107-109 CONGRESS ST - BUILDING PERMIT APP :7) 2-5
o The Commonwealth of Massachuse
T- tts
Department u Public Bd1�l 0 P 1- 22
Massachusetts State Building Co f )
�— Building Permit Application for any Building other than a One-or Two-Family Dwelling
( (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
t SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name dBudding(if applicable)
I� 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❑ 1 Alteration ❑ 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 Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: Mpiw7 5
ViAl
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here 0 an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): I 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❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 10 ❑ IIA ❑ fill ❑ I ILIA ❑ 11111 ❑ I IV ❑ 1 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❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: tc�rlc._Co..nn,jcsiy�n,ltgyitpq-l'r.,�.._.s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ 1 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:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name`and Address of Property Owner',
Name(Print) No.and Street City/Town Zip
Property Owner Contact Infonna uon:'
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 a6 matters relative to work authorized by this building ermit application.
SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix 2) - -
If buildingis less than 35,000 cu.ft.of encloseId space and/or not under Construction Control then check here D and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - -
Company Name
411.d IA i IVQID AI�) L)SIq
Name of Person Responsibl or C@ onstruction License No. and Type if Ap licable
Street Address City/Town State Zip
4&-�9 0100 42 1Z6_J14L- nUkPh/M C4I10 1� C
Telephone No. business Telephone No. cell a-mail address
SECTION 11:VVOI.KH1S'COA,IPENSA I ION INSUPANCE AEPIUAV r M.G.C.c.152.S 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 13 No ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE:-
Item 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 $
d. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
S. Mechanical Other $ Enclose check able to
6.Total Cost $ p y
(contact nrnnicipality)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 kn wledge and understanding.
Please print and sign nad a Title 7` Telephone No. Date
Street Address - City/Town ./Stage Zip
"Municipal Inspector to fill out this section upon application approval: r" /1 /�
Name Date