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5D HALSEY - BUILDING INSPECTION The Commonwealth of Massac Tusetts Department of Public Safety JUN 25 P 1= 24 �t Massachusetts State Building Code(730 C���� ��� Building Permit Application for any Building other than a One-or Two-Family Dwelling (This Section For Official Use Only) Building Permit Nuntbec Date Applied: Building Official: SECTION 1: LOCATION(Please indicate Block N and Lot!i for locations for which a street address is not available) k AL5t�-U No.and Street City/Town "lip Code Name of Building(if ap licable) SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check lure O or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ 1 Demolition O (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and'or construction docmnents being supplied os part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review rei tired? Yes ❑ No ❑ ,Brief Description of Proposed Work: Rt 0-e- �{ /trG c �A/P SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,Olt 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 d: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 CROUP(Check as, licable) A: Assembly A-t❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ AS❑ B: Business ❑ E: Educational ❑ F: Facto F-t ❑ F2❑ 11., Fli gh Hazard H-t❑ F[-2 O N-3 ❑ F[--I❑ 1-1-5❑ h Institutional [-1 ❑ 1-2❑ 1-3❑ l--I❑ NI: Mercantile❑ It: Residential R-1 R-2❑ R-3❑ R ❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below: Special Use. SECTION 6:CONSTRUCTION TYPE(Check as applicable) ilk 0 [BE3 I Ilk ❑ IIB ❑ I IIIA ❑ 111110 rly ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 790 CNIR 111.0 for details on each item) Water Supply: F 'Flood Zone Information: ewage Disposal: 'Trench Permit: Debris Removal: " Public Check if outside Flood Lune e Indicate aumicipal r\Iench will tt be Licensed Disposal Site required or trench or specify:. Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: I Iazards to Air Nav igation: \L�_I�ntygy.Cgiup.nylnn_g�.p i, Not Applicable ' Is Structure within airport 1pproa' irea? Is their review completotV or Consent to Build cndusnl❑ Yes❑ or No Yes❑ No ❑ SECTION S:CON"I-ENT OF cuunFICA'IT OF OCCUPANCY Edition of Code: U\c Gnmp(s): _ Type of Cl MINI MC l inn: Occupant Load per Hoor Itues the building conLiin.m tipriuklcr tiystcm': ___—Special 5l i pit tat ions: SECTION 9: 1'ROI'Elt'I'Y OVVNI?R ,%U"I'IIORIZA"['ION Mune and Address of Property Owner - B'e4-l"-f4l f?"/f' Goivyos � 1 Name(print) No.xnd Street City/Town Zip Property OwnerContactt Informatioir p� Ajyr�.(r w /�io/+��'�f /Try.-•r �2 7Y VeS- 1 pa f�s$ RD7 '✓ Title Telephone No.(business) Telephone No. (cell) a-mail addres's Ifa-pplicable the property �owner hereby authorizes N1 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 35,00)cu.ft.of enclosed space and/or not under Cottstmction Control then check here❑and skip Section 10.1 10.1 Registered Pro essional Responsible for Construction Control Name cgistront) relephoum No. e-mail address Registration Number reet Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name �] ) 1-t —5-- 1--An, /rY Name of Person Responsible for Gpistruction License No. and Type if Applicable !9 S.0111 ,y 1"4 u'/s yo Street MO /3,?— Telephone City/Town State Zip Zgh M GV No. business Telephone No. cell e-mail address SECTION 11:1\'iJI:Fb:KS'Cl1M1IP1;Nti,\1ION INSIAI \N(T,:V9'Iln,Wrl M.G.L.c.152.9 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 (tent Estimated Costs: (Labor and Materials) TotalConstruction Cost(from Item 6) 1. Building $ ,?,? building Permit Fee=Total Construction Cost x&—(Insert here 3. Electrical $ appropriate municipal factor)=S .Y.78' o 3. Plumbing, 5 t. Mechanical (I-IVAC) 5 Note: Minimum fee=S (contact municipality) 3. Mcchauical Other $ Enclose check n able hn NY 6.Total Cost s y98; z to,'� (contact municipality)and write check number here SECTION 13:SIGNATURE OF 13UILDING 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 application is true and accurate to the best, ny knowledge and understanding. _,3A;' e r/—5 z!'-,,y o s /f>s•�eL 7-- 97�-F&P. 26)r k 6 IT, y I'luue print and sign name / Title Telephune No. Date /9 '-f, r r S'.0 -X Sl reef Address City/Town State Zip \lunicipal Inspector to fill out this section upon application approval: bi 't'✓ Name Date I 2- -- I B- i y - 1 ) 10 ECEM, �ARVI . The Commonwealth of Nlassac lusetts Department of Public Safety iN� JUN 25 P I: 24 \iass,ichtiscits State Building Code(7S0 C,4 Building Permit Application for any Building other than a One-or-rrvo-Fainily Dwelling (This Section For Official UseOnl ) Building Permit Number. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block N and Lot N for locations for which a street address is not available) 1 14 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of Mr\State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out nod submit Appendix l) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: r\re building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review rer}�fired? Yes ❑ No ❑ Brief Description of Proposed Work: RJr� .�-.o.e f�1�.,r�!G ��!P 0. .,./ aT SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,Olt CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): I Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No,of Floors/Stories(include basement levels)&Area Per Fluor(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-t ❑ F2 Cl If: High flazard 11-1❑ F42❑ : H-3 ❑ 1-1-4ClH-5❑ 1: Institutional 1-1❑ I-2❑ 1-3❑ I-4❑ M: Mercantile❑ li: 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 TYPE(Check as a licable) IA IB ❑ IL\ ❑ IIli ❑ 1 IIL\ ❑ IIIB ❑ rIV ❑ I VA VBO SECTION 7:SITE INFORMATION(refer to 780 CNtR 111.0 for details on each item) Water Supply: Flood Information: 'ewage Disposal: 'Trench Pernit: Debris Removal: Public Check if outside Flood-Zone Indicate municipal .\trench wit n be 1-icensed Disposal Site required or trench or specify: Private❑ or indentify Zone or on site system❑ permit is enclosed❑ Railroad right-of-w.ay;/ I Lizards to Air Navigation: \I._�Il"I"",.�;...... Not Applicable-PI - Is Structure within airport apprn,t vea? Is their review completed?/ or Consent to Build enclosed❑ Yes❑ or No I Yes Cl No ❑ /y . SECTION B:CONTENT OF C'ERTIFICA'IT OF OCCUPANCY I dition of Code: Use Grnnip(s).__--_ Type of Construction: OCCnpaut Load per Ignor Dov's the building conl.titian Sprinkler System?: .._.—.__Special Stipulations: SECTION 9: PROI'EITTY OWNER AUTIiORIZA'1'ION Name,md Address of Property Owner ` f?..f' Name(Print) No. and Street Cily/Tonv❑ Zip Property Owner Contact Information: /�iNY��l.� �/a/'�T' !s /r��''r - �/�-- 7i� ��.5/ .J Pat'i's5�AaT F',✓ ...� Title Telephone No.(business) 'telephone No. (cell) a-nsnil address If applicable, the property powner hereby authorizes Nance Street Address City/Town State Zip to act on the property,owner's behalf, in all natters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (If building is less than 35,0(Al cu.ft.of enclosed space anJ or not under Constmction Control then check here❑and skip Section 10.1 10.1 Registered Pro esslonal Responsible for Construction Control Name egistrant) Telephone No. e-mail address Registration Number reet Address City/Town State Zip Discipline Expiration Dale 10.2 General Contractor �k-,,-r � CoNS��,,,c�io-✓ L,L, C Company NN-ame — /' Name of Person Responsible for Cunstructiun License No. and Type if Applicable /9 !rr //ey �eC IW4 0'/9 yo Street Address City/Town State Zip 81ro 2,63S S>--c /j„c•r,rry��y..v�sT i5/rT . 'fele hone No. business Telephone No. cell a-mail address SECTION Ill WORKHa,'COMu'LNSA I10N INSURANCH AFH tAyl r 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 Cl SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor p- .v and Materials) TnLil construction cost(from Item fi)=$ S/90a 2L0, I. Building 5 87,2,0,. 's Building Permit Fee=Total Cunstructiun Cost s Y (Insert bore 2. Electrical S appropriate municipal factor)=5 3. Plumbing, S 1. ,Mechanical (FIVAC) $ Note: Minimum fee=S (contact municipality) 5. Mcchanical Other S Enclose check payable to b.Tolal Cost s y98' z z o." (contact municip:li )and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT fly entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this ,application is true and accurate to the best ny knowledge and understanding,. p [� 91� c /7TS Z_:--e.y SG�y/ /fr/r'�T' /_/O pyp--OHO 26.7,? zs T Please9 prit�n /, y nn� / ��/ Title Telephone No. Date Street Address City/Town tate Zip i Municipal Inspector to fill cut this section upon.application approval: Nance Uatc � 6g /oil . I(J' '1 Lf— l l l 3 RECEiVEO The Commonwealth of Nlassac tusetts 1 Department of Public Safety "mm11 %lassachuseIts State Build in Code 780Ajh JUN ZS P (: 24 Building Permit Application for any Building other than a One-or Two-Family Dwelling. (This Section For Official Use Only) Building Permit Number. DateApplied: Building Official: SECTION 1:LOCATION(Please indicate Block Nand Lot N for locations for which a street address is not available) ! ' H Dez 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❑ Demolition ❑ (Please fill out and submit Appendix I) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or cunstn¢tim)doaunents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review rur tired? Yes ❑ No ❑ •Brief Description of Proposed Work: Ae! QuG Mne'G G /AP L3�o.-.,� S' w�'-tea 47- � lot SECTION 3:CONIFLETE 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 CDdR 34) ❑ Existing Use Gruup(s): Proposed Use Gruu p(s): SECTION d:BUILDING HEIGHT AND AREA Existing Proposed No.of Flours/Stories(include basement levels)&Area Per Fluor(sq. ft.) Total Area(sq.ft.)tuul Total Height(ft.) SECTION 5:USE GROUP(Check as a plfcable) A: Assembly A-1 ❑ A-2 ElNightclub ❑ A-3 ❑ A4❑ A-3 O B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ I 11: Ili gh[lizard H-1 ❑ F1-2❑ H-3 ❑ FI--1❑ H-3 Cl 1: Institutional I-1 El ❑ 1-3❑ 1-4 Cl ht: Mercantile❑ R: Residential R-t R-2❑ R-3❑ R-1❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE.(Check as applicable) IA ❑ 111 ❑ [ilk Cl IIB ❑ ❑IA ❑ 111B ❑ ly ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Mond"Lone Information: 'ewage Disposal: Trench permit: Debris Removal: Public Check if outside Flood 'Lune Indicate municipal A trench will >t be Licensed Disposal Site required or trench or specify: Private❑ or indentify tune: or on silo system❑ permit is enclosed❑ Railroad right-of-way: ILizards to Air Navigation: �I��I li t r �'ongg� i Not:\ppliiable( Is StuCtnre•wtthlit alrpUrt apprna' Ired? Is their review Completed? or CU16ent h)Build cndoscal ❑ Yes❑ or No f� Yes❑ No ❑ /y SECITON 8:CON"ITN'r OF CERTIFICATE OF OCCUPANCY I ditinn of Code: .___— Uec Croup(i): ..__ Type of Construction: Occupant Load per hour ____.__-___ Uors the built inl;inn tein on Sprinkler System): .. __Spei sal Stipulations: SECTION 9: i,ROPER'CY 06VNI'.It AU'CEfORIZA'1'ION Nome and Address of Property Owner ,P•'c�S.-�-�y �?.� �D�vyos l�/�l,rl , �!/Q e/974 Name(Print) No.nod Street City/Town Zip Properly Owner Contact Information: / , /eMr,,lr.v /�in!/,//e-f 7Y �OSy ) paf�as�ADT f ✓. •. l'itle Telephone No.(business) Telephone No. (cell) a-mail address If aapplicable,the prop�eertyp oo�wner hereby authorizes 1/1 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 35,0W cu.ft.of enclosed s ace.od or not under Constmctiun Control then check here❑and ski Section 10.1 10.1 Registered Professional Responsible for Construction Control 'Na une cgistrant) Telephone No. eanail address Registration Number reet Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Ear/' � �O.✓,f�rHGT /O w/ �L., C Company 7N/u�n—te -7/7C / -7 . 3 yy Name of Person Responsible for Ci}nstruction License No. and Type if Applicable i/ S.�l n u�i s 7o ey 4' 1"4 Street Address City/Town State Zip 'rete (tone No. business Telephone No. cell e-mail address SECTION 11: INSURAVF AH WAVIV M.G.L.c.152.§Z5C 6 A Workers'Compensation Insurance Affidavit from the YIA 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 a licatiun? Yes Cl No ❑ SECTION 12:CONSTRUCTION COSTS AND PERNIIT FEE IteU Estimated Costs:(Labor and Materials)serials) Cc L 1 Construction tnndiun Cost(from Item 6)=$ I. Building S 419 8,v-6 Building Permit Fee-Total Construction Cost x!L-(Insert hem 2. Electrical $ appropriate municipal factor)=S o• a. Plunnbing S - 1, ,Mechanical (FIVAC) l$ Note: Mininunn fee=S (Contact municipality) 5. Mechanical Other $ Enclose check payable to Y� 6.Tohl Cost $ 41?'r, z Z D.�� (contact municipality)and write check number here /d/7 SECTION 13:SIGNATURE OF BUILDING PERIMIT APPLICANT By entering my name below, I hereby attest Under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best ny knowledge and understanding. ��n� r/-S. F_-�r,y .S� �.s•�1 T- 9.7�.��o zG J�ems, Y Please print and sign name / "ride Telephone No. Date Street Address City/Town State Zip i Municipal luspector to fill out this section upon application approval: Name Date -T6 - lq-illLka�ivEo The Commonwealth of Massac lusetts Department Public Safety . JUN 25 P 12y \lassuchusetts State Buiui lding Cude(780 Ca Building Permit Application for any,Building other than a One-or Two-Fatnily DwellIng. ::> (This Section For Official Use Duty) Building Permit Number: Dane Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) 4 F LE rCA 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 Buildingp Repair❑ Alteration ❑ -Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix l) 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 r�¢r1/tirreed? Yes ❑ No ❑ Brief D/escription �of Proposed Work: Re- O uG 7/SGPµ/CC -f AAis ^7- CO7/��IY 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) ❑ - ri Existing Use Gruup(s): - Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing ['reposed 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-t ❑ F2❑ It: High Hazard H-1❑ He2❑ r H-3 ❑ 1I-4❑ H-5 CI 1: Institutional M ❑ 1-2❑ 1-3❑ 1-4❑ NI: 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:CONSTRUCCION'IYPE(Check as a licable) IA IIS ❑ HA IfB ❑ IIIA ❑ IIIB ❑ - lIV ❑ 1 VA VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: iewage Disposal: 'french Permit: Debris Removal: Public Check if outside Flood Zone e htdicate municipal oe A trench willl Abe Licensed Disposal Site Private❑ . or indeutify Ztine: or On site system❑ required 1 '5r1 permit is.enclosed❑ - - Railroad right-of-way: Hazards to Air Navigation: MA IJ i t r1('numi v n I s i, Not Applicable Pl "Is Structure within airport approa' vea? Is their review completetIA/' or Consent to Build enCIOsed❑ 1 Yes❑ or No( Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition Of Code use Group(s): \. . Type of Construction: Occupant Load per Floor: a Does the building Contain an Sprinkler System?: __ Special Stipulations:— __ SECTION 9: PROPEttTY OrVNEIt i%UTFIORIZA'rION Name and Addrss tiV[j%.p�fty Owner tP'C%C.%+"��'g% J2 %('3:G'o,��yDos Name(Print) No.and Street City/Town Zip Properly Owner Co taccttQfnfoorn_iafigiL A/l�Yr.lr.w/'/a/�.��'' rs /zrr'+r _ //�--//.1 ��S/ ✓ fGc�TAS�AO/ I• ,✓ ..n 'rill, Telephone No.(business) Telephone No. (cell) a-mail addres 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 fill out Appendix 2) !f building is less than 35,000 cu.It.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1 10.1 Registered Profess' of Responsible for Construction Control Nam, egistrant) 'telephone No. e-mail address Registration Number reet Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name 77- Name of Person Responsible for Construction License No. and Type if Applicable /9 kr Iley ew .S.plAl !W4 6Pi9 yo Street Address City/Town/ State Zip `1i 7 y 0 p 1A"r D� e,*"er-Jr�Cp..v.,s> i5/rT Telephone No. business Telephone No. cell e-mail address SECTION 11:tWJ,'KH6'COmu'GNSA I ION INSUI:: NCI:At HOAVI I 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 Item Estimated Costs:(Labor and Materials) Total Z Construction Cos[(from Item 6)_$ r9 ZO, 1. Building S 8-ZZO• '• Building Permit Fee-Total Construction Cost x!L—(Insert Isere 2. Electrical S appropriate municipal factor) 7An 3. Plumbing $ 1. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) :i. Mechanical Other $ Enclose check a able to payable 6.Total Cost $ y98`z Z o." (contact municipality)and write check number her, /O/7 SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this applicatt�ion is true and accurate to the best� iy'knowledge and understanding. Pl of prir uud sign name / I ��� 'rifle Telephone No. Date i/r ,( .,, />7� of 9 yo Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: -'y'+'✓J / Name Date J t I u — t 112- Z-/, f R GE�VEO PE" f9N•• 'Ef cRVIC-fc, — The Commonwealth of Nlassac tusetts Department of Public Safety m� SUN 25 P I� 2y Massachusetts State Budding Code(780 C�iX 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 ff and Lot N for locations for which a street address is not available) ?2 U D1r21 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❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Arc building plans and/or cunstructiun docunhenls being supplied,u part of this permit application? Yes ❑ No Cl Is an Independent Structural Engineering Peer Review rch tired? Yes ❑ No ❑ Brief Description of Proposed Work: Ae�oriG G zow /3—//D. .,.1 S 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 CkIR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Fluor(sq. ft.) Total Area(sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check asa licable) A: Assembly A-I ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F2❑ If: High hazard H-I❑ Ff=2❑ -. H-3 ❑ H-d Cl H-5❑ 1: Institutional I-1 ❑ 1-2❑ 1-3❑ f-d❑ 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 G:CONSTRUCTION'INI'E(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA Cl IIIB ❑ ly ❑ VA Cl VB Cl SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) LVater Supply: Eland"Lone Information: 'ewage Disposal: 'Trench Permit: Debris Removal: Public Check if outside Flood Zone Indicate oleo. , aI A trench willt be Licensed Disposal Site CK required or trench or specify: Private❑ or imlcnlify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Ilazards to Air Navigation: %I,\.I Ip(,q�..},,,,pn�w.j�,q� L.ww I'..•._..: Not Applicable Is Slnhcture within airport approa' hrca? Istheir review completed? or Consent to Build enclosed❑ Yes❑ or No 2?'� Yes❑ No ❑ /y SECTION S:CONTENT OF CL'RTIFICATE OF OCCUPANCY Edition Of C{thle: ___Use Graup(s):. I)I)('Of Construction: _____ Occupant Load per hour Mies the building;coolam an Sprinkler S1'stctli? _—Special Stipulations: .__—._— SECTION 9: I'IIOPEIri'Y 04VNIiR,U17'110RIZA'TION Nana and Address of Property Owner ,Pte4-1"-ml t?ne Go/yyoS �jle.*t , �"0 D/97o Name(Print) No.and Street City/Town Zip Property Owner Contact Information: L �j/LtY��IMw /�/o/f''7' if /���''� - 7/L'_•- 7/ Ids/ J Pa t'i'AS�AaT r ••n Title Telephone No. (business) Telephone No. (cell) e-mail addres4 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 fill out Appendix 2) If building is less than 35,000 cu.R.of enclosed space and/or not under Construction Control then check here O and Hkip Section 10.1 10.1 Rc istered Profess' nal Responsible for Construction Control Name egislrant) Telephone No. e-mail address Registration Number met Address City/'Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name L alp e- 7/ --5'. Name of Person Responsible for Cc nstruction License No. and Type if Applicable !9 /rr //ev ee[ s.91 r? IW v/f ya Street Address City/Town State Zip LB: �� ZG38 f',._.c /S_Cr,.ry�la.H,,,s> N:•T . 'role hone No. business Telephone No. cell e-mail address SECTION 11:WOkk1'It5'COMPFNSAI'K IN INSUUAM F A IPA\ I r 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 0 No ❑ SECTION 12:CONSTRUMON COSTS AND PERMIT FEE Item Estimated Costs:(Labor w and Materials) Total Construction Cost(from Item 6)=$ZM ZLO, 1. Building .S 91ao, 00 Building Permit Fee-Total Construction Cost x!L—(Insert heft 2. Electrical S appropriate municipal factor) 78 =5 0 � i. Plumbing $ 1. Mcchnnical (11VAC) $ Note: %lininaum fee=5 (contact municipality) 5. Mechanical Other "+ Enclose check payable to e. rotal Cost 1 5 41q8` Z Z L) (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PER1,I1T APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information Contained in this ,application is true and accurate to the best e my knowledge and understo nd ing. rr-s /` ,e A - �,s•�4, 979--M40 Z6 J B 6S• y Please print and sign name / "ritle Telephone No. Date Street Address City/Tow❑ State Zip Municipal Inspector to fill out this section upon application approval: ;.7 Name Dale