RENOVATE 11 BATHROOMS C/ ?,,,;
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The Commonwealth of Massach
Department of Public Safety ��QQ'� —3 A 0 4b
Massachusetts State BuildingCode 80 C1N
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Building Permit Application for any Building other than a One-atrro-Family Dwelling
(This.Section For Official Use OnI
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#!and Lot 4 for locations for which'a street addveps is notavatlable)
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 Repair❑ 1 Alteration ❑ Addition❑ I 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 Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
PI
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) O
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)k 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-1❑ A-5❑ 1 B: Business ❑ E- Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ 1-4❑ M. Mercantile❑ R: Residential R-10 R-2❑ R-3 0 R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use U and lease describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
[A ❑ 111 IIA ❑ IIBO IIIA0 IIIB ❑ IVO VA ❑ VBO
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposak Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ 1*40
Railroad right-of-way: Hazards to Air Navigation: -is:
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$ystem?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Pr rh'Owner
Name(Print) No.and Street City/Town Zip
Property Owner Co_ntact In formation:
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the proMrty owner's behalf,in all matters relative to work authorized by this building rmit application.
SECTION 10:CONSTRUCLION CONTROL(PleasefilloutAppendix2):
f building,is less than35,000 cu.ft.of enclosed s ce and or,not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for ConstructionControl
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10:2 General Contractor
pari Nam �
Name of Person Responsible fur struction License No. and Type if Applicable
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Street Address �i ✓�Q / City/Town State Zip
Telephone No.(business) Telephone No. celle-mail address
SECTION 11:WORKE1;T COMPENSATION INSURANCE AFFIUr�Vi'!' M:G.L.c.152. 25C(6))
A Workers'Compensation insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)-$
1.Building $ O K Building Permit Fee-Total Construction Cost x^(Insert here
2 Electrical $ appropriate municipal factor)-$
3.Plumbing $
1.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipals
5.Mechanical Other $ Enclose check payable to (ham
6.Total Cost $ K (contact municipals )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By ent ring my n below,l hereby attest under the pains and penalties of perjury that all of the information contained in this
applic ' n' t and accurate to the best of my knowledge and understanding. gj
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PI e a rint id sign name Tit l , _ ,,Teleph ne No Date
X
Street Address City/Town ?51e Zip
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Municipal Inspector to fill out this section upon application approval: I/32
Name VDate