432 ESSEX ST - BUILDING PERMIT APP (002) r t
� The Commonwealth of Massachusetts
Department of Public Safety
�UP Massachusetts 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)
Building Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for whic V eet _ t flab
No.and Street t4 1 City/Town Zip Code 0n7U Naurj� applica
St SECTION2:.PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Build ng,ja I Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑,' Change of Occupancy ❑ Other Specify: 60 yf•A�
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No A
Is an Independent Structural Engineering Peer Review required? Yes ❑ No jA
�/ tit✓
Brief Description of Proposed Work: �{�/T�{• l� /tr
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 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2 ClH-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ RAX
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 ❑ 11 IIA ❑- f IIB ❑ ILIA O IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Dis osal Site❑
PublicAT Check if outside Flood Zone❑ Indicate municipal❑ e trench will not be P
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \In I Ir,K ri, Cmmr,ssion Re,te.1 r e9s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No;a; Yes❑ No 13
SECTION 8:CONTENT OF CERTIFICATE.OF OCCUPANCY'.
Edition of Codc: Use Group(s): Type of Construction: Occupant Load per Floor:
Does fls building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Ownegt
C� q3L EEW Sole i^ oF1�1
ame(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes Lim
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 building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 13 and skip Section 10.1
11'0�.1 Re isteerled`Pr�ofessional Responsible for Construction.Control
Name(Re istrant) Telep one No. e-mail address Registration Number
Ql o2c}r,., ^Cq dl a /S-
Street Address City own State Zip Discipline E nation Date
10.2 General Contractor
M�
/'1'/1 C![3 �
Company Name
Sty AnL4-sv+ CqL �j"If3iyGr
Name of Person Responsible for Construction License No. and Type if Applicable
P) G _r3oAz_ s&
n � a)/7"L
Street Address Ci /Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
- - SECTION 11:VVORkF.AS'C>AIPF.NSA NON INSURANCE APFIDAWY 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
Estimated Costs:(Labor J
Item and Materials) Total Construction Cost(from Item 6)_$ for
1.Building $ Building Permit Fee=Totil Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee— (contact municipality)
5. Mechanical Other $ Enclose check t able ,
PAY
6.Total Cost $ 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 pain nd penalties of perjury that all of the information contained in this
application is true and accurate to the best of my k le a and and rstanduig.
r dyes
Plaprinl,t amyl�,ij name Title Telephone No. Date
YJt Ya. 4 All Ana- &IcAg,
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date -