221 LAFAYETTE ST - BUILDING INSPECTION '0 047
14 RECEIV
The Commonwealth of Nlassachusetts SERVICES"
Department of Public Safety
'i �IY7 Massachusetts State Building Code(780 CNIR)j6ly JUL L(] A II1 55 ;
Building Permit Application for any Building other than a One-or Two-Fanrily Dwelling
(Phis Section For Official Use Onl )
Building Permit Number: Date Applied: Building Official: 1
SECTION 1:LOCATION(Please indicate Block N and Lot H for locations for whit a street address IV4t available)
l
No.and Street City/Town Zip Code Name wilding(if applicable)
SECTION2:PROPOSED WORK
Edition of ivlA State Code used If Nov Construction check here❑or chuck all that apply in the two rows below
Existing Building Ise- Repair V1 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 ❑ Nu
[son Independent Structural Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:_ e=l/���al-ran clnrAer W,'Oe
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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ IL• Hi h Hazard FM ElH-2❑ 1-1-3 ❑ H-4❑ H-5❑
1: Institutional M ❑ 1-2 Cl 1-3❑ 1-4❑ M: Ntercantile❑ R: Residential R-10 R-2❑ R-3❑ Rd❑
S: Storage S-1 ❑ S-2 Cl U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION'IYPE(Check as a licable)
IA ❑ 160 1 IA C3 IIB ❑ IIIA ❑ IIIB ❑ IV 1 VA ❑ VB ❑
SECTION 7:SITE INFOitN1ATION(refer to 780 CMR 111.0 for details an each item)
Water Supply: 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 required❑or trench or specify:
or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA I Ii I m 1- npnv si ..I oiro
Not Applicable O Is Structure within airport approach,ren? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Cade: Use Group(s): Type of Construction:_ Occupant Load per Floor:.
Does the building contain on Sprinkler System?: _ Special Stipulations'
-NT- -to Dc�erarl ( I
SECTION 9: PROPERTY OWNER AUTHORIZATION '
Name and Address of Property Owner
i"i.1 O/Ci
�lIV.0 a„►/ �: Err Z2i IMP Sf S'ti /P�r !! (( 7
N,Gie,(Print) No.and Street City/Town Zip
�, , t•i tllPl
PropVArrty.O,wrferCgntacOnforniation: ' "q
Title Telephone No. (business) Telephone No. (cell) e-mail address
If a Iica{/ble,the pro eirty owner hereby authorizes /
ir',ICNGLI /o.fs d �h/ / H G/J 2�
Name Streef Address city/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit apEfication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cit.ft.of enclosed s ace and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
r
o ma o r-rm 9-7826- 9-5:12 TJ) f n�
Name Registnnl) L Tel Nu. e-mail addd�dreeess Registration
M4
Street Add ess City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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:W0I:RERY CCMIP[NSAI'ION INSURANCE APWUAV1f 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 E3
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
item Estimated Costs: (Labor
and Materials) dotal Construction Cost(from Item 6)_$
1. Building `S Building Permit Fee-Total Construction Cost x_(Insert.here
2. Electrical $ appropriate municipal factor)=S
3. Plumbing 5
4. Mechanical (HVAC) $ Note: Nlininium fee=$ (contact municipality)
s. Mechanical (Other) "+ Enclose check payable a ible to
�
6.Total Cost $ r (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
Please pr}n�t and sign S nie �Q P Title T�lephone No. Da e
k I t la i' �i / �Y7 OY 0
Street Addres5 City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY OF S�1 zml t%c-1SSACHUSETI'S
QCtLOLNG DEPAR-MI&NT
120 TASHLNGTON STREHT, 3w FLOOR
T�L (979) 745-9595
KIMBERLEY DRISCOLL FAX(978) 7-}0-934+5
LltAyo:L T toaL�3ST.PtEutB
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG CMLVISSIONER
Construction Deb
ris DISPOsal
w Ylt(requ.red for all demolitionand renovation ok)
In accordance with the sixdl edition of the State Building Code, 730 QjR sect l l I.5ion
Debris, and die provisions of tb(GL c 40, S 54;
Building permit 1# is issued%Yith the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste;disposal facility as debris
resulting
,bIGL c
S I SBA.
The debris will be transported by;
y
I QM QA
(name ot'fiautur)
The dehns will be disposed of in ;
511VCL n5 )7 tom/
r(ad�tess or raciluy)
iignatura,)(permit aPpfieant
n
Office of Consumer Affairs&Busi ess Regulation
._I OME IMPROVEMENT CONTRACTOR
egisttation i178809 Type:
xpiration , 5/812018 DBA
TO PAINTING l —�iI fir
y
- THOMAS DORAN
48ENGLISHST : 14 � � q —�c
' SALEM.,MA 01970
Undersecretary �.
i
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