WINTER ISLAND RD - BPA TENT 115- 14-1`3 -2--S Cie- 3s15 �$2500
The Commonwealth of Massachusetts
4 Department of Public Safety
➢U Massachusetts State Building Code(780 CNIR)
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 a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2 PROPOSED WORK
Edition of NIA State Colle used If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 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 ❑ No ❑
Is an Independent Structural Engineering Peer Review required? ( Yes ❑ No ❑
Brief Description of Proposed Work: t- /�tiO Lf do X qL
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CH UPANCY
Check here if an Existing Buil estigation and Evaluation is enclosed(See 780 CNIR 34) ❑
Existing Use Cro Proposed Use
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: UP(Check as applicable)
A: Assembly A-I❑ A-2❑ Nightclub - ❑ A4❑ A-5❑ Bo Business ❑ E: Educational Cl
F: Facto F-I ❑ F2❑ Fh Hi h Hazard H-1❑ H-2❑ f-I- ❑ H-5❑
I: Institutional 1.1 ❑ 1-2 -3❑ I-4❑ M: Mercantile❑ n ral R-l❑ R-2❑ R-3 Cl R-4❑
S.
Storage S-1 ❑. 5-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION]WE(Check as a licable)
IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 VA VB ❑
SECTION 7:SITE INFORMATION o 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Info n: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Chec n e Flood Zone❑ Indicate municipal❑ A trench will cense Il D si op sal Site❑
r or trench or specify:
Private or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation,,
xl�_I.Ga n I ,nnniisr I�v
.. ,Not A li- Is Structure within air ort ,c i area? Is their re vie u� im Icted?
or Consent 0 Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIEICATE OF OCCUPANCY
Edition ul Cudc xx Gnmp(s): Typeof Construction:. OCCn an or Moor
Does the I l ing containan Sprinkler System?: __ Special Stipul'o
SOVIT Tb rt•U . 8�2�
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
c,.�
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby au44R"& _ _
Name Street Address City/Town State Zip
m act on the property owner's behalf, in all matters relative to work authorized by this building ermit application,
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
Name(Registrant) Teleph lu -mail address Registration Nut r
Street Address City/Town State Zip Dtscipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for rstructmn License No. and Ty p icable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell a-mail address
SECTION 11:wan t:RS'COn 0'E NSA l'ION IN911t1AN(T AITIDAVII' M.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 applic 'on. 'lur his affidavit w' ce o e u c
MgTffmTt—
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item Estimated
Materials) 'total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x_(insert here
2.Electrical S appropriate municipal factor)_$
3. Plumbing 5
.1. Mechanical (HVAC) _ _ $$� .._.��W... Note:Minimum fee=5 (contact municipality)
5. Mechanical Other $ Enclose check payable to ee ' n d or 4/4?
6.Total Cost $ S l7 (contact municipality)and write check here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering n name low, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application' a yn rccurate to the best of my knowledge and understanding.
Zo3 .2 ye YpO<
Pleas rint and sign m
it, nae Title Telephone No. D};�e
►� G1Po?'
trc Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: 411�7�
Name Date
I __