1 KERNWOOD AVE - BUILDING INSPECTION n
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The® Commonwealth"of Massachusetts ,S 1 "'Department of Public Safety fREGENED
Massachusetts State Building Codlt ff AI SERV)GES
Building Permit Application for any Building other than a One-or
Two-Family Dwelling .
* . • r ('flus Section For Official Use Only) $ «
Building Permit Number: Date Applied: Building Official-
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� r SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available);_
Cr l Ilei OleopP AP S 9CFh; /79 f;
1 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, r
' Existing Building❑ Repair,E( Alteration ❑ 1 Addition❑ I 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 ❑.. No--[]-
Is
o ❑-Is an Independent Structural Engineering Peer Review required? : Yes ❑ No ❑ —�
Brief Description of Pro S'TK%F SAD %71=1i0l7F fJ/ZC'/'te'0Y, ' 5f-7-
!700/7/ 6 /t3/l4Yy C/Z"-cS
. _ , . 'N r 'd - s'+94". 43 - t .• C . i-ra.?di)y` uiro F,itL,Ba
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SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR,
' R CHANGE IN USE OR OCCUPANCY a1' i'tFx"
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Groups) •: �• _+.4t .., r s; t
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A 11 SECTION 4:BUILDING HEIGHT AND AREA r%
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft:)
Total Area(sq.ft.)and Total Height(ft.)
'SECTIONS:USE GROUP(Check as applicable)
" *` a
A:,Assembly A-1 ❑ A-2❑ _Nightclub ❑_ A-3 ❑ A-4❑; A-5 O, B: Business ❑ .E: Educational ❑
F: Facto F-L❑. F2'0 H: Hi Hazard H-1❑ H-2❑ H-3 ❑ : H-4❑ H-5❑
I: Institutional 1-1 ❑ I-2❑ 1-3❑ I-4❑ M: Mercantile 13 R: Residential R-10 R-2❑ R-3❑ R-4❑ r{
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S: Storage Sl❑ S2❑ U: Utility❑ Special Use❑and please describe below: .
Special Use:
SECTION 6 CONSTRUCTION TYPE(Check as applicable) +*:
IN O IB ❑ IIA 13 . IIB ❑ IIIA gat HIP O IV,❑k VA ❑.aula�r��6# �,{gall
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) x
Water Supply-. - --__ erm
Trench Pit: Debris Removal --
.psi....,.
Flood Information: Sewage Disposal: Licensed Disposal Site 13Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P
required❑or trench or specify
y Private O. or indentify Zone: or on site system❑ permit is enclosed❑ i }
Railroad right-of-way: Hazazdsto Air Navigation: MA Historic Commission Review Process . 4 .
Not Applicable❑ Is Structure within airport approach area? Is their review completed? i'
i`'or Consent to Build eiiclosed❑' Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: ` UseGroup(s): Type•ofConstraction: Occupant Load per Floor.'arvational FJ
Does the building contain an Sprinkler System?: Special Stipulations: t i` ; 'C7
Pct CTIS --7Z(— q-off
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y SECTION 9: PROPERTY OWNER AUTHORIZATION
. .Name and Address of Property Owner- ��•.:
N4,za " S e ar y y i V t) Z76 `3 w1,;1,
e(Print) No.and Street City/Town t• Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby.authorizes
Name Street Address _ City/Town State.*;'-, Zip .
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to act on the property owner's behalf,in all matters relative to work authorized by this building permit a � hcation. * L Rtl
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) ^
a. f buil din 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
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Name(Registrant) Telephone No. email address` Registration
Street Address City/Town State Zip Discipline ExprationDate
10.2 General Contractor �*� - r __r � ;.
Company NamelcP 62-122
pili/o ✓irz arty y lC as-7671 /o/z 9/zoic
Name of Person Responsible for Construction License No. and Type if Applicable
//l%CG glee %C/f r f7�' OFlz2� i s grh M
Street Address City/Town State Zip'o
q�? zz6 '970 9 °'• g�P 776' 1970 9
Tele hone No (business) c Tele hone No. cell S' email address . v r r r
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_ SECTION 11:woRKERS'coNTENSAmN INSURANCE AFFmAVnT M.G.L.-c.152§-25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be complefed and-`— #t•. "
submitted with this application. Failure to provide this affidavit will result in the denial of th issuance of the building permit.
Is a signed ed Affidavit submitted with this a hcation?._ ,Ye No 0.,,
la ' SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor - _ - r?{'i..it n f*at,• u+ i "
Item and Materials) Total Construction Cost(from Item 6)
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3.-Plumbing $ rt
4.Mechanical (HVAC) $ ' .Note:Minimum fee=$ (contact municipality)
. .
5.Mechanical Other $ Enclose „check payable to
6.Total Cost $ .Z 3 5 57. BO municipality)and write check number here r rF
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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 n is true and accurate to the best of my knowledge and understanding. k•
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{ ,fv/D 'rXPAhY ��' 726 9io4 O? z- zois, :
Please print and sign name ', i - r Title Telephone No. ,Date:v
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Street Address City/Town rF State ZiPt"` k
Municipal Inspector to fill out this section upon application approval:
Name Date ..