80 MARGIN ST - BLDG APP 14-1339 RPR SIGN if I 1 (,'01
(?j , I L4 _ iNSpErjRECEAL IVE SERVICES
The Commonwealth of Massachusetts
Department of Public Saf%Uk AUG 12 A I l
`+��4➢�u Massachusett-s State Building Code(�30CMR)
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 whit a street address is not available)
Ro yv4eozv .1-i SmE)" . 'q oi97a 117 y( _
No.and Street City/Town Zip Code I me Bding(if applicable)
SECTION 2:PROPOSED WORK
Edition of b1A State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ �CfiangeofOccupancy Cl Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Pe•r Review required? Yes ❑ No ❑
Brief Description of Proposed Work: if'A.Z'�`.
cesN y�USf.rJ �.riEt
EC% 3:COMPLETE TIIIS 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.)
7d-
SECTION 5:USE GROUP(Check as a licable)
FF- F,,t"l
Assembly A-1❑ A-2❑ Nightclub ❑ r1-3 ❑ A-4❑ r\-5❑ B. Business ❑ E: Educational ❑
o F-I ❑ F2❑ I1: Hi h Hazard H-1❑ H-2❑ H-3 ❑ II-�4❑ H-S❑
itutional [-I ❑ f-2❑ l-3❑ 1-a❑ NC Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R�4❑
age S-t❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ Ill ❑ IIA ❑ 116 ❑ 1 IIIA ❑ [fill ❑ 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:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \1A I Ikl n omm si n No,w"
:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTIONS:CONTENT OF CERTIFICATE OF OCCUPANCY
Wition of Code: Use Group(s):_ Type of Construction: Occupant Load per Floor: --
Does the building contain an Sprinkler System?: _ Special Stipulations
�(lr��L-E�Q pro, t-k' O • 7 � (��
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner /p
fs'-zae•f 9ko �F✓�y✓��J' �
Name(Print). No.and Street City/Town Zip
41+r
Property Owner Contact Information:' 411
Title Telephon usmess) Telephone No. (cell) a-mail address
If app c ble,the property owner bkreby utho ' .�_
Nqrne Street Address City/Town State Zip
t .ct on thef roper roperty owner's beha f, in all matters relative to work authorized by this building ermit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and or not tinder 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
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:WORKEW COMPENSATION INSURANCE.AFFiu; VI f M.C.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 ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
I. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=S
3. Plumbing $
d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
\ 5. Mechanical Other $ Enclose check x t able to payable
6.Total Cost $ C j _� (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 contained in this
application is true and accurate to the best of my knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip jJ /
Municipal Inspector to fill out this section upon application approval: _ "r6T�'' 1 t� All
Name Date