222-224 ESSEX ST - BUILDING PERMIT APP d ..
I� The Commonwealth of Massachusetts
¢ Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One or Two-Family Dwelling
no-.!re_:sm..,',(This Section For Official Use Only) , �,,.mi. ld�r:�
Building Permit Number -,-. .; BuiidingOfficral
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SECTION 1«.:LOCATION(Pie;
a indicate Block#and Lot#for locations for which a street address is not available) Wr
No.and Street City/Town Zip Code Name of Building(if applicable)
.::. -,,ARSECTION2:.PROPOSEDWORK�����e�m°' �"prC, � i� �„'�
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair 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 construction documents being supplied as part of this permit application? Yes ❑ No 4
Is an Independent Structural Engineering Peer Review required? Yes ❑ No Je
Brief Description of Proposed Work:
l 2 e-
�r SECTION 3 COMPLETE THIS SECTION IP EXISTING BUILDING UNDERGOING RENOVATION ADDITION OR rm
er r� ¢++ , s mi,-CHANGE IN USE OR OCCUPANCY _.. 3'�.,
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-:LmN,n R -
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):', ., ._.. .. :v..r....c.,.u,�..
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
MU N A _.::. .,..... =r SECTION 6:CONSTRUCTION TYPE(Check as applicable) _._.,� ..,r., �� .,.�='s�`.:
IA IB ❑ IIA ❑ IIBO IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
,-,; SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each Stem). c: V .M r=t�c
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: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
1i: is t':,- „ _.,,_,.�,y, , SECTION 8.CONTENT OF CERTIFICATE OF.OCCUPANCY "n� ;I5 ,, ,,; ,, i+?'
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
0"„.�) :,.;; r�,M,fi , '-,'",_SECTION 9: PROPERTY OWNER'AUTHORIZATION
Name� dAqdress of Property Owner
Name(Print) No.and Street City/Town Zip
Propgrty Own r Cog tact ormation¢�f
Title Telephone No. (business) Telephone No. (cell) e-mail address
If ap h able,the property owner hereby auth rite
N 0zl� ,
Name Street ACICI City/Town State Zip
to act on the roe owner's behalf,in all matters relatic+c*to work authorized by this building permit application.
)t i a •v SECTION 10 CONSTRUCTION CONTROL(Please fill out Appendix 2)
.t.__. budding is less thin 35,000 cm fG of enclosed s ace and oil not under Construction Control then check here O and ski Section 10.1)t.:::'.
=10.1 Registered Professional Responsible for Construction Control.,'3i,=+Ii�= •€ �1;'te'. :. _..,�:e. ...'.
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
-;10.2 General Contxactoea -�..am,,,,m ,,.eEtE.ff `% ..=...�pp, G„,�:_ _. . _.CF. „I� ,=.M .,z ,fxG," '1�_ ...�.. eif �;�
Com an11 y, d
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Name on ReBponsible for
(s�kuction / Lice No. and Type if Applicable
orccs2 /` . �Q// � �9
Street Address City/Town State Zip
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Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT 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 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 $ a
Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ t0 appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (I-IVAC) $ Note:Minimum fee=$ 7��(contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost 1 $ / (contact municipality)and write chew number here
F�cw,- Y - 'I��r' SECTION ASIGNATURE OF BUILDING PERMIT APPLICANT,; ,.e `_ �,;; ,,,M
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
applicaf'on is true and accurate to th -my 1 ow ndunderstanding.
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Please pr' t and si n e , itie lephone o. ate
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Street Address V City/To n State p
:ri, .,,.._ , '"�" MArIltm �., � M. ry, c�gitn$4r� ev.'.
Mumcrpal Inspector to fill out this section upon apphcation approval °'�
`=Lrs = E ate„ sf s+ $ I��+ i.;1+, cl «,.c °„�{ ,�: _,..Names 0:� i�'.,'�'.�