2 EDEN ST - BUILDING PERMIT APP f- 1
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The Commonwealth of MassachusettJ016 M
Department of Public Safety '� 24 P 1: 18
Massachusetts State Building Code(780 CMR)
^ Building Permit Application for any Building other than a One-or Two-Family Dwelling
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N 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)
'NP S 2
((('' N No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK.
Edition of MA State Cod used If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No el,
Is an Independent Structural Engineering Peer Revi w reyuirer . Yes ❑ No ❑
Brief Description of Proposed Work RSL= �t6 "-"""olds —
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-f❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional [-1 ❑ 1-2❑ [-3❑ 1-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ I U: Utility❑ Special Use❑and please describe below:
Special Use.
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ lB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV.❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood =Information: Sewage Disposal: Licensed Dis osal Site❑
Public❑ Check if oIndicate municipal❑ A trench will not be Prequired❑or trench or specify:Private❑ or indentor on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA I Iist ric Cummi,sion W, ,, I ry cis:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 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:
SECTION 9:-PROPERTY OWNER AUTHORIZATION
Name an Address of Property Owner
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Name(Prin ;`+ " "" No.and Street City/Town Zip
, 1 -1
Property Owner Contact Information:
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Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Naune Street Address City/Town State Zip
to act on the property owner's behalf,in a6 matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix.2).
f b dding is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 30.1
10.1 Re fstered Professional Responsible for Construction Control-
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Name(Registrant) Telephone No. e-mail address gt ratio
Street Address City/Town State Zip Discipline Expir Lion 136te
10.2 General Contractor- - - -
onnpany Name
None of Person Responsible for ConstructionCoAnstruction License No. and�T�ype if Applicable
Street Address City/Town State Zip
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Telephone No. business Telephone No. cell e-mail address
SECTION 11:W0RKF.XTC:0mO'1;NSn I'10N INSURANCE AFFIDAVIT 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 application? Yes❑ No ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
d. Mechanical (I-IVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost is ,?j l- J00 (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 b ny kn ledge and understanding.
Please print an si n name �"\ Title Telephone No. Date
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Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Dat -/