84-86 DERBY ST - BUILDING PERMIT APP JACKET The Commonwealth of Massachusetts
1. l Department of Public Safety
:j,, ,," A Llssac 11 LINOt]S1•uc ifaiIdtFig Code(780 CAII?)
"""•'r Building Permit Application for any Building other than a One-or Two-Family Dwelling
("This Section For Official Use Onh')
Building Permit Number: _ Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block B and Lot
N for locations for which a street address is not available)
0-1
No.and Street CaN /Town Zip Code Name of Building;(if appliadde)
S17CI'[ON 2:PROPOSED WORK ,
Edition of \1A Slate Code used If New Construction check here❑or check all that apple in the two roles below _
Extstillg Building Repairtg I Alteration ❑ Addition❑ Demolition O (Ple.lse fill out and submit Appondix 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 18.
Is an Independent Structural Engineering Peer Review required? I Yes ❑ No
Brief De�srri pion of 1Prop/osed Work: N0-A) ,e1eC+MIC-6,1 [lam+ olvin In6 ,�r 2njakj Cu4-cteru
Gruel s.Purl heRhrrir7lvlS M J1Y� 3 l)n'-�- —ti z,j Tcop 2 ns
2 Finall_�A ✓' S r N1 1 c,'u.r �'"n GG c �c��u ���n�,,sr��_
Wit me. I
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 C\iR..14) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basenwnt 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. Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ FI-4 ❑ 1-1-5❑
1: Institutional I-1 ❑ 1-2 El 1-3❑ hl❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-I ❑
S: Storage S-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use -
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 180 IIA ❑ IIB ❑ 1 IIL\ ❑ IIIB ❑ 1 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:
I'll bl is❑ Check if outside Flood ZoneA Irench will not be Licensed Disposed Site❑
❑ Indicate municipal❑
required ❑or trench or spenf_c:.___-._
Pnvatc❑ or indenli(y Zone: or on site slstrm ❑ permit is enclosed❑
Railroad right-of-way: Ilaznrds to Air Navigation: U ; ii.l,��„ ,nvn..._,. . i'.....,
Not Applicable❑ Is StrUclure within airport approach drea? Is their wN iew completed?
or Comment to ffuild enclosed ❑ Yes ❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OI'OCCUPANCY
I: Litton of Code: L'.sc Grou p(s)'. I epe of Construct it'll, C1cru11,1111 Load per Fluor:
Dues the building;contain an Sprinkler System.':__.-.__Special Slipulatinns: ._
c . _
SECTTON9: PROIlllt]-YOWNift AUTIIO[(IZA'ITON
Address of Ili oprrk Owner
R a m k _(j0
Name(Print) No. and Street City/Town Zip
Property Otcner untat t Information:
-- {�,M �D.�e-- Gt-7g PS 31? SL drnocboae�lhelr✓pi �� "
lido`-' —` Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the properly owner hereby authorizes
Lik1%ovse Serv1 6-7 Mo Me"4-$e_ LI
-- Nanre'3cC -P ICZ(E Street Address Citv/Town Stale Zip
to act on the property owner's behalf, in all matters relative to work authorized by This building omit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix )
If buildin•is less than 15,000 cu,ft.of enclosed space and or not under Construction Control then check here kitrId skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town Slate Zip Discipline Expiration Date
10.2 General Contractor �1
LLk1-10LiSe_ S-PY✓�trb1
Company Name
`9 o,k q,5-2,9-0
Name of Person Responsible for Construction License No, and Type if Applicable -T
4 .7 in f�fi _ wa �a M 0 (f47
Street AAdddress r py 1/ City/town State Zip
711-b1.L- f�d �'L-6�T-- k i M0.tf , c_L'
Tcle phone No. business Telephone No. cell e-mail address
SECTION 11: let n;r.rays ci.mn'r_�S:vu�� iv-ur.:,.V(:I M1111,\VII M.G.L.e.152.§ 25C6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted With this application? Yes No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=S
I. Building S (i aC/ 0 O C Building Permit Fee-Total Construction Cost x (Insert here
'_, Eleclric:rl S /T Of3 O - appropriate municipal factor)_$
1, Plumbing $
T. Nlechanical (HVAC) $ I NOW: Minimum fee=$ (contact nuuricipalit')
3. Wchanical Other S O C
Enclose Chalk payable to
h.Tidal Cost S S O Q ap J (contact municipality)and write check number here___ ___ _
SECHO 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering nry name below, I hereby attest under the pains and penalties of perjury that all of the information Contained in pis
application is true•end accurate it,tile est of my kilo ledge doll Understanding.
Please print and sigt tame l file Telepl me IN
Steen Address Cih'/Tosco State Zip
Municipal Inspector to fill out this section upon application approval:
S�
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