BPA 17-76 WINDOWS & SIDING The Commonwealth of Massachusetts
n
Department ofl�li�t (.� P
�! Massachusetts State Bu• g e 80 CMR)
Building Permit Application for any Building other than a Orae-or Two-Family Dwelling
(This.Section For Official Use Only)'
l Building Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot 4 for locations for which a street ad not•available)
,eAD)O J4 4 i9�10
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 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No W
Is an Independent Structural Engineering Peer Review required? Yes ❑ No M
Brief Description of Proposed Work
OA
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) 0
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.) 13
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP Check as applicable)
A Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
R Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ 1-2❑ I-3❑ 14❑ M. Mercantile❑ R: Residential R-10 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 a licable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IiIA ❑ IIIB ❑ IV O I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each ltenm)
Water Supply: Flood Zone Information: Sewage Disposal• Trench Permit: Debris Removal:
Public i9— Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site D
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA tt listorlc CommissiJ11 eview Proccis:
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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address o Prorty wner
�f k
6 lJr t a Q Pr GGIfelree /.5 Sal,
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
TitleeT lephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
NaiW Street Address City/Town State Zip
to act on the proarty owner's behalf,in all matters relative to work authorized by this building pe it application.
SECTION 30:CONSTRUCTION CONTROL(Please fill out Appendix 2):
f building is less than 35,000 ft:of enclosed s Iand or not under Construction Control then check here O anis skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Ad, /11l�s
NameRegistraVifut
Telephone No. e-mail address Registration Number
_ SGT _
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Ut x ,byk 40LC4-5 // c-
Com any ame
5;49 v f G S 0�395�
Name of Person Respo46le for Construction License No. and Type if Applicable
Street Address City/Town State Zip
-5QV eco_ - -
Tele honNo. usiness Telephone No. cell e-mail address
SECTION 11:WV LRKEK'S'Q0M1'ENSA'1'ION INSURANCE AFFIDAVrf M.G.G.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 issuance of the building permit.
Is a signed Affidavit submitted with this a iication? Yes 0 No 0
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Tool Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)v$
3.Plumbing $
4:Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ 5" Q contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby test under the pains and penalties of perjury that all of the information contained in this
application is true and ac to to th es f my knowledge and un00/4044T
dunderstanding.ng[.
C'o/l _ mr
Please print arkAign na Title Telephone No. Date
Street Address City/Town State Zip
OY rc
Municipal Inspector to fill out this section upon application approval•
Name Date