200 JEFFERSON AVE - BUILDING INSPECTION (2) The Commonwealth of Massaffl to t
Y�Cf»y
Department of Public Safety
V)i Massachusetts State Building Code(7819WG T�JC � J n
Building Permit Application for any Building other than a One-or wo- amt y tl� elling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official
_n SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
2eo A-'e. SA. 4StA 10 U -'tar '* 3
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 e, Repair EgliAlteration Or' I Addition❑ 1 Demolition #(Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No C3-'
Is an Independent Structural Engineering Peer Review required? Yes ❑ No CAY
Brief Description of Proposed Work:
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14Aj p LJALI— 40 Sop 01T C ra.raiGiolp LOACIve.4
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 CNIR 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-5❑ I B: Business ❑ E: Educational ❑
F: Factor F-I ❑ F2❑ 1 H: High Hazard I-I-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
f: Institutional I-1 ❑ 1-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 fd" R-4❑
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 ❑ HB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 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&K Check if outside Flood Zone❑ Indicate municipal IV A trench will not be Licensed Disposal Site❑
requiredC�trench orspecify: een5eM•r1L
.Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ 'UNF. !s 06N C
Railroad right-of-way: Hazards to Air Navigation: ,_1 t 6titonc i_o�;��n��sinn Rey-�<« ('r u _tis:
Not Applicable GV' Is Structure within airport approach area Is their review completed?
or Consent to Build enclosed ❑ Yes ❑ or No 6K Yes❑ No Ili "
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Croup(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
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Name(Print) No.and Street City/Town Zip
Property Owner Contact,Information:
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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 ermif application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
[f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here upd 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
EO ZS
10.2 General Contractor
company'
ame
—Y
1 VIow-,cl �, C 0C,,;u t_-'j
Name of Person Responsible for Construction License No. and Type if Applicable
1 ST-, L"iC�ZDD VA-,c,-e cxt► ��Q-, M/i- 0\9 C�o
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11: WORKFPS COMPENSATION INSURANCE AFFIDAVIT 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 ❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$ 1000.00
1. Building $ a.Oae, b 0 Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
1. \lechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ Z v oo-60 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under th pains ant pet ties of perjury that all of the information contained in this
application is true and accurate to best of m kn led e a u erstanding.
Please print and sign name Title Telephone No. Date
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Street Address - City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
BLO'S t ONSTRUCT10� LLC
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PEA8C7, ?Y, MA 01960-3568
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Construction Debris Disposa/Af rdovit
(required forall demolition and.re-novation work)
In aoaerdanae with the sbA edition of the State MOW Code, 780 OUX Seedw 111.5 Debris,
and the proWsions of MGL c4o,S S4; Bnlhft Permitii is issued with the
condlDn that the debris resulting from this work sha0 be disposed of in a properly licensed
waste deposit facility as defined by MGL c illy S 156A.
The debris will be transported by:
rwtk\en. WaSzc fir+ nuS4e•eS
(name of hauler)
The debris will be disposed of in:
M'• 11ew. ✓ n5+& 7rr4�s5#ti:e 5
(name of facility)
(address of facility)
Signature of applicant
Date