75 WASHINGTON - BUILDING PERMIT - OPUS �IJ . , 0 2 q(o--- I
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The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 OAR)
W- Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Onl )
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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No.and Street City/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
Existing Building Ed Repair❑ 1 Alteration Addition O 1 Demolition O (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 2/
Is an Independent Structural Engineering Peer Review required? 7 Yes ❑ No l7
Brief Description of Proposed Work: (�,Li
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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 CvIR 34) ❑
Existing Use Group(s): I Proposed Use Gmup(s):
SECTION 4:BUILDING HI1GHT 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 If A-213 Nightclub ❑ A-3 ❑ Ad❑ A-5❑ B: Business ❑ E: Educational ❑
R Facto F-1 O F2❑ 1 HI Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ 14
O M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Stmage S-1❑ 5-2 O U: Utility❑ Special Use❑and please describe below:
Special Use:
SECHON 6:CONSTRUCTION TYPE(Check as a licable)
IA IBO HA ❑ ITBD HIAO IIIB ❑ IV ❑ 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:
!( A trench to not Licensed Disposal Site
Public EI Check if outside Flood Zone t9 Indicate municipal O required F3r trench or specify:
Private O or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic C....,..+cn Review Prods:
Not Applicable O 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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If a livable,the pr pe ereby authorizes /
tic
N Street Address City/Town State Zip
to act on th ro er.s behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
f budding is less than 35,000 cu it of enclosed space and or not under Construction Control then check here O and simp 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
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Company Name
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Name of Person Responsible for Construction License No. and Type if Applicable _
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Street Address City/Town State Zip
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Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS CONIFENSATION 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 0 No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor 01D
Item and Materials) Total Construction Cost(from Item 6)=$ /Z
1.Building $ /L O D 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 $ Enclose check payable to
6.Total Cost $ ( Z O D - (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 kn led d understanding.
D/�JiI C A Not?111 r��
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: 1�au"
Name Date
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this.The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC
7 1 Electrical
8 plumbing include local connections
9 Gas(Natural,propane,Medical or other
10 Surve ed Site Plan(Utilities,Wedand,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/Investigation
16 EnerZV Conservation Report
17 Architectural Access Review(521 OAR)
18 Workers Compensation Insurance
19 Hazardous Material M ti ation Documentation
20 Other(S
21 Other(Specify)
22 Other S
`Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
an identified most not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town— State Zi Discipline Expiration Dam
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address Ci Town State Zi Discipline Expiration Date
The Commonwealth of Massachusetts
( ,I Department of Public Safety
Massachusetts State Building Code(780 OAR)
'`seyw ?r0�' Building Permit Application to Construct,Repair,Renovate or Demolish any
Building other than a One-or Two-Family Dwelling
Code and Other Requirements for Building Permits
The Department of Public Safety has issued these building permit application forms so that municipalities
across the state can move toward use of a single permit form and consistent permit application process.
The MA State Building Code specifies the requirements of building permits and the applicant is advised to
review and be familiar with these requirements in order to avoid some of the common permit application
problems. Likewise the applicant should be aware that some municipalities require that the owner confirm,
even prior to acceptance of the building permit application, that no outstanding property taxes,water fees,
etc. exist.
Filing Instructions
1.Please contact the city or town where the work will be done to ensure that the city or town will accept
this application form and if any additional information is required, and obtain the correct mailing
address. After doing so, print the application, fill in completely and then submit to the local city or
town where the work will be done.
2.All applications shall be considered complete and will be reviewed if construction documents,
specifications, fee, and other materials that may be required as indicated in the Building Permit
Application are included with the application.
3.Please include a check for the Building Permit fee.The fee may be calculated using the information to
be supplied in section 12 of the Building Permit Application.The check is to be made payable to the
local city or town where the work will be done.
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