41 LAFAYETTE ST - BUILDING INSPECTION (4) 17o
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only) .
I Building Permit Number: Date Applied: - I Budding Official:
S SECT ION
-�+
I�xO_�N 1:LOCATION(Please in�di`cate Bloyckk#and Lot#for locations for which a street address is not available)
yobbCzi
No.and Street City/Town Zip Code Name of Budding(if applice)
'U
f SECTION 2•PROPOSED WORK-. c_ A
hEdition of MA State Code used If New Construction check here❑or check all that apply in the two r ws bel
Existing Building 9( Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out mid submit App usdix 1}"t►..R -
Change of Use ❑ Change of Occupancy ❑ Other WSpecify: (Ag
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? �1 Yes ❑ No
Brief Description of Proposed Work: 'l)Eemd 4, csr+ ;L d 72&:moy^L rS�P*LL. I,,—
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) 17
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 ❑ A4❑ A-S❑ 1 B: Business ❑ E: Educational ❑
F: Facto -F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional [-1❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 1110 IIA ❑ 1IB ❑ IIIA ❑ I116 ❑ IV ❑ 1 VA ❑ VB ❑ -
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone Cl Indicate municipal❑ A trench will not be P
required❑or trench or specify:
Private❑ or indentify,Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: AMA, i2ilo,_r Gommi,tion Review Pr,n ,s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Yes❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use,Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
tName
and Address of Property Owner
I I l�td ' / I /h4(Print) No.and Str t City/Town Zip
Property Owner Contact Information:
-,m H)Ti% Sly = - 0bE&4jj � rn ; LL 1
Title Telephone No.(business) Telephone No. (cell) a-mat address✓
If applicable, the property owner hereby authorizes I
iz�El'ir�1'1- frA'Ji19TLq"d�T�'M'l. t30tx-q��Jiaa ��i� F�yi'wn�utfie�� Am c=iS� � C�l�lt�"7
N.une Street Address jj*Ir 15 City/To vn 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 budding 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( egnstnnt) Telephone No. a-mall address Registration Number o
$ i�I:iCtL '%� �! ' 67Ti3AtGWr,,v,. M4 . �lrkr G21 G'7 G'fr Xv ro
Street Address City/Town State Zip Discipline Expiration Date
`J -a; M
10.2 GenerarContractor - - -
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'CObIPENSA'1ION INSURA:NCF.AFFIDAVIT M.G.L.c.152.9 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' uance of the building permit.
Is a signed Affidavit submitted with this application? Yes VrNo ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE'. -
Item Esthmated Costs:(Labor 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 $
d. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check able to
6.Total Cost $ payable
/�.rf @/D'A (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 ail of the information contained in this
application is true and accurate to the best of my//knowledge and understanding.
Please print and sign n. Title Telephone No. Date
3 Sb 'l4, T2,46tiQ ))A—
Street Address City/Town //� St�ate Zip
Municipal Inspector to fill out this section upon application approval:
Name Date