2 HART - BUILDING INSPECTION loll
The Commonwealth of Massac iusetts
1 Department of Public Safety
%lassac 1� JUN 25 P le. 24
l./ huscusStateBuilding Code 780C�
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 Black k and Lot H fur locations for which a street address is not available)
No.and Street City frown Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If Nov Construction check here❑or check all that apply in tlae 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/ur construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review rei tired? Yes Cl No ❑
Brief Description of Proposed Work: ..-.O vG .fit-1% e-C er /aP
r r �cc
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANCE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Ex Lsting Use Group(s): Proposed Use Gruup(s):
SECTION d:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(sq, ft.)
"total Area(sq. ft)and Total Fleight(ft.)
SECTION 5:USE CROUP(Check as a licable)
A: Assembly A-t ❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ TE: Educational ❑
F: Facto F-1 ❑ •F2❑ If: High [lizard H-1❑ H-2❑ ,1 1-1 ❑ 11-4❑ 11-5 El
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ iM: Mercantile❑ R: Residential R-1 R-2❑ R-3❑ R4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use.
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA Ill IL\ ❑ fill I1IA0 IIIB ❑ IV ❑ 1 VA Cl VB ❑
SECTION 7:SITE INFORMATION(refer to 750 CMR 111.0 for details on each item) .
Water Supply: Mond"Lone Information: 'ewage Disposal:
Trench Permit: Debris Removal:
Public Check if outside FIoaJ "Lone Indicate municipal
r\trench wit n be Licensed Disposal Site
required or trench or specify:
Private❑ or inrlcnti(y'Lune: or on site system❑ permit is enclosed❑
Railroad right-of-way: llatards to Air Navigation: �I,\I li.p�ri;l�nupii.,i�m R;.h,. I'n..k
Not Applicable Is Structure within airport approa� irea? Is their review completed
/?
or Consent to Build enclosed ❑ Yes❑ or No Yes❑ No ❑ �y
SECTION 3:CONTENT OF CL'RTmCA"IE OF OCCUPANCY
Ir.dition of Code: Use Group(s): ,._:.� r t "I'ype of Construction: OCCupant Load per Hoor:
Does the building con Lain an Sprinkler tiystcIW: .._--Spec ial tilipuLdions: _._"—
SECTION 9: I'ItOVERT'Y OVVNEI1 AU'1'IfORize%,LION
Name and Address of Property Owner - 1
Name(Print) No.and Street City/Town Zip
Property Owner Contacts Information: -7p
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Title Telephone No. (business) Telephone No. (cell) e-mail addrests
H aapplicable,the prop'eerty owner hereby authorizes vl.�
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authurind by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) '
If building is less than 35,000 cu.ft.of encloseds aceanJ or tint under Construction Control then check here 13andskip Section 10.1
10.1 Registeredd Pro essitanal Responsible for Construction Control
Name egistrant) Telephone No. e-mail address Registration Number
reet Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Ew) v ! o5'0 Hod<o ✓ LG L
Company NNa,me �
si
Name of Person Responsible for Cr}nstruction License No. and Type if Applicable
!9 /cr i/ey 'ed -5.;, /r4 0 /f yo
Street Address City/Town State Zip
Zskro ZG39 fv -C /—Cr+.ry e! yr is/rT .
'rule hone No. business Telephone No. cell e-mail address
SECTION 11:wc.n:KVKS'COMPI,NSAI[ON bNSM1 \N(. FAHIPAVll' 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 a lication? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Iota!Construction Cost(from Item 6)
I. Building S ,?)Ito
Building Permit Fee=Total Construction Cost s Y—(Insert here
2. Electrical 5 appropriate municipal factor)=S o•
3, plumbing 5
1. Mechanical (IIVAC) Note:Miuiuuna fee=5 (contact municipality)
5. Mechanical Other S Gndose check m able to p,y,
6.Tutai Cost S y98` z z o.'• (contact nuumicipalily)and write check number here /O/7
SECTION 0: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 amtminal in this
Application is true and accurate to the best ny knowledge and understanding.
TrS. z,4- -,,y S� 9797-MV 263k s, Y
t'IIcf primed sign naut? _/ 'title Telephone No. Date
.ii< X �M tii� of 9 yo
.Street Address City/Town State ^ Zip
Municipal Inspector ht fill out this section upon application approval: _ t2l'1�+� m% —��6��p�/y1=�'f�%��;—
Name D,tte