BPA-17-243 RPR KIT CABS 25 U- t � 42.s02S
The Commonwealth of Massachusetts
Department of Public Safety
WMassachusetts 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#and Lot#for locations for which a street address is not available)
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No.
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 D or check all that apply in the two rows below
Existing Building❑ Repair Alteration ❑ I Addition❑ 1 Demolition O (Please fill out and submit Appendix 1)
u Change of Use ❑ Change of Occupancy D Other D Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes D No CK,Is an Independent Structural Engineering Peer Review required? � Yes ❑ No 6( .
Brief Description of Proposed Work: L
aa
Vj C4D w&R N
SECTION 3.COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITIQN,O
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) D
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Pro
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 D A-2❑ Nightclub D A-3 D A4 D A-5 D B: Business D E: Educational D
F: Facto F-1 D F2❑ H: High Hazard H-1❑ H-2 D H-3 D H-4 D H-5 D
I: Institutional 1-1❑ I-2 D I-3 D 14❑ M. Mercantile D R: Residential R-10 R-20 R-313 R-4❑
S: Storage S-1❑ S-213 U: Utility7D Special Use D and pleaase describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IAD IBD IIAD 118 C3 IIIAD IIIBD IVO 1 VAD VBD
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Permit: Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site 13Public Check if outside Flood Zone❑ Indicate municipal 9 A trench will not be P
required Wor trench or specify:
Private D or indentify Zone: or on site system D permit is enclosed D
Railroad right-of-way: Hazards to Air Navigation: 4�\.f l ititi�ric Cunuiiitisioit Kc�ii w,l'nki ti4:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No W Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Dues the building contain an Sprinkler System?: Special Stipulations:
NPVe
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
,-
Title Telephone No.(business) Telephone No. (cell) e-mail address lrollo
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 fM out Appendix 2): .
f bu ldiit is less than 35,1100 cu.ft;of enclmd space and/or not under Construct on.Control then check here Q and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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my q
Nal a(Re tract Te�lephope71N�o e-mail addr � Registration Number
Street jkddresq S Ci6y//T!g n State Zip Discipline Expiration Date
10.2 General Contractor
Compan Name
Name of Person Responsible for Construction License No. and Type if Applicable
cv 2 Z- J % S l
Street Address City/Town State Zip
Tele hone No.(business) Telephone No.(cell) e-mal address
SECTION 11:1VORKERT COMP'NSATION INSURANCE:AFFIDAVl'1 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 O No O
SECTION 11-.CONSTRUCTION COSTS.AND PERMrr FEE
Item Estimated Costs:(Labor /
and Materials) Total Construction Cost(from Item 6)a$ ( eP 00---410
1.Building $ Building Permit Fee a Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)-$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee-$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMrr 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 b es!jqfmiyjnowIedge and understanding.
Pl as pr' ig ameA� Titl_ a Telephone No. Date
Str dr Ci 1� G
t}'/T State zip�
[Nlun'ci I to: 4[Meetiksection 4oWa l
pplicati oterov
Name Date