209R ESSEX ST - BUILDING PERMIT APP - CYBERSPACE JP/ CD
The Commonwealth of Massachusetts`
l Department of Public Safety
'j 'I➢V Massachusetts State Building Code(780 CbIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Datc Applied: Builduig Official
SECTION 1:LOCATION(Please indicate.Block#and Lot#for locations for which 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 Buildingfler Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use Change of Occupancy ❑ 1 Other ❑ Specify:
Are build n 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 AT
Brief ascription of Proposed Work: O if /J 0It. — �is-r i-aa -jz �n
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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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational
F: Facto F-1 ❑ F2❑ I If: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-S❑
L• Institutional [-t ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ _ R: Residential R-10 R-2❑ R-3❑ R4 Cl
S: Storage S-1 Cl S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ I
ll t11A ❑ If6 ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ECTION 7:SITE INFORMATION(refer to 780 GMR 111.0 for details on each item)WaterSupplFlood Zone Information: Sewage DisposajMh
it: Debris Removal:Public G3' eck if outside Flood Zone❑ Indicate municipat be Licensed Disposal SitePrivate❑ indentify Zone: or on site systemnch or specify:d❑
Railroad right-of-way: hazards to Air Navigation: \I;\„I h t i,Gannv s�.n r xcse:
Not Applicable W Is Structure within airport app ch area? Is their review completed?
or Consent to Build enclosed ❑ Ycs❑ or No Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Gnmp(s): "type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler Systeu,?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
'[PFAII,
and Address of Prop arty Owner
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(Print) No.and Street City/Town Zip
rty Owner Contact Information: ZA-1/0
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Telephone No.(business) Telephone No. (cell) e-mail address
licable, the property owner hereby authorizes
Name Street Address City/Town State Zip
on the ro er owner's behalf, in all matters relative to work authorized b this building ermit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
f buildin is less than 35,000 cu,R.of enclosed s ace and or not under Construction Control thencheck here O and ski Section 10.1 Registered Professional Res onsible 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
Company Name
Name of Persoty Resp Bible for Construction // License No. and Type if Applicable
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Street Address City/Town State Zip
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Telephone No. business Telephone No. cell e-mail address
SECTION 11: 0A11'IrNSA'I[ON INSURANC8 AFI'IUr\VI"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 is ante of the building permit.
Is a signed Affidavit submitted with this application? Yes1W No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item Total Materials) otal Construction Cost(from Item 6)
1. Building $ a Building Permit Fc�=Total Construction Cost x (Insert here
2. Electrical S 'q DDo '" appropriate municipal factor)=S
3. Plumbing $ 200
Note: Minimum fee=$ (contact municipality
d. Mechanical (FIVAC) $
5. Mechanical Other S Q Enclose check payable to 1
6.Total Cost $ lorfe I (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 hest of limy knowledge and understanding.
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Please prin m t au 1 sifrr e itle Telephone No. Dale
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Street Address City/Town St e Zip
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\lunicipal Inspector to fill out this section upon application approval:
Name Date
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