12-14-16 CHERRY ST - BUILDING PERMIT APP h� The Commonwealth of Massachusetts
V➢V Department of Public Safety
Massachusetts
VyU husetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Fami D 1
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:`
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street addres not.available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED.WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ - Repair CX Alteration ❑ 1 Additfon❑ Demolition 0 (Please fill out and submit App,,ndix 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 Engineering Peer Review required? Yes ❑\ No �(
Brief Description of Proposed Work: w\"S C, lr�„QiP ne
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) ❑
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 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ HA❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ 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 ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public'K Check if outside Flood Zone Indicate municipal A trench will not be Licensed Di osp al SitclJ�
t
Private or
❑or trench or specify.or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA,I_h,t ri Commission R . c Process:
ro ess:
Not Applicable. Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or NoK Yes❑ No ❑
- SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
20 Tv, —"TQW-e-4,1 `4
A
SECTION 9:,PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner a ,
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
gc erL 3L_9aa- "t'C� -- ncyoV _-9 i
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 budding is less than 35,000 cu.ft.of enclosed space and or not under Construction Control.then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for.Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
t.y- 0 r�'%�C , SIT-. A vJ4 VA_ O\ Ji�1 `LZ_
Street Address City/TAvn State Zip Discipline Expiration Date
10.2 General Contractor
"
Company Name
;,n;�i!o c✓r �e G S - ale a9
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:4V0f KFRS'C0%M1 1.NSA'I10N INSURANCE 4FF11MVIT M.G.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 C3 No ❑
SECTION 12:CONSTRUCTIONS COSTS AND PERMIT FEE -
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ ��a. ��
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)
3. Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable able to
6.Total Cost I $ 'XO.o ri (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby at order the pains and penalties of perjury that all of the information contained in this
application is true and accurate to a best of y knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name: - .Date