69-71 ENDICOTT ST - BUILDING PERMIT APP a
The Commonwealth of Massachusetts
I {j Department of Public Safety
NIaslathusetts Stale Build ing Code(781)Ch I R)
Building Permit Application for any Building other than a One r T o-Family DwelIil ,
(Phis Section For Official Use Only)
Building Permit Number: _ Date Applied: _. Building Off inl: ____
SECTION 1: LOCATION(Please indicate Block M and Lot ff for locations for whf a ' eta ess is not available)
No. and Street City /'town Zip Cudc Name of Building(it applicable)
SECTION 2: PROPOSED WORK
Wilion of hIA Slate Code used If New Construction check here❑or check all that apply in the two rows below
Existing Buildill KRepair Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:_ _
Are building plans and/or Cunsl rucl ion dot:uments being supplied as part of lh is permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work.-
414, _
a C71�
e
_ M1
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 CNIR 3a) O
Existing Use Gruup(s): Proposed Use Grou p(s):
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a le)licab
A: Assembly A-I ❑ A-2❑ Nightclub ❑ A-3 ❑ A—I❑ A-5❑ B: Business ❑ E: Educational ❑
F: Factory F-I ❑ F2❑ 1 It: High Hazard H-I ❑ H-2❑ H-t ❑ EI-d ❑ H-i❑
1: Institutional I-1 ❑ 1-2❑ I-3❑ 14❑ 1 M: Mercantile❑ R: Residential R-10 R-2 11-3❑ R4❑
S: Storage 5-1 ❑ S-2❑ U: Utilfty❑ Special Use O and please descrifle below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IBO IIA ❑ IIB ❑ ILIA IIIB ❑ IV ❑ VA ❑ VBO
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) '
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Ficbris Rellim if:
Public❑ Check if outside Flood Zone❑ Indicate municip.nl❑ •A Irench-will not be Licensed Disposal Site❑
required ❑or Irent h or specily:,_.__, .--
Private❑ or indentih'Zono: or on site system ❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \t \ l
Not Applicable❑ Is Strut tore within airport approach area? Is their review complcled.'
or Consent to Build enclosed❑ Yes❑ or:No❑ Yes❑ No ❑
SECTION N:CONTENT OF CERTIFICATE.OF OCCUPANCY
Edition of Code: L se Group(,): l%pc of Construction'. Ottupent Load per Moor.
I loos the building;contain an Sprinkler Svsh'm?: Special Slipulations: ._____—.____._.
i
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SECTION 9: I'ROI'ERl'Y UWNtili AU'1'1IOItIZA77UN v
N.uuc.md Add rcssul Pi operh Ow tier
Name(Print) No.and Strect —__— -- City/Tote.n Zip -
Properh Otv ner Contact Information:
Y I illy -- — Tr lephune No. (business) Telephone No. (cell) c-mail address
/\ If applicable, the propene owner hereby authorizes
Name Street Address City/Town State Zip
lu act on the pro periv owner's behalf, in all matters relative to work authorized by [his building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,0W cu.ft.of enclosed space and/or not tinder Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Nano(Registrant) Telephone No. e-mail address Regislrillion Number
Street Address City/Town Slate Zip Discipline Expiration Dale
10.2 General Contractor
Company Name
XName 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:tvrva.el" (i.)N)1•1 INI-u1:nNCr :\I I.a AVII M.G.L.c.152. 25C 6
A Workers'Compensation Insurance Affidavit from the NIA 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) _$
I. Budding $ Building Permit Fee-Total Construction Cost x (hpserl here
2. Elcclricnl $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) S Note: Nlininmm fee=$ (contact nut n icipal ily)
.i. Nechanical Other S
Enclose cluck payable to —
i+.Total Cost $ (contact municipality)and write check number here_—_—_—
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Hv entering nh name below, I hereby attest under the pains and penalties of perjuh that all of[he information contained in this
application is true and accurate to the best kZ11 knowledge and understanding.
please print and sign nano ------ ----- Title --- -telephone No. Date
Strect Address City/town Stale Zip
Municipal Inspector to fill out this section upon application approval:
Name Dale
t
SECTION 9: PROPERTY OWNER AUTHORIZATION -
Naine_#Dct Address of Pro erty Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
9 7d'_'44. 6S2 3
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
A/DU/7 COnclrrrcf,�a tSf/,!�ia,'rts �d 0/94r
Name U 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 application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and 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 State Zip Discipline Expiration Date
10.2 General Contractor
Na 11,q Coif a bh �C2/ytoe�2l•' /��_
Company Name
�EazY kl#6410 CS /o�33d'
Name of Person Responsible for Construction License No. and Type if Applicable
/o c, -rear ct A/*41-RA/T Hh 0/Q
Street Address City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.152.6 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 O
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 $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to -� W0
6.Total Cost $ f 3�SO (contact municipality)and write check number he e
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest der the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best o my knowledge and understanding.
j15Rz1! lei sal _ 94o4 ,1
Please print and sign na Title Telephone o. Date
loo f 0�D ( Q
Street Address City/Town S e Zip
Municipal Inspector to fill out this section upon application approval:
Wine—
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