12 1ST ST - BPA-14-1630 NEW BOILER 291 so
The Commonwealth qfi
%KICES
Department of Public Safety
Massachusetts State Buildinge67ET?R)
Building Permit Application for any Building oth a 04 o v 10aily Dwelling
(This.Section For Official Use Only)
.Building Permit Number: ! Date Applied: '`' "" Building Official.
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.: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 Building Repair❑ Alteration 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 ❑ /
Is an Independent Structural Engineering Peer Review required? s No NI-
Brief scri tion of Propose Work: i J�RVGT /���
SECTION 3 COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE.IN USE - e `:
. .� .,
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 a
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❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-111 R-2 R-3❑ R-4❑
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 HB ❑ IIIA ❑ IIIB ❑ IV ❑ 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 Zoned Indicate municipa
A trench ill not be Licensed Disposal Sit
Private❑ or indentify Zone: or on site system❑ require or trench or specify:
permit is enclosed❑
Railroad right-of-w y: Hazards to Air Navigation: MA Historic Commission.Review Process:
Not ApplicablVe Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or N0% 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:
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• SECTION 9: I'IIOPEIY(Y OWNER AUTIIORIZA'EION
Name and Address of Property Owner
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Name(Print) , No.and Street City/Town Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes p
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Name Street Address City/Town State Zip
t0 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 O and skip Section 10.1
ll).1 Registered Professional Responsible for Construction Control
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N e(R J;istr 4M �Tcleph ,el C e-mail adr� Ar Q /� Re str� ^ _ dumber
M T S 4J1�7 Ci S I��L 2 (`-•c-(•f.
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Company Nam, .
1'�ILL Noun,
GS - O�IR � S�S
Name of'P'}ar's"on�1 es �]f�sible for Constrtrufm License No. and Type if Applicable
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Street Address City/Town State Zip L
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Telephone No. business Telephone No. cell a-mail address
SECTION 11:WORKFRS'COMFFNSA I ION INSURANCE.AH IUAVI I M.G.L.c.152.§25C6
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 Q
and Materials) 'rural Construction Cost(from Item 6)=$ 2
1. Building S 00 0 Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical $ /sv appropriate municipal factor)=S P.06/100
3. Plumbing S
4. Mechanical (HVAC) $ ^- Notr. �lininuun fee=$ZQ 1' (contact municipality)
5. Mechanical Other S —
Enclose check payable to
6.Total Cost S QQ I (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereby attest carder pains and penalties of perjury that all of the information contained in this
application is trues and accurate to the best of , ovledge and understanding.
n
1,11-L ( L fJrz 7-$1-63o- -;eo3 /0-1 - 4
Please print and sign name Title I phone No. Date
3Uao t yelfPoP� pk\t� �14iU'r0atJ / OZ021
Street Address City/Town State Zip
It
Municipal Inspector to fill out this section upon application approval: �'t� �d l
Name Datc
SECTION9:-PROPERTY OWNER AUTHORIZATION
f Name and Address of Property Owner
!1L/N1O?� S
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Ti Telephone No.(business) Telephone No. (cell) e-mail address
a a e, roperty owner hereby authorizes
e Street Address City/Town State Zip
act on the roe owner's behalf,in all matters relative to work authorized b this buildingpermit application.
SECTION 10 CONSTRUCTION CONTROL(Please fill out Appendix 2)
Y f c
' Ofbuilding' is less than 35,000 cu.k.of encloseds ace and/ornot under Construction.Control then check here and ski SecHon.10.1
10.1Re stered Professional Responsible for Construction Control
Name(Registra ) Telephone No. e-mail ddress Re n umber
WGeeral
City/Town State Zip Discipline Expiration Date
tractor •,r
MCompany Namee/"�-y��/�/
Mw /r �^
Name of,_ PeRes�op.ibletar CggsIiyctjon/� License No. and Type if Applicable
AI �f4� �Z
St;eet A dress - City/Town State Zip
Telephone No.(business) Telephone No.(cellf e-mail address
SECTION 11:WORKERS'=COMPENSATION INSUILANCE AFFIDAVIT .G.L.C:152:§2SC(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 O No 0
"' ='t' s; t SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE `"r
�. . 4-
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)
1.Building $.2,SpO Q
Building Permit Fee=Total Construction Cost x (insert here
2.Electrical $ appropriate municipal factor)_$ '
3.Plumbing $ i O� 6O
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $
/ Enclose check payable to
6.Total Cost $ �`j� (contact municipality)and write check number here
fj..: w SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT-
.........-'`
By entering my name below,I hereby todwlidg
and penalfies of perjury that all of the information contained in this
application is true and accurate to th tand understanding. 9�.
01 �
Please print and sign name T1 e Telephone No. Date
Street Address City/Town State Zip
MnnicipalInspector to fill out this section upon application approval ` } .�:, # a "'ilF
'= .. Date Name ;,' a.t