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HomeMy WebLinkAboutMiscellaneous - 87 FARRWOOD AVENUE 4/30/2018 (2)Date..o/.. a/ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... r...................... ......................................................... has permission for gas Installation 1---ws ..... . ................................ inthe buildings of ................................................................................................................... ....................................11h ndover, Mass. Fe&_3 .... 44� ...... Lic. No. .14F .............. .............................. Check # `i Lj/'6 G TYPE OR PRINT CLEARLY APPLIANCES 7 BOILER BOOSTER MASSACHUSETTS UNIFORM APPLICATIONS FOR A PERMIT TO PERFORM GAS FITTING WORK CITY A � p Jc-i MA DATE 03:J PERMIT# W177 JOBSITE ADDRESS 22►�/0� 0 NER'S NAME � 4�.✓ a•'� `' OWNER ADDRESS TE`� F OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL ® RESIDENTIAL 21 NEW: Q RENOVATION: ® REPLACEMENT: ® PLANS SUBMITTED: YES[] NOD FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER COVERAGE have a current liansurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES bilit i _ NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE Y, CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY ® BOND F OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT I I hereby certify that all of the details and information I have submitted or entered regarding this applicat on are true and ccurate he best of my le e and that all plumbing work and installations performed under the permit issued for this applicatio wife be in complianc with all rtineRt+r i io the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLU�MGF BER-G SFITTER NAME T LICENSE # SIGNATURE MP JP ® JGF LPGI CORPORATION PARTNERSHIP ®#= LLC [#= COMPANY NAME: u- aa- I �� ADDRESS ��'F - - ZIP 2� TEL CITY STATE E=EMAIL FAX CELL .__ - - - 0 F] t The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street, Suite Boston, MA 02114-2017 �t www.mass.gov 'e Affidavit: Builders/Contractors/Electricians/plumbers. Workers' Compensation InsurancPERMITTING AUTHORITY• TO BE FILED WI`T'H THE please Print Name (Business/Organization/Tndividual): Address: Phone-- City/State/Zip:Type of project (required): Are you an employer? Check t appropriate box: 7. [] New construction 1.111 am.a employer with __,._. employees (full and/or part-time).* 8 El Remodeling 2.❑ I am a sole proprietor or partnership and have no employees working forme in o workers' comp. insurance required.] 9, ❑ Demolition any capacity. [N 10 all work myself [No workers' comp. insurance required.] t Building addition 3.01 am a homeowner doing roe I will 11.0 Electrical repairs or additions 110 1 am a homeowner and will be hiring contractors to coarenduct work oryare sole ensure that all contractors either have workers' comp 12. [] plumbing repairs or additions proprietors with no employees. 13. Roof repairs 5 ❑I am a general contractor and I have hired the sub -contractors listend�oaznantheattached sheet. 14 ❑Other These sub -contractors have employees and have workers' comp. fficers have exercised their right of'exemption per MGL c. _ d (.❑We are a corporationand its o , , o workers' comp. insurance require .1 152, DO), and we have no, employees. [N ensation olicy information *av li ant that checks such - box #1 must also fill out the section below showing their workers' comp P Any app the aze doing all work and then hire outside contractors must submit a new notaffithus indicating v i Homeowners who subs s box must, artt indicating hed ti additional sheet showing the name of the sub -contractors and state whether or not those entities have lContractors that check must rovide their workers_' comp. policy dumber. employees. If the sub-corilraciors have employees, they p em to ees. Below is the policy and job site I am an employer that is providing workers' compensation insurance for my employ information. Insurance Company Name: Expiration Date: policy # or Self -ins. Lic. #: City/State/Zip: the olicy number and expiration date). Job Site Address: ensation policy declaration page (showing P Attach a copy of the workers' comp , . p a fine u to $1,500.00 e as required under MGL c. 152, §25A is a criminal violation punishable by p Failure to secure coverag a office of Investigations of the DIA for insurance ent as well as civil penalties in the form of a STOP WOE ORDER and a fine of up to $250.0 a and/or one-year imprisonm be forwarded to the ' 1 t A copy of this statement may __�_ day against the vio verification. hat the information provi and penalties of perjurJ' tded above is true and correct, I do hereby certify under the pains one It: official.. completed b city or town off Official use only. Do not write in this area, to be comp Y permit/License #�--- City or Town: Issuing Authority (circle one): Department 3. City/Town Clerk 4. Electrical Insp 1. Board of Health 2, Building ector 6. other Contact person: Phone #: 5. Plumbing Inspector Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fillout the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractox(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other Than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents foi• confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial A ccidents. Should you have any questions regarding the law ox if YOU are required to obtain a workers' on the appropriate line. compensation policy, please call the Department at the number listed below. Self insured companies should'enter their self-insurance license number City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in ity or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to th(ce applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Revised 02-23-15 Fax # 617-727-7749 www.mass-gov/dia Date ..a/z ���. � ....... . TOWN OF NORTH ANDOVE r ; i PERMIT FOR GAS INSTAL This certifies that ..(�. F. .,/. � .?.......................... . has permission for gas installation ... /... ../� .............. . in the buildings of ... %*. 1`. .,./ H t^ .... ........ at ...CA)i?!............. North Andover, Mass. Fee.. � : � .. Lic. No.. .�� .% .1 1.1?..- ........... . GAS INSPECTOR Check # ) rr 7 MASSACHUSETTS UNIFORM �,:PPLICATION FOR PERMIT TO DO GAS FIT I INU City[Town: + Nth �c�J k -C , MA. Date: t% Permit# 2O 3 Jr Building Location4l IFqc ooO QSolL Owners Name,�1Q'�`, `q�Q reek Type of Occupancy: Commercial ElEducational F1Industrial ❑ Institutional E]Residential K] New: ❑ Alteration: EJRenovation: El Replacement © Plans Submitted: Yes ElNo Q�,,y4,n� FIXTURES co UJ UJ X a W fn 0 � = rn W =11 2 0 W W �= to Op n W W z H z p W H n W a 0 Q I= - O W N w m O Q p. I- W W= xLL W a w w W z cn = W o fn Z W W W Z w>. W (n J rt Q m w O z 0 N > I. - Q 2 v o 0 U. t9 z z O OR 2 H>>> O SUB BSMT. BASEMENT IL 151 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOORc�^^ Check One Only Certificate # Installing Company Namel r,6§ Corporation '— ` �c�s"t a n State _ Address3 , \jj%v tct � CityITown-- ❑ Partnership Business Tel: 1O! Coif �"���� Fax: ElFirm/Company Name of Licensed PlumberlGas Fitter: V%Q``Vct04 INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No 171 If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. Other type of indemnity ❑ Bond ❑ A liability insurance policy � Yp Y OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives thisCheck One Only Owner ❑ Agent ❑ Si nature of Owner or Owner's Agent By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By ® Plumber ❑ Gas Fitter Signature o Licensed Plumber/Gas Fitter Title Master Journeyman License Number� City/Town Co — E] LP Installer _-- noo�nvPn (nFFICE USE ONLY) —' v 'c7 to r a ro ro r a � x 0. 0 o o 11 O � C) r c �n Date% ..... n�� .... . w N°RTh 01, �` a° ° TOWN OF FORTH ANDOVER • - PERMIT FOR GAS INSTALLATION r This certifies that .................. ...................... . has permission for gas installation .'� `.` '� ................ in the buildings of ...f'` °`�c'.............................. . atNorth Andover, Mass, Fee.?.d..... Lic. No.. Z'' 5.. .......................... GAS INSPECTOR Check # S -G Z z Z- 69/2 M= i � - MASSACHUSETTS UNIFORM .%APPLICATION FUR ?tKNII I I U UU UA,) rl I I INN City/Town� , �JMA. Date: 0 2A0 -%s Permit# h Building LocationC$ a►\C'' N:�` Owners Name:AQ.<' >, ggnt '��'eQ� Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ® Replacement: N Plans Submitted: Yes ❑ No FIXTURES vi wLu _ Z Y W Q W 0 D Lu rn Z Z Z Q H w 0 Q F- O W U) W m 0 Q o. a W = x cn > w W N 0 = CO p Lu~LL W w Z W }W W N J Q H m W 0 Z 0 try > Z Q i=- SUB BSMT. BASEMENT --TsT FLOOR 2 Nu FLOOR 3 K u FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 T H FLOOR 8 FLOOR j _ (7 Check One Only Certificate # Installing Company NamS %c�^►y '*�� t �� � 0�� cc [� Corporation :Address es �i� N-"(� Act 4:?i City/Towa n State: CA ❑Partnership Business Tel: C,13Fax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter:'�7'r%. 9.'T _(Jc INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy X Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives thisCheck One Only Owner ❑ Agent ❑ Si nature of Owner or Owner's A ent By checking this box ❑; i hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Typ�eitc ense:By r❑ Gas Fier Signature o Licensed Plumber/Gas Fitter Title a Master Q ❑Journeyman License Number: Cit [Town ❑ LP Installer APPROVED OFFICE USE ONLY 0✓ WESSLING ARCHITECTS ARCHITECTURAL FINAL AFFIDAVIT Stephen J. Wessling Architects, Inc • AIA • BOCA • IFMA • BOMA - 40 Willard Street, Suite 102, Quincy, Massachusetts 02169 Tel 617.773.8150 • Fax 617.773.4902 • www.sjwarchitects.com PROJECT NUMBER: 04101 PROJECT TITLE: Pool House, Units 1416 & 85-87 Balcony Replacement PROJECT LOCATION: Heritage Green Apartments, N. Andover MA NAME OF BUILDING: SCOPE OF PROJECT: Balcony Replacement To the Commissioner of Buildings, N. Andover, Massachusetts: certify that I, or my assistant inspected the progress of the construction work associated with the building permit, during the balcony replacement or the Pool House, Units 14-16 & 85-87, located at Heritage Green Apartments, N. Andover, Massachusetts, and that to the best of my knowledge, information and belief, the work has been completed in conformance with the approved drawings, and accordance with the requirements of the Massachusetts State Building Code sixth edition, and all other known pertinent ordinances. sqg?svqglV 9. Yvgss�e-vyq 40 WILLARD STREET SUITE 102 QUINCY, MA 02169-1229 t�weo 617-773-8150 0` STEPHEN J. WESSLING IA, CSI, BOCA � No. 4191 Ar ectur - assach efts Registration No. 4191 ¢6 QU►NCY ' oy MA /4 �f 0 ��Tk of tf Ns5 S EN W IIS, PRESIDENT DATE: 4. Ondrick Emplimeerimp Design Group Inco ASCE- ACI- BSCE- SEI Commercial . Industrial. Residential STRUCTURAL ENGINEER FINAL AFFIDAVIT PROJECT NUMBER: PROJECT TITLE: ..............Balcony Replacement, Pool House, Units 14-16 & 85-87 PROJECT LOCATION: ......... Heritage Green Apartments, N. Andover, MA NAME OF BUILDING:........ Heritage Green Apartments SCOPE OF PROJECT: .......Balcony Replacement at Pool House, Units 14- 16 & 85-87 To the Commissioner of Buildings, N. Andover, MA. I certify that I have inspected the progress of the construction work associated with the building permit periodically during the construction of the balcony replacement, located at Heritage Green Apartments in N. Andover, Massachusetts, and that to the best of my knowledge, information and belief, the work has been completed in conformance with the approved drawings, and accordance with the requirements of the Massachusetts State Building Code sixth edition, and all other known pertinent ordinances. STEPHEN ONDIUCK PE Structural Engineer Massachusetts Registration No. 39029 STEPHEN ONDRICK , PE 1250 Hancock Street. Ste 815N. Quincy, I F. G ��' April 14, 2006 DATE: 17.472.1800 F.617.773.4902 sfoengr@juno.com Lil Cd ui om o � 94 o w a u �o �A z O w•a, 32mC, y v � v w z °o a o o x G w o G W o c o ° w c� w oG U w rs. rx c� w a w' as cn cn ui om N V 0 M CA y L a. O O v rQ 6L y O v .y O O C cc CLH roolo 0L 3� di 0 Q O CL C *-, C Q O O Z CA C IS� �o �A 0 iV O w•a, 32mC, y O L m O I AV 0 m CL : y"' y a �l E OCD C_ E H1 y r C 7v 400 COLSL m •r...r.0 : C cm" C .mom m 1�• `° o •� cmoac c .o a o :cmc C3: N COD M W cc ~' C _,,, •� r � •y •az m = Z •E � vs W CDH o a cc: 5 mgm CD =4-a=� N V 0 M CA y L a. O O v rQ 6L y O v .y O O C cc CLH roolo 0L 3� di 0 Q O CL C *-, C Q O O Z CA C D J IV -NAP � OL c A AG O �. � AG ISO CJ V :w: Ilk. 0. Lo � O ofA a Uw a w�' w w a v cn w n�' 79 w Irl cn 0 cn D J IV -NAP OL c A C N O �. � ISO CJ V :w: Ilk. 0. Lo � O ofA fl. a E� 'ts cm. oc 1= E N l0 mm A C C � � :L C N C o m CL H m O , Of C! O c �• O O tr m aO: UM Z mce"E 4 0 cp em CL. o c o o sm W CO fl . • ,.- ,_,,, -Ra !.s F.. CIS E v�ON Z o LU W m C L3 4D d •QCs y Z eNv °��=•7 O as.m� 2 cm I O y O •O •� m m D. = :ilk CD �3 C L oa _ ME cmac Q_ coO 04) ca Z0 CL ai C.± CO) w c CLy 0 TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING for Official Use OnI BUILDING PERMIT NUMBER:_r f a J7 bl DATE ISSUED: 1 SIGNATURE: Property Address: 19 (" — ) L q7 d 1.3 Zoning Information: Proposed Use 1.6 BUILDING SETBACKS (ft) Front Yard Provide Date 1.2 Assessors Map and Parcel Number: - 63.E - Map Number Lot Area Side Yard -Required T -Provided Parcel —Number Rear Yard Provided 1.7 Water Supply M.GI.C.40. 9 _5 4) 1.5. Flood Zone Information: 1.9 Sewerage Disposal System: . Pub , lic 0 Private 0 1-7 F Zone — Outside Flood Zone 0 MunicipalOn Site Disposal System 0 1611 Building/Frame Permit Fee $ Hu act: yes 140 2.1 Owner of Record Foundation Permit Fee $ C Name � TOTAL (Print) / .P� _\ Address for Service J/,% 145p" -'i Tel 3.1 Licensed Construction Supervisor �i �)_CSC PP, A s Qf r e Licensed Collgtction Supervisor: Signature Tel 3.2 Registered Home Improvement Contractor Company Name Address Signature ,:-lephon Telephone T M X 0 0 to 0 M X > /00U.) Locati6n Q' 6-1 Date No. -70 E. -I .0 Date L TOWN OF NORTH ANDOVER OL t 41 INS Certificate of Occupancy $ Building/Frame Permit Fee $ Hu Foundation Permit Fee $ Other Permit Fee $ TOTAL $ -1 oPf0b, Check# r; I -i, 7 Building inspector e /" TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Section for oficiai use Oifl K."i'ia �' Y t+l ..: L.. -X;h�E s' •S:y; M ,�. .Y i..Y C: A BUILDING PERNUT NUMBER: DATE ISSUED: c� SIGNATURE: BuildingCCom.miisssioner/I or of Buildin Date rCj ( ruA. { LI t Property Address: 1.2 Assessors Map and Parcel Number. _Q, C Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: ZoningDistrict Pr used Use Lot Area Frotna ft 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Required provided 1.7 Water Supply M.G.L.CAO. 34) 1.3. Flood Zone Infotmatioo: 1.8 Sewerage Disposal System Public 0 Private ❑ Zone Outside Flood Zone ❑ Municipal On Site Disposal System ❑ M(f ict: YCS �( 2.1 Owner of Record Name (Print) Address forService: S Telephone 2. uthoriz ` J L 71� /i / N e n t Address for Service: Si store Telephone 3.1 Licensed Construction Supervisor Not Applicable ❑ Q- A� Address License Number ff_ — r .- ZGr�� Con" nsction Supervisor: , —Licensed (/ L( Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address �V Expiration Date Signature Signature Telephone T u K 0 SECTION 4 - WORKERS COMPENSATION (M G.I.: C 151 1. 25c(6) Workers Compensation Insurance affidavit 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. Signed affidavit Attached Yea ....... No ....... ❑ SECTION 5 - PROFESSIONAL DESIGN AND. CONSTRUCTION SERVICES FOR. BUH DINGS AND STRUCTURES SUWECT .TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR.1 t6 (CONTAINING MORE THAND 35,040 C.F. OF ENCLDSED SPACE) 5.1 Registered Architect: Ae: Address Signature Telephone 5.2 Registered Prafessiogel.Engineer(s) d� �� fir) t a l� r C ^� CQ F r • �s s �� Area of Responsibility Registration Number Expiration Date Nine: Address: Signature Total Not applicable ❑ Registration Number Expiration Date Name: Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone _.s• -S + t.!_ Q jo,\`�-y"rr Cl IrtQk -i� t 1 N ` Not Applicable ❑ Comnatty Name: I Responsible in Charge of r. t SECTION G;,>E 01 t. —, E R 4F PRO"EO 'ORB (cheek all applicable)' , . New Construction 0 Existing Building ❑ . Repair(s) Alterations(s) ❑ Addition 0 Accessory Bldg. 0 Demolition 0 Other 0 Specify Brief Description of Proposed Work: �. CTpN 7 - US)& . OU) AND CNST)ZiTC i Itil[?E' USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly 0 A-1 0 A-2 0 A-3 0 A4 ❑ A-5 0 ]A 1 B 0 0 B Business ❑ 2A 213 2C ❑ 0 ❑ C Educational 0 F Factory ❑ F -I 0 F-2 ❑ H High Hazard ❑ 3A 3B ❑ 0 IInstitutional ❑ I-1 0 I-2 0 I-3 0 M Mercantile ❑ 4 0 R residential R -I ❑ R-2 ❑ R-3 0 5A 5B 0 0 S Storage 0 S-1 0 S-2 ❑ U Utility 0 M Mixed Use 0 S Special Use 0 Specify: Specify: Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34: Proposed Use Group: Proposed Hazard Index 780 CMR 34: BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels Floor Area per Floor s Total Area st Total Height (ft Independent Structural Engineering Structural Peer Review Required Yes ❑ No 0 SECTION 10a Owner. Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Owner of the subject property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner Date ` JJ as Owner/Authorized gen creby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. S' under the pains an penalties of perjury ff t e Si tune of Owne ent Dat SECTION 11; F.STIlViATEgt#NS''it1I41rt: CoS' Item Estimated Cost (Dollars) to be ©1�'�'kC�IML U $; ONLY Completed by permit applicant . ., . 1. Building Y� .. (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of O Construction from (6) 3 Plumbing Building Permit fee (►) x (b) 4 Mechanical (HVAC) ® F + 5 Fire Protection 6 Total (1+2+3+4+5) Check .Number 52 07 4 OD '15 L - NO. OF STORIES SIZE t BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 N 3 SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CBRANEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE I - L r r •;, � Ar,�. � r..