16 HOLLY ST - BUILDING INSPECTION (2) � �5 - I � " S 2 INSPECMIS96VICES.
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The Commonwealth of Massachusetts
Department of Public Saf q SEP Il A Ih 30
Aiassachusetts State Building Code( 8(l CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Budding Permit Number —Applied: Building Official:
r SECTION 1:LOCATION(Please`i_ndicate Block k and Lot N for locations for which a street address is not available)
l0 CA
No.and Street City/Town Zip Coale Name of Budding(if applicable)
I t y} L SECTION 2:PROPOSED WORK
Edition of MA State Code use _ If New Construction check here❑or check all that apply I in the two rows below
Existing Building Repair❑ Altenntion al 11111 11l (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy Cl Other ❑ Specify:
fy
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? ^
Brief Description of Proposed ork: J C'��^O \ Yes ❑ No
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) Cl
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 a lieable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ I B: Business ❑
F: Facto F-1❑ F2High
E: Educational ❑
❑ H: Hi h Huard H-1❑ H-2❑ H-3 ❑ F!-d❑ H-5❑
f: Institutional 1•f❑ 1-2❑ 1-3❑ 14❑ 1 M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-0❑
S: Storage 5-1 ❑ S-2❑ I U Utility❑ Special Use❑and lease describe
" Special Use:
p below:
SECTION 6:CONSTRUCTION"TYPE(Check as applicable)
IA ❑ 10 ❑ IIA ❑ If8 ❑ IIL\ ❑ [fill ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Sup ly: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Zone Indicate municipal A trench will not be Licensed Dis oral Site❑
Private❑ or indentify Zone: or on site system required❑or trench or specify: C. Z t�i.•��
permit is unclosed❑
Railroad right-of-way: Hazards to Air Navigation: �L I Iia or n�nnniiauur It ii•q It a:car:
Not Applicable - -
PV Is Structure within airport a proach area? Is their review Completed?
or Consent to Build enclosed❑ .Yes❑ or No
Yes❑ No
SECTION 8:CONTENT OF CE IPICATE OF OCCUPANCY
Edition of Code: Use Gruu V(s): Type of Construction:" Occupant Load per Floor: _
Dues the building,contain an Sprinkler System?:"___Special Stipulations:
—
I....fYMOM Z'L
SECTION'). PROPERTY OWNER AUTHORIZATION
N:une and Address iif:[ro p' tY;.�r Owner A' A
�tPrr�1('�I��C' _L �'��? ir. 'f�j �Jiv4��lCe.f S • K02(dn2r.-L S
Name(Print) No.and Street City/Town Zip
�F :If A f i gga` itl '
Property Owner Contactlnfonita4on4i •5e—ff /en
Title OL,. N Telephone No.(business) Telephone No. (cell) a-mail a ddress
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the propertyowner's behalf, in all matters relative to work authorized by this budding permit application,
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildingis less than35,000 cu.ft.of enclosed space and or not tinder Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
639 ao ✓�'
Nam• Re strdnt) Tcl h ne N e-mail address 1� Regist Number
Street Address —�— City/Town State Zip iscipline Expiration Date
10.2 General Contractor -
:5'KAA,
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
2,\9 wivk4-,� 4b"r gran- a \q 45
Street Address City/Town r State ZIP
-&-l�/old/ 7V -MQ 63 21 S`f�f lcl S[-W >&rf jAll djqd
Telephone No. business Telephone No. cell e-mail address
SECTION 11:4V01,KER9•COMPENSATION INSURANCE AN IUAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the NIA 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 O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor �1
Item and Materials) Total Construction Cost(from Item 6)_$ 'S cloD
10
1. Building Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical 5 - appropriate municipal factor)=$
3. Plumbing $.
d. Mechanical (HVAC) - $ Note:Minimum foe=$ (contact municipality)
5. Mechanical Other $ Enclose check payable r able to
6.Total Cost ind write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pain and penal ' s of perjury that all of the information contained in this
application is true:md accurate to the best of my knowle ' and a rst Jing.
41
0- 1711V
Please print a id sign/n me � He Tel t o. *,e!
Street Address City/Town a Zip
Municipal Inspector to fill out this section upon application approval: 61 414°
Name Date
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 104546
Type: Private Corporation
Expiration: 7/14/2016 Tr# 255407
SHELDON FRISCH DEVELOPMENT`INC ; r
Sheldon Frisch
P.O. BOX 811
Marblehead, MA 01945
`Update Address and return card.Mark reason for change.
" ` --
SCA 1 G 20M-OSA 1 Address ❑ Renewal ❑ Employment D Lost Card
C�Lee ipmm�u nwea��i a��inwtc6cuaeltt ��
`� Onice of Consumer Affairs&Business Regulation License or registration valid for individul use only
MeRm ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Ve,giistration: 104548 Type: Office of Consumer Affairs and Business Regulation
iration 7/14/2016:: Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
SHELDON FRISCH DEVELOPMENTaINC.
G
Sheldon Frisch
�7
218 HUMPHREY STREET _
Marblehead,MA 01945 -_ —�
Uadersecretary Not valid without signature
Jmm Massachusetts -Department of Public SafetyTilliffl
_
Board of Building Regulations and Standards .
Construction S;'Penisor t
License: C5-051135
Sf1ELOON W FRI$CH {�3
PO BOX 811
Marblehead MA
* irns`� Expiration
!7'4. 07/1412015
Commissioner