BP APP 17-68 FINISH BASEMENT a
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)
Butilding Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block a and Lot a for locations for-which•a street address is not.available)
7 Jder G' �•�+ X .kAn 4912749
`-- No.and Street City/Town Zip Code Name of Building(if applica e)
SECTION 2•PROPOSED WORK.
Edition of MA State Code used If New Construction check here❑or check all that apply in the two roto
Existing Building Repair❑ Alteration ❑ Addition D I Demolition ❑ (Please fill out and submit Appe ' 1)
Change of Use ❑ Change of Occupancy ❑ Ofber Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes Of No
Is an Independent Structural Engineering Peer R ' w required? Yes ❑ No
Brief Description of Proposed Work: &J"W rr
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): 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.)
SECTIONS:USE GROUP Check as applicable)
A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business D E: Educational D
R Facto F-1❑ F2❑ M High Hazard H-1❑ H-2❑ H-3 ❑ H4 D H-5❑
I: Institutional I-1❑ 1-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2 D R-3 D R-4❑
S: Storage S-1❑ S-20 U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6 CONSTRUCTION TYPE Check as applicable)
IA D IB ❑ IIA ❑ IIB ❑ IIIA ❑ Hill D IV C3 1 VA ❑ VB a
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal Site❑
Public❑ Check if outside Flood Zone C3 Indicate municipal 13A trench will not be pos
Private❑ or indentify Zone: or on site system D required❑or trench or specify:
permit is enclosed D
Railroad right-of-way: Hazards to Air Navigation: SIA Ilistorw C���nmissiun Kc�icH t'nkas:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes D 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:
VAN%LA,1-p �I � l0 I ZO i
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name.�nq Address of Property Owner ] l ��++
G i 1 7 Ake C�. ,' .dt .JS/P.nt 70
Name(P t) 6ofNo.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If ap licable,t//he prop ty owner hereby authorizes
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 ermit application.
SECTION 10-CONSTRUCTION CONTROL(Please fill out Appendix 2)
f buildiit :is less than 35,000 cu. ft;%of enclosed s andor not under Construction Control then check here I1 and skiSection 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
Name of Pe4son Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
2w.2Z -4,10 74V -V frPb
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:woR'FRS'c omPENSA'l'ION INSURANCE AFFIDA PI' M.G.L.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 a !station? Yes O No 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE'
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)s$
1.Building $ Building Permit Fee s Total Construction Cost x_(Insert here
Z Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ p V (contact municipality)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 wledge and understanding.
Please rint and sign name y� Title Telephone No. Dat
�9� d3
Street Address City/Town State Zip
1
Municipal Inspector to fill out this section upon application approval• ) "m `
Name bate