129-151 LAFAYETTE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Deparhnent of Public Safety
VIA 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)
Building Permit Number: Date Applied: Building Official. _
SECTION 1:LOCATION(Please indicate Block 8 and Lot d�for locations for which a street address is not available)
— / �< o P7T ✓r..
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 bere)]or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration Cl I Addition❑ 1 Demolition 0 '(Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes Ar No D
Is an Independent Structural Engineering Peer Review required? Yes D No ❑
Brief Description of Proposed Work: OA✓n a Tal c✓ Zdx iJ7'//U tS e f/9,90'1 4,&t A'
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SECT ON 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
• CHANGE IN USE OR OCCUPANCY
Check here if yr Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): I 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.k.)and Total Height(k.) �! -%I y16
SECTION 5:USE GROUP Check as a licable)
A: Assembly A-1 D A-2❑ Nightclub O A-3 ❑ A-4 Cl A-5❑ B: Business Eo Educational Cl
F: Facto F-1 ❑ F2❑ H. High Hazard H-1 ❑ H-2❑ H-3 D fi-4❑ H-5 Cl
1: institutional 1-1 ❑ 1-2❑ I-3 D T-4❑ M: Mercantile❑ R: Residential R-10 R-2 R-3❑ R-4❑
S: Stora a S=1 ❑ S-2 D I U. Utility❑ Special Use❑and please describe below:
Special Use: rrIt/ " rG s . r -i Z /trf
SECTION 6:CONSTRU- ION TYPE Check as applicable)
IA D IB Cl IIA D IIB ❑ IIIA ❑ UIB D 1 IV ❑ I 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:
PubBcK Check if outside Flood Zone Indicate municipalfx A trench will not be Licensed Disposal Site D
Private❑ or indentify Zone:_ or on site system❑ required❑or trench or specify:_
permit is
Railroad right-of-way: Hazards to Air Navigation: MAliistoricCommission.Reviewlhocess
Not Applicable Is Structure within airport ap roach area? is their review compl /N6
or Consent to Build enclosed❑ Yes❑ or No Yes❑ No
C;
SECTION 8:CONTENT OF CERTIFICATE OF O
Edition of Code: Use Groirp(s): Type of Construction: Occupant Load per Floor: —
Does the building contain an Sprinkler System?: Special Stipulations:
a: 004MMAT J
'�L�,,,,,,�v /,,W {�, '�/ SECTION 9: PROPERTY OWNERS
AUTHORIZATIONName and Address of Prrty Owner V, r �//q �•� �
Aww
9
Name(Print) No,and Sir et City/Town Zi
Property Owner Contact Information:Gtoiul P
gA" 71/!L<C7ZK (A-a.3Sh
Title Telephone No.(business) Telephone No. (cell) e-mail address
If, lrle, p perty owner hereb u orizes
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 lessthan 35,000 cu ft of enclosed space and/or not under Construchrnt Control then check here 13 and skip Section 10 i
10.1 Registered Professional Responsible for Construction Control
C'►tcataEi J�, 13(nef-le.. �gg�.- k4o�-- +obi � ri �li`tt _
Name(Registrappt) , elgphone No, a-mall address Registration Number
SoCoNAYuarld4n� S WA4 i^� 8. 2. Sa �+t.kt•1a�4Uhe.,
Street Address �— City/Town State Zip -Discipline ExpiraAonDate
10.2 General Contractor
Company Name
-T'.�sr n ,tTe.•�-z,lct r+a r` e 5 ��3 5�A rYl�5s L a'."
Name of Person Responsible for Construction License No. and Type if Applicable
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• treeST t Address City/Town State Zi
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Telephone No. business Telephone No. cell e-ma0'address
SECTION 11: WORK tR .OMPhNSn O U N 9i E V 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.
1s 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—(Insert here
-2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost 1 $
57 5 000 (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 all of the information 2ontained.in this
a lication is true d accurate to the best of my knowledge and understanding.
lrv/�P� ` Cdr � o� lio
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Please pryntarrd •gn n59MA(+ltC/ l�f��� (�^S� ftle �Telep o eNq.— at
Street Address II+LLL`� City/Town/1 fate Zip O
• Municipal lnspectorto-fllloutthissectionuponapplicationapproval: "-
Name Date