109 LAFAYETTE STREET - BPA-12-296 I
Commoriwea ih of.Massachusetts�`
Department of Public Safety
A1.14sa1luuvlts Slone Budd ing Codc(780 CAI R)
Building Permit Application for any Building other than a One-or Two-Family L)w • 10, g 'I
('Phis Scctiun For Official Use Only)
Build iugl'ecmit Number _.__` Date appliedi ._ Building Official: �noa
SEC'f10N'1: LOI ION(I lease in,icateBloik k and Lut p fur locations fir which a street ad
No mid Street City/-Town /ip Code Name of Building(if applica ble)
SECTION 2:PROPOSED WORK
lidilion of MA S1,11e Code usi•d If New Construction check here❑or check all that apply in the two rows below --
I-.xistiol; Building "Repair❑". Alteration 0 Addition Cl Ucmidition ❑ (Please fill outand submit;\p�tvn�f isl)
Change of Use ❑ I Chaogeof Onup,utcy ❑ Other ❑ Specify:----- -- .---_____--
\rc building plans Jlld/Ur CUII]IrlIc IIUII dlN nlnl'niti bClllg Slipphell als perrof this parmit applicat'un? Yes O No
le
Is an independent Structural Engineering P rr Revi'W requireyl? Yes 0 No 0
Brief Dcwip ion of Prof:os•f Wurk:_��OS� f�-��� C �
lo
SECT-ION 3:`COMPCE'TE'CEII&SECTION IF EXIS'CING.BUILDING'UNDERGOING RENOVATION,AUDI'rION,OR'
" CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed (See 7riQCNIR 34) ❑
Existing Use Group(,): " t.' _- '..'�,% Propuscd Use Group(,):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flom s/Stories(include basement levels)&Area Per Floor(sq. ft.)
l'utal Area(sq. ft,)and Total Height(ft.)
SECr10N S:USE GROUP(Check as appIicable)
A: Assembly A-I'Q A-'_'0 Nightclub ❑ A-3 ❑ A4 ❑ A-i❑ I B: Business ❑ E: Educational ❑
17: Fade F-I ❑ F2 0 H: Ili h Hazard H-1 0 .H-2.0... . H-3 ❑ li-I❑ li-i❑
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1--1 ❑ 61: ", cantfle R: ltesidential R-1.0 R-2❑ R-3❑ R-4❑
S: Storage S-I ❑ S2❑ U: Utility 0 Special Use 0 Ili!I?icase describe below:
_ 0,
Special Use .
SECTION 6:CONSTRUCrION I'YPE(Check as a p plicable)
IA ❑ (B 0 (I.\ ❑ IIB 0 IIIA ❑ IIIB Os, ..I,I V,[3 VA 0 V11 ❑
SECTION 7: SITE INFORMATION(refer to 780 CJIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench I'ermft: Ucbrfs Removal:
Public 0 Check if outside Hood Zone❑ hnlicate municipal❑ A tr ICln Will not be I.ievnsed Ufspnsal Site❑
priv.tte Cl or indt-nlify Lone: ._._ — or on site sastein ❑ requiredwii e or In•ncit onprrily. _-
pennitisrnclnscd❑
Railroad right-of-way: Ilaiards to Air.Navigation:
Not Applicable❑ Is Stnnetu re Within ,airport approach an•a? Is their w%wwwniplOod'
If C,nneut lu Hu dd cnclo.r,1 ❑ Iles 0 or.No❑ I Yrs❑ No ❑
SECTION 4:CON EN"r OF CFR'1'IIICA'IT OF OCCUPANCY
Iid1IIIIn nl Code: _. L'sv C:nmpf+): _ I\pv�d C,nulnnl�on: ulra up.inl Lead por l loor.
Ito,. Iho huildingwnlam,in Sprinkler St shin' Sprci.11 Sl it'll alions: ..
SECTION 9: PROPER'I"Y OWNER AUI'IIORIZA"IION `
Name,unl Addruss u Proprrl Owner
f
Name(Print) N I.ant Strout / own Zip
d Oi L
Property Ourncr Contact Inhm tatlon:
Title Felephone No. (business) Telephone No. (Cell) c-mail address
It ep 11Cabla, the property owner hereby authuriZus
35 Tt --- ��r3/
Name Street Address City/Town State -- Zip
to act on the property owni•r's behalf, in all matters relative to work authorized by this buildiii u•nnit a ++I icatiuii.-••>; ,,��, ••'1.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
if buildin+is less than,15,001)cu.ft.of enclo--w•d Space and/or not under Construction Control then check here O and 3ky Section 10,1
111:1 Re gistered Professional Responsible for Construction Control
Name(Registrant) Telephone No, a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
(/ /Q /Ii /&
Company Name �r
u
Movie of PcrsyM1�Respunsible for Cut action � License No gnat Type if Apylicnble�3�
Street`Address _�!•�-C�._ � CityCity/Townr/S,t`attee Zip
�• (11�ep.ie1 1 OS/ ll�v & YvlWee
Telephone No. business Telephone No. cell e-mail address
SECTION 11:lit ((All'[ lox 1:.0 I it'A"I 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 si gned Affidavit submitted with this a lication? Yes O No ❑
-SEC TION•i2:,CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and :Materials) Total Construction Cost(from Item 6)=S�/ .
I. Building S Od0 Building Permit Foe=Total Constnuction Cost x_(blsert here
1. Electrical S 'jOp� appropriate municipal factor)=5
t. Plumbing 5
N
J. Mechanical (HVAC) S Note: Minimum fee=S__(cuutact nuulicipall
3. Mechanical Other 5 {%A
Fn ,»�closc rhutik pablu to
t,. rotal Cost 5 (l GG (Contact municipality)and write check mum+er icre
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering im name N-1mv, I hereby attest under the poins,md penalties of perjury that all of the information Cont,iincd in this
application is true and accurate to the best of my knowledge and understanding.
Mease print and sign name I"tile rrlCphone No. Mete.._.
';trvvt AddrCSS Cit.%rown State /1 )
I
Municipal Inspector to fill out this section upon application approval: -._—.._. _------------------_.-_.
_._------ ------- — --- Name _ Dme---