364 ESSEX ST - BUILDING PERMIT APP The Commonwealth of Massac use 5 L SERVICES
n Department of Public Safety
+ �yU ;• Massachusetts State Building Code(780CMtV14 FE8.20 A a 2b ;
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official UseOnly). '
Building Permit Number: Date Applied: Building Official:.
SECTION 1:LOCATION(Please indicate Block k and Lot H for locations for which-a street address is not available)
4'Gy ES5e� Sc.Aern
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Cod-• tsed_ If New Construction check here❑or check all that apply in the two rows below
Existing Building<
Repair GVTAlteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 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 ®-�
Is an Independent Structural Engineen.nA Peer Review required? L Yes ❑ No EP-'
-Brief Description of Proposed Work:
Ce)bs0 C COO' in �('OC1T
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): I I 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 ❑ Alf❑ A-5❑ 1 B: Business ❑ E: Educational ❑ .
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ I-3❑. 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ 111% 13 1180 IIIA ❑ HIB ❑ I 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: MA_I,iisL rn C...
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes Cl or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an-Sprinkler System?:__Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and ALI -es."sfo Pro erty Owu cr
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Name(Print) �� ��pp No.and Street City/Town Zip
Propeit�0;011eP�Conta AM"!
tact I"ri@b�r!i�ilo�n:
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name 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)
If buildingis less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here O and ski Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Q',cLe r6 r -o9j 4 fi 4of,_ 1*-41
Name Re istrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline - Expiration Date
10.2 General Contractor -
LcoSs
Company Name
a.1:hA(^d cro67) Ls-
Name of Person Responsible 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:WORKFRS'COPiPI.-.NSA I[ON INSUR: NCF AfF'IDAW1' 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 klaterials) Total Construction Cost(from Item 6)_
1. Building $ IIo0o •bb
Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
1. Mechanical (HVAC) $ Note:N-lininmm fee=$ /(pn/nt :Fumunici—
S. Mechanical Other $ Enclose check payable to
6.Total Cost $ P Y
(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 best of my knowledge and understanding.
Please print and sign name - Title Telephone No. Date
Street Address City/Town 1 3tattee Zip -
ibfunicipal Inspector to fill out this section upon application approval: ''�""�✓ �" / ��
Name V Date