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The Commonwealth of Massachusetts
1 Department of Public Safety 2114 OCT —3 A *0 45 ,
Nlassach use Its State Building Code(780 CtiIR)
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)
o C-I r\ of-970
No.and StrA4 City/Town Zip Code Nance of Building(if applicable)
SECTION Z 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 Mteration ❑ 1 Addition❑ Demolition ❑ (Please fill Out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or cunstruction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an ludepeodent Structural Engineering Peer Review required? Yes ❑ No ❑
"Brief Description of Proposed Work: - /' C2:S C S ev)c
SPGOrrC�Ar•t/ C &1-AS'S r%d ffJ L YcfL ool L/nn VLr Sfrhii � r
z
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 Grou p(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sy,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-1 ❑ F2❑ FL• Fli h hazard H-1❑ H-2❑ H-3 ❑ FI-4❑ FI-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-I ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCr(ON TYPE(Check as a livable)
IA ❑ 1110 IIA ❑ IIB ❑ ILIA ❑ 11180 1 IV Cl I 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 Zune❑ Indicate municipa Cll
A trench will not be Licensed Disposal Site❑
required ❑or trench or specify:
Private❑ or indenti(y Zune: or on site system❑ permit is enclosed❑ `
Railroad right-of-way: hazards to Air Navigation: NI_,t_I I 1 n �:,,mn ti n giro I r r<c
Not Applicable❑ 1 Is Strtcture within airport approaclt'area? Is their review completed? -
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CON rENT OF CERTIFICATE OF OCCUPANCY �.
Edition of Code: Use Group(s): Type of Construction:- Occupant Load per Floor: u
Does Ilse building contain an Sprinkler System?: _ Special Slipuldtinns:_ _
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G S- bT2(,�, 3'f 4 Z C
SECTION 9: PROPER'rY OWNER AUTIIORIZA'riON
Name and.Addrusstof'Prapeity'�O�yner
CO r `�1__0 L r 1 v la n l�fn IQf.� ?�7�Ir wra(�aNecl( rt;s/ �ySy3 —2 3
Name(Prm t) IZZJ NCo.and Street �— City/Town Zip
10-
Property Owner Contntactt Inforrmatio:
Title Telephone No. (business) Telephone No. (cull) e<Ail address
If applicable, the property owner hereby authorizes
16clme)e-(,es'A PT i 4(Je4 S �� OI v
Phhie Street Address City/ own State Zip
to act on the property owner's behalf, in all matters relative to work auth, 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 O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
176 e'
Com/p/any Name
rrar�/ _ C' S -6726139
Name of Person sponsible for C nstruction License No. and Type if Applicable
Street Address City/Town State Zip
I/
Teie hone No. business Telephone No. cell a-mail address
SECTION 11:M)1,'kV s'C)\lf'GN5A i'ION hNSUI:ANCH AH ID Wr 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) TotalConstruction Cost(from Rem G)_$
1. Building S Building Permit Fee-Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)=5
3. Plumbing $
4. Mechanical (HVAC) $ Note:Minimum fee=S (contact municipality)
;i. Mechanical Other $
IEnclose check gable to
6.Total Cost $ P y
(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
application is true and//accurate to the best of my knowl dge and understanding.
y,� /-f ",'er- 3a
Plc,ue ri t and sign name 'rifle Telephone No. Date
Street Address City/Town J, State Zip
Municipal Inspector to fill out this section upon application approval: Jitgsnu ��l �Y
Name Date