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BP APP 17-20 ' The Commonwealth of Massachusetts . Department of Public Safety Massachusetts State Building Code(780 CMR) IBuilding Permit Application for any Building other than a One-or Two-Family Dwelling (Ibis.Section For Official Use Only) Building Permit Number. Date Applied: Building Official; SECTION 1:LOCATION(Please Indicate Block it and Lot 4 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 MA State Cade used If New Construction check here 0 or check all that apply in the two rows below Existing Building Er Repair O 1 Alteration ❑ Addition❑ I Demolition ❑ (Please fill out and submit Appendix 1)" Change of U ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No Vr Is an Independent Structural Engineering Peer Review required? Yes ❑ No 10 1 Brief Description of Proposed Work: jK Ch a-w-?E Qt21`S A ( &a5c-S nsM&5c . SECTION&COMPLETE THIS SECTION IF EXISTING DUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check hei9e,if!!Existing Building Investigation and Evaluation is enclosed,(See 780 CMR 34) O Existing Use' up(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 a licable) A: Assembly A-10 A-2❑ Nightclub 0 A-3 ❑ A4 0 A-5 0 B: Business ❑ E. Educational 0— F: Facto F-1❑ F2 0 H: High Hazard H-10 H-2❑. . H-3 ❑ H-4 0 H-5❑ I: Institutional I-1❑ I-2❑ I-3 0 I4 O M: Mercantile 0 R: Residential R-10 R-2❑ R-3❑ R-40 S. Storage S-1❑ S-20 U: Utility 0 Special Use 0 and please describe below: Special Use: SECTION&CoNg"Wajo TYPE{Check as applicable) _ A Q IB ❑ IIA 0 IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 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: Public 0 Check if outside Flood Zone 0 Indicate municipal❑ A trench will not be Licensed Dis Site Private❑ or indentify Zone: or on site system E3required 0 or trench or specifypermit is enclosed 0 Railroad right-of-way: Hazards to Air Navigation: _ im Pxc,s:« Not Applicable 0 Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No 0 Yes❑ No ❑ SECTIONS: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: If SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner lk* 0404o;&e S 1 O VIES, 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 authorizes Name Street Address City/Town State Zip to act on the property owns behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill ouf Appendix2) f buiktin is less than 35,000 cu.ft.of enclosed'space and/or not underConstruction:Control then check here d and skip Section 10.1 10.1 Registered Professional Responsible for ConstrucHon Control Name(Regis�) Telep one No. e-mail address Re is ation Number L 70aNka Streets Address City/711own State Zip Discipline Expiration Date 10.2 General Contractor Company Name Ar O'�G 3� ' o Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip qV-— -�2S - ane.,_._2R 1 Telephone No.(business) Telephone No. celle-mail address SECTION 11:WORKENS'COMPENSATION iNSURANCB AF'.FIUAVU M.G.L.c.152:I 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 O SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE ` Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ -aw= Building Permit Fee=Total Construction Cost x_(Insert here Z Electrical $ appropriate municipal factor)_$ 3.Plumbing $ a.Mechanical (I NAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ *�' -'tom (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 my knowledge and understanding. PI name Title Telephone No. Date Street AddressCity/Town O State Zip sh-- Z CA AMA Municipal Inspector to fill out this section upon application approval: Name Date