1 SPRUANCE WAY - BUILDING INSPECTION 1Q' The Commonwealth of MassaNN iESE NAL SERVIC
Department of Public Safety
'7 S 3: 3b f Massachusetts State Building Code(780 C[d6YA ePR b A J 3 6
Building Permit Application for any Building other than a One or wo- amily Dwelling
(Phis Section For Official Use Only)
Building Permit Number: Date Applfdti: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
I SP2y P Nc E S la t_r�yV1 MA Trk�
No.and Street City/Town Zip Code Name of Bfting(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alterati ition❑ Demolition ❑ (Please fill out and 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 ❑
-- Is an Independent f Propose Work:
F wired? n — Y eS ❑ No ❑
Brief Description of Proposed Work: � / .-� ^ --- �„ �-(YY�-�-��-r„�fffff/UUU,��!ll.....fffflLLL 7 r`
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.h.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 13F2 13H: Hi Hazard H-1[3H-2❑ H-3 ❑ H-4[3H-5 13I: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
RAI'B
❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
SECTION 6:CONSTRUCTION TYPE(Check as a H ble)
❑ IIA' ❑ 1IIB ❑ IIIA ❑ IIIB ❑ TV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
: Flood Zone information: Sewage Disposal: Trench Permit: Debris Removal:
Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
or indentity Zone: or on site system❑ required O or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA H-F---istoric Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ 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:
J
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Ap4ress of Property ner
N me(Print) No.and Street City/Town zip
Pr�erty Owner Contact Information
Titler� K 40pq fr Telephone No.(business) Telephone No. (cell) e-mail address
If ap IicaBle,the roperty oter hereby authorizes
Name Street Address Gty/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this buildin emut application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 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 Co tractor
Co aName
Mama
aS,*
CSS - 075'gt�S�
NrarKe of Person Itesponsible for C truc.;q Lic e No. and Type if Applicable
y6! 04-- Yrs/ e yPI.� e
Street Address �
Town t a� �
7aa -3 as lb �e�l�g0,t.7rral- 1
Telephone No.(business) Telephone No. celle-mail address
SECTION Il:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.152 A 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 s!--A Affidavit submitted with this application? Yes 0 No O
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ !)
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $
7� -- Enclose check payable to
6.Total Cost $ (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 i true and accur t o the best of my knowledge andhentandimng.PI asenot and sign name Telephone No. Date
X1 7 ►'Icr _ �1��=��' 1
Street Address G Town
tY/ State Zip
Municipal Inspector to fill out this section upon application approval
Name Date