52 DOW ST - BUILDING PERMIT APP JACKET `1t -`9 Oro ;RECEIVED
murtThe Commonwealth of Massac use s
Department Buildinf Publicg
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Massachusetts State Buildin Code
WIT Building Permit Application for any Building other than a One-'or Two-Flarily n
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Offici
SECTION 1: LOCATION(Please indicate Block#and Lot#for locations for w ich 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 If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition ❑ (Please fill out anal submit Appendix 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 ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 13
Brief Description of Proposed Work: '��r.r��rt-t07L — `l'O 54Nd /N -2- 5
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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):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement 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=1❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional [-1 ❑ I-2❑ 1-3❑ 1-4 El Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ 11I1313 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 not be Licensed Disposal Site❑
Private❑ or inden[ify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: V\,Ili tr n C,,q,,mssi n Rc,ic,p t w e,s:
Not Applicable❑ Is Structure within airport approach area? Is their,review completed? _
or Consent to Build enclosed❑ j Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: ' Use Group(s):_ Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AU'rFIORIZATION
Name and r\ddress of PST°lire ty�O^w�gicr 1
Name(Print) No.and Street City/Town Zip
Rr •11 p re Yt+ll 0111 Property Owner Conkact•1nfarmation.
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'ride Telephone No. (business) Telephone No. (cell) e �
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 building permit ae2lication.
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❑and ski Section 10.1
10.1 Registered Professional Responsible for Construction Control -
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Name(Registrant) Telephone No. e-mail address Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name .
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell a-mail address
SECTION 11:WokKt;AS'(,0t,11TNS, LKLN IiNSU1tAN0,.4fP11)AV1'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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and bhntcrials) Total Construction Cost(from Item 6)_$
L Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical S appropriate municipal factor)_$
3. Plumbing S
T. Mechanical (HVAC) $ Note: bfininuun fee=S (contact municipality)
5. bfechanical Other S Enclose check Y�p�n able to
6.Total Cost S 4r avD ` (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby 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 and understanding.
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Please tint and sign name Title Telephone No. Date
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Street Address City/Town State Zip Ad A
Municipal Inspector to fill out this section upon application approval:
Name Elate