BPA 17-64 REROOF Gv- agq�
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"-TKZT344ealth of Massachusetts
�'� 2�M�ac ep rent of Public Safety
JAN 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:
( SECTION 1:LOCATION(Please indicate Block it and Lot M for locations for which a street address is not available)
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 0, Repair AL Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 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 aAJ C
e -rL.A A.&-I% ADA&A 1L
AL .0LOOMIL
E
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE Olt 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)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
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❑
1: Institutional I-1❑ I-2❑ I-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 18 IIA ❑ IIB IIA E3 111B C3 IV VA C3 VB C3
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 inden ' Zone: or on sites stem❑ required❑cl trench or specify:
my y permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: k1 k tistoric Commission Review Vrocm%:
Not Applicable O 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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION a
Name and Address of Property Owner
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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
-A-5
Name Street Address City/Town State Zip
to act on the property owners behalf,in all matters relative to work authorized by this building permit application.
SECTION 1(h CONSTRUCTION CONTROL(PIeasefittout Appendix 2).
budding.is less than 35,000 cu.ft.of enclosed s ce and or not under Construction Control then check here Q 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
�t��� PfT y Ca��TcK s
Co any Name
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
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Te
Tele honeNo.(bufsin ess) Telephone No. celle-mail address
SECTION 11:WURKFk'S'CONVEN 3A'F1QN INSURf1NCl;A'FII:)AVfl' 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 application? Yes 0 No 0
SECTION 12 CONSTRUCTION COSTS AND'PERMTI'FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6) $
1.Building $ a
` 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 $ 760- (contact municipality)and write check number here
IF
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.
Pie riot and sig nm , Title Telepho No. Date
�� � IK�t4 01766
Street Address CityTown State Zip
Nfunicipal Inspector to fill out this section upon application approval' s+o ! 3Y17
Name Date