TP APP 17-64 ROOFING G a�q�
e o ealth of Massachusetts
All SAN 21 &J
ep �ment of Public Safety
YY7 c t[�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).
Building Permit Number. Date Applied: Building Official:
h� SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for rshich a streak address is not ova latile)
.38 SiF1ttM S T_...SNU-91T44A- _C O jW --
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 I1 Repair AL I Alteration O 1 Addition❑ I 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 Engineerin Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: 41N 6Z
rQLJ6�SLOF-OkAMS AT
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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): IProposed Use Group(s):
SECTION&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.)
SECTIONS:USE GROUP(Check as a llcable)
A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H. High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5 O
I: Institutional 1-1❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-113 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(Check as applicable)
IA ❑ 1B ❑ CIA ❑ IIB ❑ IIIA ❑ IHB ❑ 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❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA tlistoric_Coinniksion Revit;w,Proce.vs:
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:
CY1CS, TU N
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/To n Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,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 permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix.2)
f building is less than 35, 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 ConstrucHon Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
YyK CLU CaMecT02 s
Co parry Name
Name of Person Responsible for Construction License No. and Type if Applicable
13 i-40y t 44691 7144 O/ Cdr
Street Address City/Town State Zip
Tele hone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKM"T CO&VENSATION INS i1NQ AFFIL)AViT M.G.L.c.152:S 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 $
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ -- appropriate municipal factor)_$
3.Plumbing $
1.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ ��, (�
Enclose check payable to
6.Total Cost $ (contact munkipali )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my none 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.
Plea runt and sig mg Title MA, Teleph No. Date
PAWray
Street Address Cityown State Zip
Municipal Inspector to fill out this section upon application approval• `
Name Date