116 HIGHLAND AVE - BUILDING INSPECTION (2) k
I * � The Commonwealth of Massachusetts
U/ Department of Public Safety
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: Building Official:'
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1l� .n�`G^ Ale- `j wle AI\ b I9'x7 -
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 Vj Alteration ❑ 1 Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ I 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? ��__ �1�., t Yes ❑ No N '
Brief Description of Proposed Work: (2 '1 -1 �-aFo C
O. �4b
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 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.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-S❑ B: Business E: Educational ❑
F: Facto F-1❑ F2❑ : H h Hazard H-1"0_. H-2❑ H-3 ❑ H-4❑ H-5❑
McI: Institutional I-1[1 I-2❑ I-3[1 I-4❑ antile❑ R: Residential R-10 R-2❑ R-3❑ R 1❑
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 ❑ IIB ❑ 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 Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Comndssion Review Process:
Not Applicable❑ Is S re within airport approach area? Is their review completed?
or Consent to Build enclosed❑ 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:
Does the building contain an Sprinkler System?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION -
Name and Address of Property Owner
Name(Print) No.and treet City/Town Zip
Property Owner Contact Information:
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Ti a Telephone No.(business) Telephone No. (cell) e-mail address
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:CONS CONSTRUCTION CONTROL(Please fill out Appendix 2) '
building is less than35,000 cu.ft.of enclosed space ace and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
-Street Address City/Town State Zip Discipline Expiration Date
102 General Contractor
r (va f Cal-, T1, -
ompany Name
6,V fegT �}Vt-
Name of Person Responsible for Construction License No. and Type if Applicable
0192 9
Street Address City/Town State Zip
--
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE:AFFIDAVIT 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 O
- .SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)_$
1.Building $ OD Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ ( @ t� appropriate municipal factor)_$
3.Plumbing $ 00
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (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 info ion contained in this
application is true and accurate to the best of my knowledge and understanding..I
_ 4�OJ'S� No1 ( id�ti In - O 3-
Please pr' 1 and '�n name Title Telep on o. Date
eet dress City/Town S Zi
v Ter O9 z j9
Municipal Inspector to flit out this section upon application approval: J ��
'Name - Date.
M.
1
i
CITY OF S. .r-.M, 2NLkssACHUSETTS
BUMDL`G DEPJRTNCV%T
t30 WASHLNGTON STREET. 3t0 FLOOR
T L (978) 745-9595
Fnx(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THomAs ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BL M=NG COSMASSIO,iER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
t 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed off in :
(name of facility)
(address of facility)
sign a of permit applicant
ill- l3
date
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