0006 LORING HILLS AVENUE - BPA-16-802 $) C ZS
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 Dwiing �i
(This Section For Official Use Only) r— :
Building Permit Number: Date Applied: Budding Official: r
O SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not avail0ble) :yirr '
�q /n 1-62 "Nri 91II.s i9y e 's L4t 9 alb UN,T E
1 No.and Street City/Town Zip Code Name of Building(if applica%
�Q SECTION 2•PROPOSED WORK. '0D
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two row%.Kelowt
Existing Buildin&V— Repair❑ Alteration A' I Addition❑ 1 Demolition ❑ (Please fill out mid submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No�v
Is an Independent Structural Engineerin Peper Review required? Yes ❑ No�
Brief Descrit:jT fProposed Work: W it il-CT%/rrC �`aC ,9A4
�, 1 � �4 I o..l ra.7r Faa 1' Prr-✓1' ,55� c nrv?tn-cT )
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.)
Total Area(sq.ft.)and Total Height(ft.) it
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❑ Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-S❑
1: Institutional 1-1❑ 1-2❑ I-3❑ 14❑ • Mercantile Cl R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ It8 ❑ IHA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CIVIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
A trench will not be Licensed Disposal Site[IPublic❑ Check if outside Flood Zone❑ Indicate municip:il❑ required❑or trench or specify:
Private Clor inden[ify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: :-M\I 1 t r ic_Coi omission ito.u, I'n�ics:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ❑ Yes❑ or No❑ Yes O 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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
R�cLA/.A T L6,4 + G-K-V.
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title _.•� Telephone No.(business) Telephone No. (cell) e-mail"address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the ro er 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 space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered
cProfessional Responsible for Construction Control
z)
f�vISU.t� tr l l nr� -7?&_ `�S_ Y So G %u/iA1,T7`Ar 8/31r'y �' 1`
Name(Registrant) Te ph aF r No. a-mail address Re�istr�ation Number /
G/S /> s.✓7a ✓ £f�i✓ �`1 6/FYci 7(z7 /7
r"et Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor p
_l/ /e ao
Cot piny Name
Name of Person Responsible for Construction License No. and Type if Applicable
ZC) v/%✓ S%/ p� SU" lei ✓a /-M O! 2 Cyr
Street Address Crty own State Zip 7"',
,7f Y�o hone No. business Tele hone No. cell a-mailaddress
A:W0iZKIr." ,1PF:NSAI' I ` 'SUR ' .H APF'IDAV11' M.G.L.c.152 25C 6A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completedand
mitted 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 O No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE.
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Qcr 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 payable to
6.Total Cost $ QQ P y
(contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest Ivier gins and penalties of perjury that all of the information contained in this
application is true and accurate to the bes f my 14por ledge. nderstanding.
Please print and sign name .� Title Telephon No. Date
.)O -V 6`17 G( 6 6
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date