q'D Building Permit Fee=Total Construction Cost x—(Insert here
2. Electrical $ r615 appropriate municipal factor)_$
t. Plumbing $
4. \1e chanind (HVAC) $ Note: M m inimu fee=$ (contact municipality)
S. \lechanical Other $ Enclose check payable to
b.Total Cost $ CZ 0 U (contact municipality)and write check number here
SECT - . IGNA"rURE OF BUILDING PERMIT APPLICANT
By entering my n.ume belOtc, I hereby l ast;u nder the pants and penalties of perjury that all of the infnrm;niun Contained in this
A application e rue and accurate to the +e.t o"my knowledge and understanding.
?V 9 ?Z �
Plc sc +r nl a t Lsi+ 1"itle
y { h w}-- 4 le'lepl nnc- Date
AD
tiUcrl \dares ----- Cit.N Fown tote Zip
Municipal Inspector to fill out this section upon application approval:
a n� Date