2 STILLWELL DR - BUILDING INSPECTION q,g 7 The Commonwealth of MassaMM49NAL SERViC
f ( 7 Department of Public Safety
Massachusetts State Building Code(780 CIM SpA b A 3 b
Building Permit Application for any Building other than aOne-or wo- amily Dwelling
(This Section For Official Use Only)
Building PemUt Number: Date Appli id: Building Official;
SECTION 1:LOCATION(Please indicate Block#i and Lot q for locations for which a street iddrW is not available)
Z ST ) U L&)I> -t— I'D V—. M
No.and Street Gty/Town Zip Code Name of Building(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
Fxistng Building❑ Repair❑ Alterati ition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineer#n Peef Review required? Yes ❑ No ❑
Brief Description of Proposed Work: F .., , / 7i 1/ c-•
74 �(�T—�j ( :5
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.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Ni htclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Factory F-1❑ F2❑ I H: Himh Hazard H-1❑ H-2❑ H3 ❑ H4❑ H-5❑
I: Institutional I-1❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill ❑ IIA ❑ IIB ❑ ILIA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply:1 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❑
Private❑ or indentify Zone: ' or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic 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:
_1
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and A ess of Property ner
N me(Print) No.and Street City/Town Zip
Pry° -e_ Owner C ct Information
Title q�,c �'1 Kew SS Ir Telephone No.(business) Telephone No. (cell) e-mail address
If ap IicaBle,the roperty 0 er hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized!?y this building permit a lication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 ca.ft.of enclosed space and or not under 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 Co tractor
Co an ame
NifirKe of Person espomible for C true Lice a No. and Type if Applicable
-f-/ ✓Pd✓ ;Yx C e
Street Address 1 'ty/Town St to Zip
1 Q / -3 as w► t6��)
Telephone No. sines Telephone No. cell e-mail address
SECTION il:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 signed Affidavit submitted with this application? Yes O 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 $
I 6.Total Co S� r Enclose check payable to
st $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT f� S
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 accuriteAo the best of my knowledge and erstanding.,
PI ass not and sign name -���t'A/ Title Telephone No. Date
le
Street Address City/Town
State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date