BP APP 17-24 r
n
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
N (This Section For Official Use Only)
Building Permit Number. Date Applied: Building Official:-
SECTION
fficial:SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a streek add reos is not-available)
pct'*rSdA,; 1 ' o/ 4. J6 � t 11
ti No.and Street City/Town Zip Code Name of Built (if applicable)
SECTION 2-PROPOSED WORK.
+w...y' Edition of MA State Code used If New Construction check here O or check all that apply in the two rows below
Existing Building Repaii0 I Alteration O Addition O 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use O Change of Occupancy ❑ Other O Specify:
Are building pians and/or construction documents being supplied as part of this permit application? Yes ❑ No O
Is an Independent Structural Engine Peer Review required? Yes O No O
Brief Description of Proposed Work
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): N JA 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.) �LSrj Linn:
SECTION S.USE GROUP(Check as a licable)
A. Assembly A-1 O A-2❑ Nightclub O A-3 ❑ A4 O A-5❑ 1 B: Business E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 O H4 O H-5 O
I: Institutional I-1 O 1-2 O I-3❑ I4❑ M: Mercantile Er R: Residential R-10 R-2❑ R-3 O R4 O
S: Storage S-1 O S-2❑ U. Utility O Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE Check as applicable)
IAO 111 IIA 0. IIB E3 IIIA 13 11111 C3 IVO 1 VA 13 VB 13
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 will not be Licensed Disposal Site O
Public O Check if outside Flood Zone E3 Indicate municipal O required❑or trench or specify:
Private❑ or indentify Zone: or on site system 13permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation NAA t,listoric_C�)mniis loll Kew i�« I'rkm-s%:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No O Yes O No O
SECTION 8:CONTENT OF CERTIFICATE OF O CUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
44 *.KAIA-
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
=c 0435-3 6 '1U419
Title Telephone No. Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
%1 11
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 permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
f buddingis less than35,0011 cu,ft:of enclosed space and or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
des 9 . 5f57p X78 k !�_
ame a istrant) ephon���o� e- ail ad ess 01983 COM Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company ame �O�' mc-e-)
Richards P
,Name of Person Responsible for Construction License No. and Type if Applicable �\
tban a. +L �T P�
Street Address City/Town State Zip ri
s�$'lb X78 ato5_s3 to e�cl�Olumni�x' �'rna. C'D11'1 A
Telephone No.(business) Telephone No, cell e-mail address
SECTION 11:`WORKERS' MPENSA'i'ICN iNSURANCJ:i AFFiUAVrr M.G.L.c.1519 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' uance of the building permit.
Is a signed Affidavit submitted with this a !cation? Yes the
0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Libor
and Materials) Total Construction Cost(from Item 6)
1.Building $ Building Permit Fee=Total Construction Cost x—(Insert here
2.Electrical $ appropriate municipal factor)a$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ DO (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest nde t pains and penalties of perjury that all of the information contained in this
application is true and accurate to thZf owledge and understanding.
• Gb1�l 1 1 1,
Please prbd and sign name Title Telephone No. Date
7QoGCTtCr1 KA_ -L9$k3_
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approvab
me Date