1 COUNTRYSIDE LN - BUILDING PERMIT APP '�/ � � VJJ �� C� �i � j �
� The Commonwealth of Massachusetts �
� r �4,��,, Department of Public Safety
yQ .+ Aiassachusetls Stite Building Cude(730 CMR)
(� Building Pemiit Application for any Building other than a One-or Two-Family Dwelliu$
� .(This SecHon Pur O(ficial Use Onl ) � ✓'
� Building Permit Number. Date Applied: Bui�ding Official: �
SECTION 1:COCATION(Please indicate�lock N and Lot#Eor locationa for which a slreef ddr s is nataaailabl'e)�
� N --=c7
� COvn."(kY Ssp 6 L�v ',�LEr� -e� �`m
�� No.and Slreet City/Town � Zip Code Name uf Building(if app icable)�� .
m
— SECTION 2 PROPOSED WORK m
�
� Editiun of bfA Sfate Cude used_ If New Construction check here O or check.ill tha[npply in the Iwu rows bc,`Gnv
„^ Existing 8uilding❑ Repair❑ rU[erntion ❑ Additirni❑ Dcnwlition O (Please fill out and submit.�`�p endi�I)
ui Change of Use ❑ Change of Occup.mcy ❑ � Other ❑ Specify: �.�o L ... .
I"'— Am building plans and/or construcliun ducwnents being supPlied:vc pnrt of this permit application? Ycs � No ❑
Is an ImlependentStructunl Engincering Peer Review required? Yes ❑ Nu Sl
Brief Desttiption of Propuseil Wurk: I�Y!a✓.b-D c p S�--i a 7/� /�L,g S 7C 7 Fr�.,r1 !d
Ov bl C ls �• �
�n/O 15A-1Jf1?oo.�. �E MoDFts 4
.r .
SECTION 3:WMPLETE TffiS SECTION IF E?([STING BUILDING UNDERGOING RENOVATIOIY,ADDI'CION,OR
CHANCE IN USE OR OCCUPANCY
Check here if an ExisHng Building Investigation and EvaluaHon is endus�vl(See 780 CMR 3-4) �
Esisting Use Croup(s): Propus�d Use Group(s):
SECTION 4:BUILDING HEICHT AND AREA
� . � Existing Proposed
Nu.of Fluors/Sturies(include basement levcls)&Area Per Ficwr(sq. ft.)
Tutal Arca(sy.(t.)and Total Height(ft.) � .
SECTION 5:USE GROUP(Check as a liwble)
A: Assembly A-1❑ A4 O Nightdub ❑ A-3 O� A--4❑ A-5❑ U: �Uusiness ❑ E: EJucaHonal ❑
F: Facto F-t ❑ F2❑ � H: Hi h Hazud H-1 O, H-2❑ H-3 � H-d❑ H-5 0
1: InsfituHonal Fl ❑ [-2❑ 1-3❑ 1-!❑ M: MemanNle� R: Residential R-l❑ R-2❑ R•3❑ R-�k❑
S: Sforage S-I ❑ � S2❑ U: Utility❑ Special Use O and please describe beluw:
. Special Use:
SEClION 6:CONSTRUC[fON'I'YPE(Check as a licable) -
IA ❑ 16O IIA ❑ 118 ❑ IIIA ❑ f11B ❑ N ❑ VA ❑ VO ❑
SECTION 7:SITE INFORMATION(refer to 78U CMR I11A far det.tils on each item)
6Vater Supply: Flood 2one Information: Sewage Dispasal: �
Trench PermiF. Debris Removal:
Public❑ Ch�Yk if uutside Flood Zune❑ InJicate municipal❑
A trench will nut be Licensed Disposal Sih O
rcquircd 0 ur trench ur sp��ci(y:
Priv�le❑ or indentify Zune: ur on site system� v�m�it is encluse�O�
Railroad righRof-way: flatards to Air Navigation: \I-\I I i:.�i �_,nnn��c� �i It n;�•� �_��:�,.:
Not Appiic.ble❑ � Is Structure within aiipurt approach an�? -...... Is�their review completeJ?
. . or Cunscnt lo Iiuild cncloseJ❑ Ycs� ur No❑ Yes❑ Nu ❑
SECTION 8:CONTENT OF CERTIFICA'(E OF OCCUPANCY
�ditiun uf CuJ�: Ux GrnuN(ti): I'YNc of Construclion:_ Oetupunt l.o.�d F�er flnur
Uucs thc buildiny,cumain.m Sprinklcr Systcnd: _ Special S�ipulafiuns: _—_ .
S�.T) fl '� L�N.�Iz.�c,TC�dZ � t ��{ S (�cVl L�I�C S'r
S�—'NT �� 3v
SECTION 9: PROPERTY OWNER AUTHORRA"CION • -
N;imc and Addmss of Pmperty Owner
CIfE �ely � L� psce .l CO✓✓72YSapE Lv sr0L6�.. t
Name(Print) No.and Street � City/Town Zip
Property Owner Cuntact Infonnation:
OW w- F7 � �-�-� 3 �S y -
TiUe Telephone No.(business) 'fclephone No. (ttll) e-mail aJJress
If applicable,the property owner hereby authorizes
�] L iNd2-IlFc�KrE lOy $pV,tLLF 97 ��V uS �q. p/ 906
N.une SU�wt Address City/ own State � Zip
to,ut on the ro er owner's bchalf, in all matters«lative to work authorizcd b this buddin ermit a lication.
� SECCION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)� �
If builJin is iess than 35,000 cu.ft.of enclased s oce and or nat imJer Construction Control Ihencheck heie O and ski SecHon 10.1
10.1 Re istered Professional Res onsible for Constzuction Conhol
� L lvo�r/1 FouzcE � 5��� yp85 /5644 b
❑me(Registront) Tclephone Nu �mail addrese Registration Number
�O� SADrLLg C j SA� [J� S � O/ 30E 0 O/.S
Strcet Address - City/Town State Zip Discipline Expiratiun Date
10.2 General Conhacto� � - � - � �
.� a L WOdtlt FiDlQC6 C�n.S � `IrC.
. mp:my Name
��vr�. Ey �Fnossns D �So38� CS
Naine of Person Responsible for Cunstruction License Nu. and Type J Applicable
lo�L S'ov�ZG � s 7 S � ., S" i+^a o/ So
Strcet AJJress � Cily/ own , State Zip
�=5,��/ `JQBS
Tcic hune No. business Tcle hune No. cell e-mail addrcss
SECi'ION IL•�vO21:eh5'COnu�tuS�Yno�wSUR:�NGi:���F7U��v[T M.G.L.c.152 25C 6
A 6Vorkers'Compensation Insur.ince Affidavit from H�e MA Department of Industrial Actidenls must be mmpleted and
submi[ted with�this application. Failure to provide thu affidavtt will result in the denuil of the issuance of the building permit.
Is a si ned Affidavit submitted with this a IicaHon? - Yee❑ No ❑
SECIION]2 CONSTRUCIION COSTS AND PERMIT FEH
��� Estimuted Costs:(Labur �
and Matcri.ils) Total Constructiun Cost(Gom Item 6)_$
L 6ullding � Building Permit Fce=Total Cunsfruction Cost x_(Insert here
2.Electrical � � npproprinte municipal factor)_$
.l. Plumbing $
d. Ai�tihanical (HVAC) $ Nute:Minimum fee=$ (contact municipality)
5. Mcch.nic.d Other '� Enciose ch��ek payable to
6.Tota!Cust � !�_ OOV �O (mn Wct municipality)and write check number here
SECIiON 13:SICNATURE OF 6UILDINC PERMfI APPL[CANT
6y entering my mm�e beluw, 1 hcreby attest uuder the pains anJ penalties uf pe�jury that all of the informatiun contained in this
application is true.ind accura[e lo the best of my knuwledge:md understanding.
� F�. D.�niG7 �(�dlV! CrYLB C.�w�7viscT�rR 61�- SS-`r g a8 S
Plea+e print and sign name Title Tclephune Nu. Date
re�l se �_.-« � s7 �eu � � c r.a oisa6
Sirect Addmss City/To+vn State Zip
Alunieipal Gispector to fill out this section upan application approval: _ -!t!"�n e� �
Name Datc