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12 1ST ST - BPA-13-487 T-MOBLE REPLACE 6 ANTENNAS . f i � The Commonwealth of Massachusetts i � Deparhnent of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling ('I'his Section For Official Use Only) (�_� uilding Permit Number: Date Applied: Building Official: �� j SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) � I� �i�'S� S��R e-i- S�� I Err � Y�'�Gi, f� � 9 °70 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❑ Alterarion AddiHon❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other Specify: F1nL �Po-� Are building plans and/or construction documents being supplied as part of this permit applicaHon? Yes No ❑ Is an Independent Structural Engineering Peer Review required? I Yes ❑ No � Brief Description of Proposed Work: '� M6�i�L LS �/�-P/�J tf/� t-� Q�' '��4�� o D F j�-}� � i�-t- :�i -e.� �f.'./htq W - "3"" ' .LG- v i'' ..��c• ' !�' "�- (yr ! -� n0 O .C 'L - f L .. :�-frc .h4 • I D t� cp-{-t: � 1� e t �� SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY � Check here if an Existing Building InvesHgaHon and EvaluaHon 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.fr.)and Total Height(fr.) .. 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 Hazazd H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-1❑ 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 7'YPE(Check as applicable) IAO IBD IIAD IIB ❑ IIIAO IIIBD NO VAO VBO � 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❑ Public❑ � Check ff outside Flood Zone❑ Indicate municipal❑ A trench will not be P Private❑ or indenrify Zone: or on site system❑ requ'ued �or trench or specify: P�(zRfL�Q pernut is enclosed❑ s c�-r5 RaiUoad righbof-way: Hazazds to Air NavigaHon: MA Historic Commission Review Process: Not Applicable❑ ,� � Is Structure within airport approach r � Is their review comple . or Consent to Build enclosed ❑ Yes� or No❑ Yes❑ No � SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY EdiHon of Code: Use Group(s): Type of Construcrion: Occupant Load per Floor: �, � Dces the buIlding contain an Sprinkler System?: Special SfipulaHons � ! 1�,�� , �c� �� - �a��' SECTION 9: PROPERTY OWNER AUTHORIZATTON Name and Address of Property Owner ,-7 Pp,�ut�l� II I,imik[d (�fa�4nusk� �r.✓�Pvi I I'IQII M�M�'Pknl/f , FS05IvYlil�G�. Da � 0� Name( rint) No.and Street City/Tow Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes + �i u/�D3iC� IS 4'Of'J�LK �A:Q �cs'TQ�1-�d� .c+��/M /2J-��lD(R¢� o �4C�o �A-�a�.ta-�p -(�' Name StreetAddress City/Town State Zip to act on the ro er owner's behalf,in all matters relative to work authorized b this buildin ermit a lication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If buildin is less than 35,000 ca h.of enclosed s ace and/or not under Constructlon Control then check here O and sM Sectlon 101 10.1 Re istered Professional Res onsible for Consiruction Control h p Q,�� en(��neQnnc � rAu Th� ba� l �- 5�8 _480_ ��I o 0 �i �- ��;' 3�f Zo,6 Name( egistrant) Telephone No. e-mail address Re vstraHon Number d01 -r�n Qns� �I �4QS� S�i�-e �ol nlailbora�h__ 1'��a (�I`7 ��sa ! Street Address City/Town State Zip Discipline ExpiraHon Date . 10.2 General Contractor ,). L�'4 �ssor�akes Co any Name �{=F �nvs� C'S � R91G Name of Person Responsible for Construction License No. and Type if Applicable � 10 UleS(' r�� f2d (Z��zd;r�a .�a b � 8b7 Street Address City/Town State Zip � -�i7��3h �I' -a��a I`]l� �- r��orsc � i�qs.5� c�a,�s.�� Tele hone No. usiness Tele hone No. cell —T— e-mail address SECTION 11:WORKERS'COMPEIVSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6 A Workers'Compensarion Insurance Affidavit from the MA Department of Industrial Aceidents must be completed and submitted with this applicaHon. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a si ned Affidavit sabmitted with this a licaHon? Yes❑ No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ I�V�U i� 1.Building $ Building Permit Fee=Total Construcfion Cost x_(Insert here ' 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality 5.Mechanical Other $ Enclose check payable to � 6.Total Cost $ �� o-Z,l�..��' (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 penalHes of perjury that all of the informaHon contained in this application is true and accurate to the best of my ledge and nderstanding. • �� s�d— ' -��o��L�.� S'� LC� v�-nP P.��-� nn�a c�r�. s'i�- _�3`_��_— Please print and sign name Title ne No. Date � s� F�✓u��-- st-�-f� „vi a-rz..ib�n��cYs�- Street Address � ��-�6 1 �� City/Town State ip Municipal InspeMor to fill out this section upon application approval: � - Name Date , � ; • T • •Mobile• r-uom�Natn�ensz u.c 15 CWINFRCE WAY,SUIIE B NtltTON,MA 027fi6 OFACF: (50B)YB6-27W . / �CHqpPELL P EQ U 0T H I G H LAN D S 4 �ENOWEERING ,��--ASSOGIATES.LLG R.K IXECUI�vE CINIRE 201 BOSrON POSf ftOaD WESr w� im wwieoxoucN. 'u oiisz . � (soa)+ei-»oo �wr.c�ap�llan9�n9.mm �,ZH OF ,Q�� DAVI . 12 FIRST STREET � SALEM, MA 01970 • � " � - , c�stER�°��.� ' �ONAL EN�' , STE NO . : 4BN � 070A PPPROVALS . � BUIIDING ONNQt ' SITE TYPE: MODERNIZATION UPGRADE �9NG R.F. �1 ZONINC � CONS7RUCPON GENERAL NOTES VICINITY MAP: .�p 1"=1000' SHEET INDEX PROJECT SUMMARY "� i. �conxinm suu r�.i.u�xoins uo axar em ru ia �m�mrnm a asa�[rm rwaxc iu�rmsm �� = � �, � ��-1�"( `F�A . . ��,,��ff ��iqh�x�y��µ� �. r c, p� 5lR. PRO,ECT N6. 4BN0070A utt n�x xmuarc Mrs�w xa unm omm /u uus xm maofs�s.auo m mismun�u oixavoirs f/ �• �"'� � � e `,`. ` "�� ' N0. DESCRIPTION y�_ SifE NUMBER: 4BNOO70A �¢sranoxs,�w iorx uo su�c umnaxa aacs s sa�x�wa J� /.,'�, -. 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