Loading...
175 WASHINGTON ST - BUILDING INSPECTION t r The Commonwealth of Massachusetts Department of Public Safety .l Massachusetts State Building Code(780 CMR) / 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 which astreet address is not available) No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used Jae W01 If New Construction check here❑or check all that apply in the two rows below Existing Building 0,' Repair Alteration VY Addition❑ Demolition ❑ (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 9� No ❑ Is an Independent Structural Engineering Peer Review requued? ,( Y� ❑ No Q� Brief Description of Proposed Wo/rk7 I2 E1( �j �,UU .ri47 /N U �f �y'7 4 , u E � ) rr ULC 1, / P f-e ln7�` 5 Gintl il�P fY! 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❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ 1-2❑ I-3❑ I-4❑ M; Mercantile❑ R: Residential R-10 R-2❑ R-3❑ 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 IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) _ Trench Permit: Debris Removal: Water Suppl Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑ Public Check if outside Flood Zone[I Indicate municipal Er' A trench will not be P Private❑ or inden ' Zone: or on sites stem❑ required❑or trench or specify: thy y permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable❑ Is Structure within airport approach an Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY �i Edition of Code: Use Group(s): - Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: Ve_ .a / SSECTION 9: PROPERTY OWNER AUTHORIZATION - - Name and Address of Pro a �er olao klj, K74 sL 65 //z Name(Print) V No.and Street City/Town Zip Property ,O,wner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address if applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the ro owners behalf,in all matters relative to work authorized by this building permit ap2lication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.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. itii� �vg 9 �4464 Na strt T N e-mail address Reg a 'on N tuber j� $ 2 G Street Address City/Town State Zip Discipline Expiration Date - 10.2 General Contractor 9rx4 & 44, Company Name " G-s dgd4ts Z Name 3f Person$esponsible for Construction / License No. and Type if Applicable Street Address City/Town State Zip Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .G.L.c.152.§25C 6 A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No O SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ ( O OLv appropriate municipal factor)_$ 3.Plumbing $ /� 'Pv OYa Note:Minimum fee=$ (contact municipality) 4.Mechanical (HVAC) $ 601 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ /�jQ j/®D (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By ente ' g my me below,I hereby attest under the pains and penalties of perjury that all of the information contained in this appli tion is ue and accurate to the best of my knowledge and understanding. Aw4v.�� �rys�c L 60- Q OTO Please print and sign name Title Te one No. Date fo I3 '$rd�a+w A+ti SA1 rvro. of -- Street Address City/Town State Municipal Inspector to fill out this section upon application approval: '"^ ^• / /7 Name Da e I 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'Y'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 Electrical 8 Plumbing include local connections 9 Gas(Natural,Propane,Medical or other K Surve ed Site Plan tilities,Wetland,etc.S ecificationsStructural Peer Review Structural Tests&Ins ecFire Protection Narrative Re ort Existin Buildin Surve /Investi tion Ener Conservation Re ortArchitectural Access Review 521 CNM 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other S 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must 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 Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot # for locations for which a street address is not available) No. and Street City /Town Zip Name of Building (if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) ;f= •;�. The Commonwealth of Massachusetts Department of Public Safety ;y Massachusetts State Building Code'(780 CMR) 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 citv or town where the work will be done.