39 ESSEX STREEET - BUILDING PERMIT APP Cr— `3 1'7 8
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The Commonwealth of Massachusetts
Department of Public Safety
W 61assachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Budding Permit Number: Date Applied: IBuilding Official: _
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street adtVAs is ava'
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No.and Street City/Town MtT 2 ip Code Name of Budding(if applicabre7<
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•PROPOSED WORK "I
Edition of MA State Code used_ If New Construction check here❑or check all that a r the ro
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Existing Building Repair❑ 'Alteration IEC Addition❑ Demolition O (Please fill out and submi0ppe 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
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Is an Independent Structural Engineers g Peer Review required? Yes ❑ No Yv
Brief Description of Propos I Work: Ct .� 156
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 a Iicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ 8: Business ❑ E: Educational O
F: Facto F-1❑ F2 Cl H: Hi h hazard H-1 ❑ H-2❑ H-3 ❑ - 1-1-4❑ H-5❑
1: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-l❑ R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a Iicable)
[A ❑ IB 0 1 IIA ❑ IIB ❑ IIfA ❑ 11100 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 indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: �I\I li,t,ri �•nnnihsum IL•cinv I'nn.:cssr
Not A licable❑ --...____..._..
NP 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
E'dition of Code: Use Group(s): Type of Construction:. Occupant Load per Floor:
Does the building conlain an Sprinkler System?. Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Pro erty Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:QM ppa
Title Telephone Na.(business) Telephone No. (cell) a-mail address
If applicable, the groperty owner hereby authorizes
'•'''"" Name - Street Address
City/Town State Zip
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to act Wthe proper owner's behalf, in all matters relative to work authorized by this building permit application.
:-z vn SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
IPbuildin 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
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Name(Rikistr nt) Telephone No. e-mail addross Registration Number
Street Address _ City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
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Name of Person Respons for Construction License No. and Type if Applicable
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Street Address City/Tow State Zip
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Telephone No. business Telephone No. cell �j J e-mail address
SECTION 11:IVOI:I:b:RS'COMI'ENSAPION INSURA.N(T AFFIDAVIT M.C.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 0 No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materia 'Total Construction Cost(from item 6)_$
1. Building .S724oco WuBuilding Permit Fee-Total Construction Cost x (Insert here
2.Electrical S appropriate municipal factor)=$
3. Plumbing $
d. Mechanical (HVAC) $ Nate:Minimum fee=S (contact municipality)
S. Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipals )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.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date