PER APP REMOVE GARAGE B17-48 The Commonwealth of Massachusetts
Department of Public Safttoll JAN I q P 5: 01
WMassachusetts 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).
1 Building Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block it and Lot#for locations for which a street address is not available)
j5011 2O
(� No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2.PROPOSED WORD.
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 ❑ I Addition❑ 1 Demolition fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other pecify:
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 Q_--
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) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)do Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E. Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R. Residential R-113 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U. Utility❑ Special Use❑and please describe below:
Special Use:
SECTION&CONSTRUCTION TYPE Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA C3 111B E3 IV ❑ VA E3 VB C3SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal• Trench Permit: Debris Removak
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or inden ' Zone: or on site stem❑ required❑or trench or specify:
�y �' permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: vlr\I listoric Commission Review 1'rocc*:4:
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 System?: Special Stipulations:
.0 .
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Ow er
3s� �e�,��,t� s��t°�• Dry�� .
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 pETerty owner's behalf,in all matters relative to work authorized by this budding permit application.
SECTION 10;CONSTRUCTION CONTROL,(Please fill out Appendix 2)
budding is less than 35,000 cu.ft.of enclosed space and or,not under Construction Control then check here O ana ski 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
Company Name
>-lr,9t A!-V-e Cs_ 09320 6
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:4VQRKE C Q 4PENSATION INSURANCl3 AF.FII)i\VP!' M.G.G 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)a$
1.Building $ p Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee-$ (contact municipality)
S.Mechanical Other $ Enclose check payable to
6.Total Cost $ 1 (contact munici ality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,Ireby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate t th C ly knowled a and understanding.
Please pmt and sign name Title Telephone No. Date
�� c 0f5-70
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval
Name Date