7 CENTRAL ST - BPA The Commonwealth of Massachusetts
/nb�l �'• t� Department of Public Safety llllll"'"'
d�/j�j' �'i 'I� � \Iasnachusclts tiLltc building Cudc(7SII C\IR)
o,.
Building Permit Application for any Building other than a One-or'1'wo-Faro' y L welling
(This Section For Official Use Only)
Building l'rnnit Number _"—__ Dalc;\pplicd: _I[! _� Building Official: _
SECTION 1:LOCATION(Please indicate Block B and Lot N fur locations for which a street address' nut available)
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No and Slrcrt City/Town /ip Code Name tit Building(if applicable)
SECHON 2:PROPOSED WORK
Edition Of MA Shur Code usad" If New Construction check here❑or check all that apply in the two ruus tw1mv -
laisling Building W- Repair :\Iteration ❑ Addition❑ Demolition ❑ (Please till out and submit Appendix 1)
Chanyrof Use- ❑ Change of Occupancy ❑ Other ❑ Specify:
;Arc building plans and/or ronslntrtiun dlxumrnts being supplied as part of This permit application? N'es ❑ No ❑ _----
Is an Independent Structural Engineering Peer Review required?, L Yes ❑ No ❑
Brief Description of Proposed Work:"--r 1 i �._7�p(&_ 'fD-r ✓L2.a.o r.o. __
SECTION 3:COMPLETE THISSECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 700 CINIR}L) ❑
Existing Use Group(s): Proposed Use
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)dr Area Per Fluor(sq, ft.)
"I'Otul:Aral(sq. ft),ind'rutal Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-1 ClA4❑ A-5❑ B: Business ❑ G 1.'ducational ❑
F: Facto F-1 ❑ F2❑ L�111
: lIi h Hazard H-1 ❑ H 2❑ 11-3 ❑ 11-4❑ I 1-5❑
I: Institutional 1-1 ❑ 1-2❑ 1.3❑ 14❑ : Mercantile R: Residential R-1❑ R-'_❑ R-1❑ R-1❑
S: Storage 5-1 ❑ S-2❑ Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION INPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ [fill ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMA HON(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information; Sewage Disposal: Trench Permit Debris Removal:
Public .\ trench will not be Licvused Disposal silt.❑
0� Check if outside Hood /_oni Indicate numicipal
Priv , ..
ate❑ or indrnlily Lnnr: ---- or un site seslem ❑ required❑or lunch or a - -_ -
- - pcnnil is enclosed ❑ pVMY-
_
Railroad right-of-way: [lizards to,\it.Navigation: - s:
Not Applic,lble❑ ' Is Slink our with In.urport appma,11 area Is Ih,it Icvi,R I,I nl plc It
„r C[mirth III Build cuclosed ❑ \vs❑ or.No❑ Ycs❑ No ❑
SECHON 8:CUN'I'EN'I'OF C'F'Itl'IIC',VI'F OF OCCUPANCY
I do it'll of Code: ._. - ._ Car Gnnl p(x): - . . - I\ 'v of Clmelructllm: llu up.tot Load per I loar
I tor.III,-building,ontain mSj,riokIvr S%,tv l' ;pvci.d Slipulations _
SECTION y: 11ROPER'IY OIVNI:'R AU I'IIORIZA7lON
-dmc and ArlJress ul Pro rrrlV'Uwncr
MA-
No.adtreC
.uuPint Se �« v
—_-Cit}/Town Zip
Properly Ott net Cinnact Information:
y�
Title 1'vlephone No.(business) Telephone No. (cell) a-mail address
It applicable, the property owner hereby authorizes
Name - ---StreetAddress ---- -City/Town State Zip
to art on the property owner's behalf, in all matters relative to work authorized by this building permit a ,pl ication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if building is less than 35,0tA1 cu.ft.of enclosed s pace and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional
Responsible for Construction Control
Iv � -
Name(Registrant) Telephone No. tt-mail address Registration Number
Street Address City/Town State Zip Discipline Espirntiun Date
10.2 General Contractor
t.)
apany Name r''A � C ' cS !ot 71gs
Nam•of Person ResRuCisible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Tcle phone No. business Telephone No. cell a-mail address --
SECTION 11:ia, t_i,mi I h•i1(:.\.M I NI_).n?AVI I M.C.C.c.152.1 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 a licatiun? Yes 0 No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) S_
1. Building S 5p Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical S / OIxJ appropriate municipal factor) S
3. Plumbing S
J. Mechanical (HVAC) s Note: Minimum fee-S__(contact municip,dity)
A .Mechanical (Other) S Enclose cluck payable to
h. rotal Cp (contact municipality)and pyrite check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
liv ci •riot; my n•I r below, I headily attest under the pains and pen perjury alles of perju that all of the information rontainrd in this
applicat a is Ir p and le" I e to the h•. of nay knapvlodge and understanding.
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- -
I'la ue p i ,u , le I'ii 1 h phone:No Dmv
ti TO :\ddrrs.s Cili/Ibsen Slate Zip
Municipal Inspector to fill out this section upon application approval: