PER. APP - OFFICE FIT OUT 17-39 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
(This Section For Official Use Only)
t Budding Permit Number. Date;Applied: - Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for whick a street address is not-available)
a S �. 01at
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❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering P r R dew required? ` {. '! Yes No tact
Brief ri tion of Proposed WLork: n a� I n �I !►0'7 1 1 � t� C r
4n Nr ot h r `N rt p r ,b
k .SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDFITON,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): 7-71 Proposed Use Group(s):
SECTION&BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.fk)and Total Height(ft)
SECTION 5:USE GROUP(Check as a livable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A=1❑ A-5❑ B: Business Gt E: Educational ❑
R. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ I-2 O I-3❑ 14❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage S-1❑ S•2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE i2eck as a livable)
IA ❑ IB ❑ IIA ❑ ItB ❑ ITIA IIIB ❑ 1V Cl VA ❑ VB 0
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&;;" Check if outside Flood Zone a Indicate municipal. A trench w' not be Licensed Disposal Site
Private 0 or indentify Zone: or on site system❑ required Odor trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NAA 1 Listoric Commission Revi�.w_Pnkc,l
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION&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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
df name and Address of Property Owner ,1 / d
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41 7 Fr 7 #� ur h 0�f
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Name(Print)""rO� L to s Py No.and Street City/Town Zip
Property Owner Conti;tInformation:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If a piicaable,the property owner hereby authorizes
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Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building emit application.
SECTION 10 CONSTRUCTIONCONTROL(Please fill outAppendix2)
buildingis less than 35,000 1.cu.ft of enclosed space and or not underConstructionControl then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Name of Person Responsible for dqjruction License No. and Type if Applicable
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Street Address City/Town State Zip
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Telephone No.(business) Telephone No. celle-mail address
SECTION 11:WORKFiR 'COMPENS TION INSURANCE AFFIDAva M.G.L.c.152:§25C(Q)
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' ance of the ding per it
Is a signed Affidavit submitted with this application? Yes C9' No O O e mai
SECTION 12.CONSTRUCTION COSTS AND'PERMIT FEE
Item Estimated Costs:(Labor '��
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 7W I Building Permit Fee a Total Construction Cost x_(Insert here
2.Electrical $ 75- appropriate municipal factor)_$
3.Plumbing $ 600
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ / Enclose check payable to
6.Total Cost $ ?4 (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.
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e_pr' I�n as�ix 4� LI wu� � A I C� Title TelephoneDate
Street Address T `fiity/Town State Zip
Municipal Inspector to fill out this section upon application approval: Pw
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