BPA-17-260 C-TOP/SALON .Y
The Commonwealth of Massachusetts
Department of Public Safe;P11 AP I`, P 2- Q
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)
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)
�y No.and Street City/Town Zip Code N e ofit ing(if applicable)
h- SECTION 2 PROPOSED WORK.
1 Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair[3Alteration 13Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy. O Other ❑ Specify:
Are building plans and/or construction documents being supplied as pat of this permit a plicatio Yes ,❑ No
Is an Independent Structural EngineeringPeer Review r wired? C " L- Z� � Yes ❑ No
Brief Description of Proposed Work: OE
K
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITIONe 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 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-213-- U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IAO 111 IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IVO I VA E3 VB E3
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Removal:
Licensed
Water Suppl • Flood Zone Information: Sewage Disposal: Licensed Dis Trench Permit: Debris Remo Site
Public Check if outside Flood Zone Indicate municipal A trench wi Wot be P
required or trench or specify:
Private O or indentify Zone: or on site system E3required
is enclosed❑
Railroad right-of-wa Hazards to Air Navigation: 1.\I listaric_Cummissiut Kc�ie�_,Ik�kc;±s:
Not Applicable IT Is Structure within airport ap ach 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:
Q -19- -' 31 5
��l 4 l � �
t
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Add of Property O mer �Ce0 r) �1
h a �� Q rvr I(.t �� o'er t �_ ?
Name jPrint) , ! No.,and Street City/Town Zip
Property Owner Contac I form 'on: - ( !� f0e
c tom-,
Title ale:plh No. uA ess) TO No. (cell) e-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 h this buildin emit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2):
f building is less than 35,000 cu.ft:of enclosed space and or not under Construction Control then check here E3 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
ka-t W(Registrant) _ T�lepho�e�'No. e-ma' Q/�� 'Registration on Numbe
Street /;—�� City/Town State Zip Discipline► Expiration Elate
10.2 General Contractor
/k%ek 4&p9*4h►ti 6
Company Name
&mEi- LS-di 73�f
Name of Person Responsible for Construction License No. and Type if Applicable
M i7r"" j!84 O tf 7d
StreettAAdddress City/To State Zip
-I- �-�-� O d lfoi►►f�tfi/st-
Tele hone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKI-W COMPENSATIO INSURANCE AF.Fil)i.kVfl' 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 ice of the building permit.
Is a signed Affidavit submitted with this application? Yes W No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE.
Item Estimated Costs:(Labor
and Materials Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x—(Insert here
2 Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ f Note:Minimum fee=$ (contact municipality)
5.Mechanical then $ Enclose check payable to
6.Total Cost $ contact municipality)and write check number here
SECTIO 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. `
r_ f�—
PiRt anTitled d sign name
urmi Av f- -50511g#" elep401 a No. Date
Striet Address Ci Town
tY/ State Zip
Municipal Inspector to fill out this section upon application approval•
Name Date