224 DERBY ST - BUILDING JACKET The Commonwealth of Massachusetts
1. W Department of Public Safety
NlassachuseltsStmeBuddinl;Code(7NI)C%W)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(Phis Section For Official Use Only)
BUildiog Permit Number: Date Applied: Building Officiate
SECTION 1:LOCATION(Please indicate Block N and Lot N for locations for which a street address is not available)
No.•Ind Street Cit Fawn Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
.. Edition of NIA Stale Code used If New Construction chock here❑or check all that apply in the two ruses below --
;xisting Building❑ Repair❑ :\Iteruliun ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
:.Change of Use-, ❑ 1 Change of Occupancy ❑ Other ❑ Specify:--
\re building plans and/or construction docunients lit in r supplied as part of this permit application? Yes ❑ No O----_
Is an Independent Structural Engineering Peer w re uired? 1 Yes ❑ No ❑
Brief Description of Proposed Work:- - 0.i r• �I f I+�_G><'D•--�c�_✓�•^d"u us S _
CVIcL Ulr]F�Inr '�°s'�-C.,.,�...- \w4 . . r-at r r a •r.
SECTION 3:COMPLETETHIS SECTION IF EXIS"rING BUILDING UNDERGOING RENOVATION,ADDrrfON,OR
CHANGE IN USE OR OCCUPANCY
Check here if,m Existing Building Investigation and Evaluation is enclosed(See 7W CNIR 34) ❑
Existing Use Gruup(s): --- Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Fluor(sq. ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION S:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ .Nightclub ❑ A-3 ❑ A4❑ A-i❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ 1 H: Ili h Flazard H-1 ❑ H-2❑ 11-3 ❑ 1-1--4❑ li-i❑
1: Institutional 1.1 ❑ 1-'_❑ 1-3❑ 14❑ �I: Mercantile❑ R: Residential R-1❑ R-'_❑ 1(-\❑ R-4❑
S: Storage SI ❑ S2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONS"TRUCriON TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ [III ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ Vito
SEC:'TION 7:SITE INfORl11r\'TION(refer to'NU CN1R 111A fur details on each item) -
Water Supply: flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
PubliC❑ Check it outside flood Zone❑ Iodle,ne MU1110p,d ❑ A bench will not be I.ICP11SVII Disposal Site❑
Troaien or indontify /one: __-- oron site sv.vtem ❑ eyuinaf ❑t b or ench orsp�rlh:..._.. -
c. -t r .permit is enclosed ❑• e.
Railroad right-of-way: [lizards to Air:Navigation:[ 'd 1 1; 1, : ., I , , ..
.Nor :\pplicable❑ Is Glruclure within airport approach area? Is their review cumpleled'
or C,nlsrnt to Hudd enclo,ed ❑ Ws❑ or.No❑ Yes❑ .No ❑, ,r
SECTION 8:CON I ENT OF CFR IIIICA 11:Of OCCUPANCY
I dillnn„1 Code: ...L'se Croup(n): - - _ I\po,u Conslruihan: 0,,upant Load per Ilonr
Pow, the buildingcomain:In';priukler I;%,wm' ;pvcwl ;hpilations:
���.� &
SE(:'I'ION 9: I'I(OPF.R'I'Y OWNI[R AU'I'IIORIZA"LION
N,unc and AJJrtss ul Pnipeny brace
-21
Nanny(Print) No.and Street �- -----City/Town ---- _--- -- -- Zip
Property Owner Contact Information:
I ole Iblephone No. (business) Telephone No. (cell) c-mail address
If applicable, thperly owner
hereby aulhim �s e ro
e ;ACC-
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building ermit a p plication.
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 O and skip Section I0.I
10.1 Registered Professional Responsible for Construction Control
-261 /6!?'�e6
Nat (IL,gi1t�,tt� n J� "f •p one Nu. e-mailadrlrek.5 Registration Numb yr /
Street Address (- City/Town Stale Zip Discipline E. piratiun Date
10.2 General Contractor 11 l
Company Name 0
Nance of Person RespunsibIq for Construction r License No. and Type if Ap lictble
Street Address City/Town State Zip
Telephone No. business Telephone No. cell a-mail address
SECTION 11:lccua.tat,'rtWill tn \I Vfd-nt\Rc'I AIM AVID M.G.L.c.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 a lication? Yes O No 13
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from ftem 6)=S_
1. Building S ,sSO, �' Building Permit Fee=Total Constnuction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=S
3. 1'lu11113ing $
J. Mechanical (HVAC) S Note: Minimum fee=S _(contact municipality)
i. \Icrh,tnical Other S Endase check payable to
n. Total Cost S �.La (contact nnuticipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERNI T APPLICANT
11v entering nn' n,unc below, I hereby,tllest under the pains,md penalties of perjure' that all of the information contained in this
appliialiun is Iruc and aenratc to the hr o my kt uwlcdge anJ undershmdiny,.
I'Ir,tse print and si};n name fills lblcl+ anc: 'o. 1 Ic
itircel :\ddress 1 I / ^ , O Cityi rows at \<ip
Municipal Inspector to fill out this section upon application approval:
�--"___--- _-- — --Nance Pale
.:-" •. . . REVISIONS _.
ZONE - REV DESCRIP716N wDATE APPROVcD
T-F
LLU
224 Derby St
Window Flashing and Composite Panel
Application
SIZE FSCM NO. DWG NO. REV
SCALE SHEET