207 HIGHLAND AVE - BUILDING INSPECTION a _1
The Commonwealth of Massachusetts
Department of Public Safety
IJSSaC11 uset is Sato It wild ing Code(780 CSi R)
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 l:LOCATION(Please indicate Block #and Lot#for locations for which a street address is not available)
a O_ HUAMP 4 Jc k-A o r?70 Ps >Na ✓sc� A—
No.and Street City/Town Lip Code Nance of Building(if applicable)
SECHON 2:PROPOSED WORK
Edition of MA State Code used If Now CunstruCtiun Check here❑or check all that apply in the two rows below
Existing BuildingRepair❑ I Alteration ❑ Addition❑ Uenwlition ❑ (Please fill out and submit A f Iondix I
)
Change of Use. " ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building Flans and/or cons[rue tion dtk'nmenlS being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No G;Y
Brief Description of Proposed Work; ArcW( Dople WA i * V j s(.K 010PAI !qAeA�ic 0 Me
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here Ban Existing Building Investigation and Evaluation is enclosed (See 780 CbIR 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 S:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-3❑ 1 B: Business ❑ E: Educational ❑
k Facto F-I ❑ F2❑ H: Hi h Hazard H-I ❑ H-2❑ H-3 ❑ 1-1-4❑ 11-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-i❑
S: Storage 5-1 ❑ S-'_❑ U; Utility❑ - Special Use❑and please describe below:
Special Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ ' IB ❑ ILA ❑ 118 ❑ IIIA ❑ Hill ❑ IV ❑ VA ❑ V'll ❑
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 Renwval:
Public❑ Chock if outside Plead Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:_
Private❑ or indentily Lone:_ or on sift system ❑ permit is enclosed ❑
Railroad nghl-of-way: [lizards In Air Navigation: U h I;ni. .• ., , :. ., .
❑ Is tit ruclu re. within airport appro•k It area r? Is their review ant plclod\ot:\ppliCable '
or Consent to Build cnClosed ❑ l es ❑ or No❑ Yes❑ No ❑
SECTION 8:CON'TEN"r OF CERTIFICATE OF OCCUPANCY
P:ditinn ut Cu Ir: __C'sr Gnmp(s): I\'pe of Cunstrurtion: _- __, 0,upon) Load per Floor:
I loos the building contain,uh Sprinkler Sh stem.,. .. Spec ial Sl i pit a tit ns:
IXQ
ou
SECTION 9: PROPISR'TY OWNER AU'1'l101tlZAI'ION
N.uue and Address ut Property Owner —
Name(Print) No.and Street City/Town Zip
Pru perty Owner Contact Information:
_ y za' '8_2
8-9990
'Title Telephone No. (business) Telephone No. (cell) a-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:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10,1
10.1 Registered Professional Responsible for Construction Control
✓ �
C�k L 6l'/✓CD q� yoS/ r 7 95, C'Are r teNTO ►� co Ho
Nam Re�istrant roleyho'ie No. e-nmil address Registration Number
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Stract Address sly/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
GS 7o6 �f3
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Tole phone No. business Telephone No. cell e-mail address
SECTION11: tvcu:Lcl;ticomi't_NSACIct_I�\q�,_U:XN( VAJ_1-111AVII M.G.L.c.152. 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 0 No 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
Total Construction Cost(from Item 6)=S
and Materials)
1. Building boo Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical S appropriate municipal factor)=5 t
3. Plumbing 5
1. %techanical (HVAC) 5 Note: Minimmrip fee=S (contact numici�y)
3. Mechanical Other S Enclose check payable to
6.Total Grit S 4500 (contact municipality)and write check nunpbc lcrc
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
liv entering my name below, I hcrcbv attest Under the pains and penalties of perjury that all of the information contained in this
application is true and accurate br the best of my knuw ledge and understanding.
I'lease print.1 pd sif;n name Title Telephone Nu. ),to
QU
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>trvet":.Wdress City,Town /f Stale Zip 1
Municipal Inspector to fill out this section upon application approval:
Name Date