1 FLORENCE ST - BUILDING INSPECTION (2) l0
C_r- T 2
` The ommonwealth of Massachusetts
Department of Public Safety
1I➢P/'� 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: Buldin
SECTION 1:LOCATION(Please indicate Block#and Lot#for locatio Ywhich a street address is not
7
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 BUildingV Repair❑ Alteration ❑ I Addition❑ 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? Yes ❑ No
Brief Description of Proposed Work:
Jt
t
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 CNIR 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 Cl A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ I H: High Hazard H-I❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ I4❑ M: Mercantile❑ R: Residential -111 R-2❑ R-3❑ R4 Cl
S: Storage S-1 ❑ S-2❑ U: r tility❑ Sl:^::nal Use and p:casc•iescdbe be w:
-- _ Special Use. C aA- - O SCG
5"top 6:CONS RUCTION TYPE( eck as applica )
[A ❑ [B'❑ IIA ❑ 116 ❑ IIIA C3 IIIB ❑ , IV ❑ 1 VA El VB [I
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) -
Water Supply
Floodnformation: Sewage Disposal:
Trench Permit. Debris Removal:
Public Flood Zone❑ Indicate municipal trench will not beLicensed Disposal Siterequired❑or trench or specify:
,Private❑ ne:` or on site system❑ permit is enclosed❑
Railroad
Appl icable w Is Structure w thin airport appro,ch area? \I�\l llIs their review complet'l r�u•s:
b Y' g
Ia
or Consent to Build enclosed❑ Yes❑ or No Yes❑ Na
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY -
Edition of Code: Use Group(s): Type of Construction: Occupant Loud per Floor: -
Does the building contain an Sprinkler System?: Special Stipulations:
\ T -Tb Plcraeo
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SECTION 9: PROPERTY OWNER AUTHORIZATION `
Name and Addr ,ss of Property Owner t
r\ Y cc,r?e GL l 01 �I
Name( nt) No.and Street City/Town Zip
Property Owner Contact Information:
/.( Title Telephone No. (business) Telephone No. (cell) e-mailaddress
6/ if applicable,the property owner hereby authorizes
Nurse 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 ip2lication.
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 Constmction Control then check here O and skip Section 10.1
10.1 Registered Professional Res onsible for Construction.Control
Name(Registrant) Telephone No e-mail address Registration Number
i
Street Address City/Town State Zip Discipline Expiration Date
2 neral Contractor
Co mipany Name +, ✓ �-- rN� CS0 ';-605- CV
l�
�( Name of P—elon Responsible for Construction License No. and Type if Applicable
�-ir _'5�-, b----
� AL3 o t S
Street Address City/Town / State Zip
`11areala.vci c�Sl�� YS t :. t
Telephone No.(business) Telephone No. cell e-mailaddress
SECTION 11:1V0ItKkk13'C:O(.•IPFNSA'IC M.G.L.c.152.9 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents mu�t'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 Materials) Total Construction Cost(from Item 6)
L Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ _ _ appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipalit )
5. Mechanical Other $ .y
Enclose check payable to '-
6.Total Cost $ OGOr C�` (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
J application is true and accurate to t e best of m knowledge and understanding.
GL,,LC ,V 78=?i37-33F
leaA�anrmTitle TelephoneNo. Date
Stre ( tty/�wn State. 'pl �7 O
CIh Av_
Municipal Inspector to fill out this section upon application approval:
Name Date