7 DANIELS ST - BUILDING PERMIT APP (003) RECEIVED q
INSPECTIONAL SERVICES / 5
The Commonw0jQVJ8fZ%a2aW&tts
ry
Department of Public Safety
q, Alassachusetts State Building Code(780 CMR)
4ss��� Building Permit Application for any Building other than a One-or Two-Family Dwelling
.(This Section For Official Use Only)
1. Building Permit Number: Date Applied: Building Official:
n SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used g If New Construction check here❑or check all that apply in the two rows below
Existing Building I( Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix l)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No
Is an Independent Structural Engineering Por Revie required? Yes Cl No 1(
Brief ascription of Proposed Work: U #
C
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 encloser!(See 780 CMR 34) ❑
Existing Use Group(s): Proposer!Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)do Area Per Fluor(sq.ft.) I t fi-5— 1 025it
Total Area(sq.ft.)and Total Height(ft.) 13TQ2 1 X
SECTION 5:USE GROUP(Check as app licable)
it: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-I❑ F2❑ H: Hi h Hazard H-1❑, H-2❑ H-3 ❑ H-d❑ !!-_I❑
1: Institutional I-t❑ 1-2❑ 1-3❑ 14❑ NL• Mercantile❑ R: Residential R-l❑ 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 a licable) -
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB IV ❑ I 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:
Publicd Chuck if outside Flood Zone❑ Indicate municipal A trench wi nut be Licensed Disposal Site
El
required 61'ur trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑.
Railroad right-of-wa : Hazards to Air Navigation:
Not Applicable Is Structure within airport ap roach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No 1 Yes❑ No 431,
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code:ld Use Group(s):_ Type of Construction: t� Occupant Load per Floor:
Does the building contain an Sprinkler System?: D Special Stipulations:
f3 aV i 7 I b
Cal- �,J�1J c�ji2� iS CZE�`i
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and dXddress of Property Owner r
11- Ro trS T
Name(Print) No.and Street City Town Zip t1\
Property Owner Contact Information: I_- W__gV_&Jq— C L'C ®Nd kil/
.0 ✓t r
Title Telephone No.(business) Telephone No. (cell) e-InaiLilddress
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 building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here D and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Nuci&r
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - -
l
Company Name
Dom,rd 2!2:5.es-T S -1 D(S7�n 1.1 .vim fr c�rcQ
Name of Person Respctly6ble for Construction License No. and Type if Applicable
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Street Address � �j� Tity/Town , State Zip
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Telephone No. business Telephone No. cell - `-mail address
SECTION 11:%VORKEh9'COAII'EN5A I[ON INSURANCE AFFIDAVI I' 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/'ssuance of the building permit.
Is a signed Affidavit submitted with this application? Yes.de No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
t. Building $ Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
d. Mechanical (HVAC) $ pe Note:Mininwm fee=5 (contact municipality)
5. Mechanical Other - $ Enclose check payable to
6.Total Cost $ �. oaD 7 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurat o the best of my knowledge and understanding.
Ple.nse print at sign name Title Telephone Nu. Date
Street Address [City/Town 41,/� State Zip
Municipal Inspector to fill out this section upon application approval• -""+, ;
Name Date