0094 LAFAYETTE ST - BPA-12-155 A 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,Two-Family Dwelling .
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used ft New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 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 ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: Ai+e' Aa1,Jfe/-" f6 eY•S/�1� /��ic £-
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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.) l/8pp Cc-
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-5❑ 1 B: Business ❑ E: Educational Cl
F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ -
I: Institutional 1-1❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-1❑
S: Storage S1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use: - — -.
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ HA ❑ IIB ❑ 1ILIA ❑ IIIB ❑ IV ❑ VA VB ❑
ECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Sup y Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or s gcify: fNC
permit is enclosed ❑
Railroad right-of-way: liazazds to Air Navigation: bl l\Ili tr nr �,�ipunucreur N}v:u 1 i c,.i
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ 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
Name and Address of Property Owner '
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Name (Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title I Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
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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 p ace and/or not under Construction Control then check here O and 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
10.2 General Contractor
Conga Name
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
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Telephone No. business Telephone No. cell e-mail address
SECTION 11: ION INSURA.NCF \V1'f 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
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x (hisert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality
S. Mechanical Other $ Enclose check payable to , /j, �
6.Total Cost $ 3�Du (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest un r the pains and enaltics of perjury that all of the information contai ed in this
application is true and accurate to t knowl g d understanding.
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Plea nt amyl si ame�� Title c h e0. Date
Street Address City/Town Ste e
Municipal Inspector to fill out this section upon application approval: //"fry 'oil
Name ate