4 DEVEREAUX ST - BUILDING PERMIT APP JACKET =� , The Commonwealth of Massachusetts
� Department of Public Safety
V � / Massachusetts State Building Code(780 CbIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
O (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
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 M11A State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repairs I Alteration ❑ Addition❑ Drmolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other El 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 req Yes ❑ No o
Brief Description of Proposed Work: sT2 uired?-i d _ V_ Q/la/<e
(/ iN ✓ .S/ C✓. /L�i �/ Y Cu�✓/tJO�Z o�Ti
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 CMR.34) ❑
Existing Use Group(s): Proposed Use Group(s): S> Fr✓�>,.t--l''
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basenent 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 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-I ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
L• Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-41❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as ap licable)
IA ❑ IB ❑ IIA ❑ 11B ❑ 1 IIIA ❑ IIIB ❑ 1 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 net be [Accused Disposal Site❑
Private❑ or indenufv Zone: or on site system❑ required ❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: R,ch.,p.I'i.x•..:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or C0IISV11t to Build enclosed ❑ Yes❑ or No❑ Yes❑ No J
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of COde: Use Cruup(s): Type of Construction: Occupant Load per Floor:
Dues the building contain an Sprinkler System?: Special Stipulations:._
SECTION 9: PROPERTY OWNER AUTHORIZATION
Narne and Address of Property
�Owner a
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If aa}'plicable, the property owner hereby authorizes / /y ,{ n
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Nam Street Address City/Town Stale Zip
to act on the property owner's behalf,mail matters relative to work authorized by this building 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 O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Reg�iDstrant) ylephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.22,(JGenerall Contractor `0-
7
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Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11: WORKFKS COM I NSXftlN IN�UIt:VNCI:AF191aAVl'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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No 13
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$
1. Building $ 0 .7� 'fl
Build ng Permit Fee=Total Construction Cost it_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
T. Mechanical (HVAC) S - Note: Minimum fee-3 (contact muniapali
5. Mechanfcal Other S Enclose check payable to �1�
6.Total Cost $1d J o'd. `>- (contact municipality)and write check number rare
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereliv 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 knowledge, u[ understanding.
X.
Please print and sign name Title T Ieph i a. Dale
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Street ic.. - T City/Town Stale p
Municipal Inspector to fill out this section upon application approval: r/4
Name Date