0011 - 0013 CHERRY ST - BUILDING PERMIT APP � �-7
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The Commonwealth of Massachusetts
Department of PubliAbetO 13 A U. 55
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Budding Permit Number: Date Applied: Bu ldirig Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
lI l3 C errdg7 To Ptx 0/97 �
No.and Street City/Town Zip Code Name of Building(if applicable)
N 1 SECTION 2:PROPOSED WORK.
FQL�=� Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineertn eer Review required? . Yes ❑ No
Blief Descri lion of Proposed Work: '
a �
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) O
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/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❑ B: Business ❑ E. Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ RIB ❑ IV ❑ VA VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:i Permit:Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p
required O or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: \_I_.\t I. ( �ie,Comnu,ciun
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Dues the building contain an Sprinkler System?: Special Stipulations:
�'ND �b 60''A—j-yLCL z V Zrc- —
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SECTION 9: PROPERTY OWNER AUTHORIZATION _
Na and Address of Property Owner • , ,r'
a 3 a 5� lek /,a o � 97a
Name(Print-� 4 I No:and Street V 6ty/Town Zip -
Property Owner Contact Information:
-
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 budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please-fill out Appendix 2). - -
If buildingis less than 35,000 cu.ft.of enclosed s ace and or not under Construction Control then cheek here O.and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mall address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor "
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Name of Person Responsible for nstruction License No. and Type if Applicable
a 6 r le Ave vs, Ma ma 452/9d �d
Street Address 7 f -City/Town [ate Zip
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Tele hone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'CONIPI NSAI'IC,v tNSURANCB AFF'IUAWF M.C.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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE"
Rem Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4.Mechanical (LIVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ I Enclose check payable to
6.Total Cost $ �'� (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 knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
N[unicipnl Inspector to fill out this section upon application approval: �"'r`t Ll.-
Name Date