45 FEDERAL ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
o Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than aOne- r Two mily'Dwel 'n
(This;Section For.Official-Use.Only)k "' -= �
Building Permit Number ' Date.AppGed ; '' :"'Builduig Ofhci�i
SECTION 1:LOCATION.(Please;indicate Block#and Lot-.#for locations for wtu AaLre Znv&Q'
-
Lfs FPder•Ql 's� sa\em
No.and Street City/Town - Zip Code Name of Building(if applicable)
Y ,.u:€. . . ,; • , ,,;`• .•:.:SECTION 2:PROPOSED.WORK"
.-
Edition of MA State Code used If New Construction check here❑or ch ck all that apply in the two rows below
Existing Building❑ Repair Alteration ❑ 1 Addition❑ 1 Demolition (Please fill out and submit Appendix 1)
Change c I Other ❑ Specify:
Are building 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 ❑
Brief Description of Proposed Work: 2 s�U :cS O �:ca �(�
Gwr.4\\ Vo- ceyo.:C' � iakA Demo �o 5ee ccN tao.\ls�
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(See780 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 Cl— A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2 El 1-3❑ I-4❑ M.
Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4 Cl
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 ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ - IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR111.0 fordetails on each item)"•,;'. <
Water Suppi Flood Zone Information: Sewage Disposal: Trench Permit: FLicensed
bris Removal:
Public L9 Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Disposal Site❑
Private❑ or indentify Zone: or on'site system❑ required❑ or trenchfy:
permit is enclosed❑
Railroad right-of-wa Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable I Is Structure within airport ap ach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No Yes❑ No ❑
SECTIONS:-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 Address of Pr ope �,)er,
wu� Fedeco \ s� S�\ew1
Name(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
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'fi]Lopt Appendix2) '
If buildin �s less than 35,000`cu.ft.of enclosed s aob6and/or riot under Construction Control then cheek'herelE1'a"nd ski Secuon 10.1 - 1
-:101 Registered ProFessional'Res'"onsible focConstru'e(ion Contcol ': .
- Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General:Contractore, ....,...
Cross CO t'l Company Name /� CS "' to\`a cZ � \l\`6 1,5
1��Cho cc` w CcosS l-1\P
Name of Person Responsible for Construction License No. and Type if Applicable
Ocv\ve lCt,D3
Street Address City/Town State Zip
( y-ll == Cv�3Coc\6NOCA V_C-tmc.: Cor'
Telephone No. business Telephone No. cell e-mail address
SECTION_11_.WORFEI S'COMPENS.kT[ON PISUPANCE PPit7Ab'rl' 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::`CO,NSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ a 6O ' Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (1-IVAC) $ Note:Minimum fee=$ (contact municipality)
$5.Mechanical Other /7� ,
Enclose check payable to / '�� SO
6.Total Cost $ �rj O O .60 (contact municipality)and writ�hec nu her 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
ap-plliication(is true and accurate to the best of my knowledge and understanding. 1
CcoSS GWrec
Please print and sign name Title Telephone No. Date
� � 2 L= l\ o is �o.u�v e C 1, C\ G L`\D-3
Str t e City/Town State Zip
Lfi
Municipal Inspector'to fill out this section upon application approval -
Nard '> "'' Date s