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The Commonwealth of Massus�tt ; ,
} Department of Publag.
ll� 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) _ '2 C7 .SwPrr St,0 ti
Building Permit Number. Date Applied: Building Official:
SECTION 1:L CATION(Please fadicat Block#and Lot'#for locations for which a street address is not.available)
�L`J7 1� ikm A
o.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2-PROPOSED WORK.
Edition of MA State(=ode used If New Construction check here O or check all that apply in the two rows below
Existing Building Repair❑ Alteration E3 Addition❑ Demolition C3 (Please fill out and submit Appendix 1)
Change of Use ❑ I 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 Engineering Peer Review r uired? / / t _Y�P No ❑ Q
Brief Description of Proposed Work: � Tt /'1 Dt/s - q
SECTION 3.,COMPLETE THIS SECTION IF EMSTING 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)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION S.USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑. A-50 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❑ 1-2❑ 1-3❑ I4❑ M. Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a plicable)
IA 1B IIA ❑ IIB 13 1 IIIA ❑ IIIB ❑ IV 1 VA E3 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❑
required or trench or specify
Private❑ or inden'yZone: oron site system❑
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: CdA t tistoric_Commission Review 1'nkcs:
Not Applicable 17 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
Name and Address of Property Owner
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Name(Print) No.and Street Ci Town Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the property 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 permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2).
f bulldin is less than 35,000 cu.ft.of enclosed s and/or,not under Construction Control then check hen 0 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
Company Name °
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Name of erson R nsible for Construction License No. and Type if Applicable ,
_<4J-9-19 Sccv # o'a
Sttrre�eett Address City/ own Sty a Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANOI:AFFIVAvrr M.G.L.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 application? Yes O No 0
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE.
Item Estimated Costs:(Labor
and Mate ' Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $ s
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ r'9 (contact municipality)and write check number here
SECTION 13:SIGNATU_ OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest a pains and nalties of perjury that all of the information contained in this
app tion is true and accurate to the b of my kna wle ge and derstanding.
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Please print and meTitle Telephone
No. Date
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Street Address �— City/Town State Zip
Municipal Inspector to fill out this section upon application approval• AC
Name bate