48 HOWARD STREET EXT - BUILDING INSPECTION � � °lci ,
h� The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
-I Building Permit Application for any Building other than a One-or Famil. welling
(This Section For Official Use Only) -
Building Permit Number: (This
Applied: Build ng O cial:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for w ich a e ress is not available)
, 0
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK -
Edition of MA State Code used If N v Construction check here❑or ch k all that apply in the two rows below
Existing Building❑ Repair Alteration Addition❑ Demolition (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes Off No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Wprk: Y\ QYi pp
ms
�eP Sovh Su�tn� �t S M plc,wln n 1
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.)
MA: AssemblyA-10
(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
ly A-1 ❑ ;A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑F-L❑ F2❑ FL' Hi h Hazard H-L❑ H-2❑ H-3 ❑ HA❑ 1-I-5❑
nal 1-1 ❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ Rd❑
S-1 ❑ S-2❑ U Utili ❑ Special Use❑and please describe below:
: — --
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
[A ❑ IBWSITE
IIA ❑ -❑B ❑ IIL1 ❑ 1116 ❑ IV ❑ VA ❑ VB ❑
ON 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Zone Information: Sewage Disposal: Trench Permit: Debris Removal:Public❑ outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑Private❑ tify Zone: or on site system❑ required ❑or trench or specify:permit is enclosed❑Railroad rl 5l ipRCviuw �`9q;FLrzards to a\u Navigation:Not AppIs Structure within airportapproach area? Is their review completed?
or Consent to Bed ❑ Ycs'❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): - Type of Construction:'_ Occupant Load per Floor:
Dues the building cont5in all Sprinkler System?: Special Stipulations:
s
SECTION 9: PROPERTY OWNER AUTHORIZATION
- r
Name and Address of Property Owner
�CeonC1 � yE�f/iPrxaln �ISEnI\\tx cl�irl wn�hotQ ��I� 02�
Name(Print)
�— No.and Street City/Town Zip
Property Owner Contact Information:
0
Title 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:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed s ace and or not render Construction Control then check here❑aqNumbeb
10.1 Registered Professional Responsible for Construction Control
le Registr nt) clelrI Re No. e-maiLtlJklr s Registration Street Address City/Town State Zip Discipline
10.2 General Contractor q \
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
► el l )oQcC\f>W h b i k vux M—L M,fin�—.
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:1VO1,Kh:RS'CON1PFNSA'f[ON INSURANCE AH 11MVf I 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
Estimated Costs:(Labor Q np
Item and Materials) Total Construction Cost(from keen 6)_$S�•ODb
1. Building $ ! •000 00 Building Permit Fee=Total Construction Cost x._(Insert here
2. Electrical $ t •000.10 appropriate municipal factor)_$
3. Plumbing $ 7.t{ 000.c0
Note: Mininuun fee=$ (contact municipality)
4. Mechanical (HVAC) $
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ A 4.0OD,1c` (contact nut nicipality)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 knowledge and understanding.
MAIO—
P ease print a d sigr name Title Telephone No. Date
C 6� Aye e'�3 ea
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: Date
Name