84-88 ESSEX ST - BUILDING PERMIT APP (002) 7-71
The Co" I'fi-'of-Ma' g 1 'hl iS'
minonwea t S aic U ettS ,
Department of Public Safety
MossaklovsvitsState Building Code(7$oC,%Ilt)
ilili�g other than,,x0ne-orTwo,-FajI1iIy'0%�vIIing Building Pernlit,Applicati f ry Ht an 'k :.
on% 0.
('Phis Section For Official Use Only)
BLIIIIIiIIII,I1erniitNoWbV—, _—\ Dale Applied: I Building Official:
SECTIOD6 LQKkl-lC)N(I'lease indicate Block #and Lot#for locations for which a street address is not available)
][,to
zip Code Name of Builklit'r, YLV v C V rown
No, mid St cot ll�cl
SECTION 2:PROPOSED WORK
Edition of 1A State 01 used if Now Construction check pore 0 or Check all that apply in the two rotas below
FXiStitle, BUil" ..g Mwftiti(lff Deniolition-0 (Mvilsviill ouftind slifini4t;\PJIVIILIIX Ili'-'
C11,111ge of Use 0 Change ofoccupancy . 0 Other 0 Specify:
Arc building plans and/or construe Lion doc toncrits being supplied as lia ft of this permit application? N,, C3 I 1,N
Is an Independent Structural Engineering P R w -qui Yes 0 No 13
,V, g,Z�i; required?
Brief Description of Proposed P rk: JIA a4q.i
la, of k5�
SECTION 3:,CONIPLETE THIS SECTION IF EXISTING,HUILDING UNDERGOING RENOVA rION;ADDI 1`10N,OR ,;".
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(5e.,e780CNIR 34),,C3
Existing Use Group(s): Proposed Use Group(s):----L: i
SECTION 4: BUILDING HEIGHT AND AREA
IExisting Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(ski, ft.)
1
Total Area(sq. ft)and Total ifeiglit(ft.) I
SECTION 5:USE GROUP(Check as applicable)
A: Assembly.A-1 13 A-213 Nightclub 0 A-3 0 A4 13 A-5 UT B: Business 13 E: Educational E3
F: Factory F-1 0 12 0: If: friji'g,1cl-lazard H-I 0— H-2 13 1 f-.1 0 11-4 C3 11_5 CI
-1 C3 -20 -30
3 14::
1: Institutional 1-1 C3 1-113 1 0 antile 13 R. Residential R R R R4 C3
S: Storage 5-1 0 S-20 U: Utility 0 Special Use 13 and please describe below:
Special Use
SECTION 6:CONS rRucTION TYPE(Check as applicable)
LA 0 IB El T1 1A 0 [111 13 111A a 111H VA 0 IV 0 VB 0
I
SEC NON 7:SITE INFORINIA rION(refer to 780 CNIlt iff.6 for detailii on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Perinit,. Debris Reinoval:
I'LINIC 13 Cli,,,k it outside Hood /,,fit,13 Indicate numiciVal 0 A trench will not be Licensed Disposal Site 0
required 0or trench
I't-tvalt-V ,rwdVIItiI.N,zv1w oron-silo sl\stvvo 13 pernot is clik lose,.I
Railroad rfght-of.way; lialards it) ;\it Navigation:
NotApplik.�,o'Iv 1 titrotlury Is their fV%IVW I 0111111111'Ll.'
0 1 L'S 0 or No 13
SECTION 8:CON I EN r OF CFRI IFICA IT OF OCCUPANCY
:d1it'll nl Code: L av Group(s) - I\pc of Co,,Wrtj,tion: 0,k 11 I'alit I""Id I'cl I loon.
1)"c' the 1,1111ding coo t,1111,111?prmklvr'Sedan' stipulations:
C>20
SECI'ION9: PROPERTY OWN ER AU I'I IORIZA IION
:Nmuc and : ddnvs of Po p,rh.Owner p --
Name(Print) No. and Street City/Town Zip
Pro pert_Ow tier
�Contact information:
YJ --�/�c3 36�L�_�T�1� ��{6I af]ece�gyGeNnY� I M
fide relepht n> No. (business) Telephone No. (cell)- e-mail address
If applicable, the property owner hercbv authorizes
Name Street Address city row State Zip
to ac t on the property-owner's behalf, in,all matters relative to work aulhoiized b this build in li nnit.i p ificatiun.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) -. 0,
if building is less than 35,0W cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Soetion 10.1
10.1 Registered Professional Responsible f�_�or Construction Control
Name(Registm rclep one No. • pail address Registration Number
nrn a 14{� L n �
Street Address City/To State Discipline Expiration Dote
10.2 General Contractor + s
O f
ompany Name Cr /
i Ch Q YIN
Nome of Person Responsrppl fur Cunstr uctdon License No. and Type if A plicuble
S7 Ly Y� Vt , YK 47 D J g O'gi
Street Address City/Town State Zip
Telephone No.(business)' Tel hone Nu. cell a-mail address
SECTION 11:t%t rki-m.,'t uaut.:�f::vu?� fu�•ur..v.vt.r.?rlu�,�(11 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 tIlLs application. Failure to pnwide this affidavit will result in the denial of the issuance of the building permit.
I5 a si med Affidavit submitted with this application? Yes❑ No ❑
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
I tcm Estimated Costs:(Labor
and Materials) Total Construction Cost((ram Item 6) S_
I. Building Building Permit Fee-Total Construction Cost x_(Insert here
_. Elewlricol S appnppriete municipal(odor) S
1. Plumbing $
a. Mechanical (FIV,-AC) S Note: Minimum fee-S__(contact nuu nicipalily)
3. Mechanical Other S
Enclose check payable to
ti.Total Cost S , D a (contort municipal itv)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering tnv name below, I hercbv attest under the pains and penalties of perjury that all of the information contained in this
aplplic,uion is Irte and accurate to the best of my knowledge anJ d ending.
fscrnY_1khQSchoPosl-_1D1_� _ __.
Ple.tsc print and sign name I the Telephone No. hale
5PPI'1. vale 4.ve - - - - .. __Lys- l . - Sa 2 . �( 9Q c,
�Ireel :Wdress Citvi rot n le Zip
Municipal Inspector to fill out this section upon application approval: .