0001 PIONEEER TERRACE, BPA-17-137 C) � � d 7 0 � 3�s �
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The Commonwealth of Massachusetts
Department of Public Safety
r Massachusetts State Building Code(780 CMR)
(—" Building Permit Application for any Building other than a One-or Two-Family Dwelling
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(This Section For Official Use OnI j
Building Permit Number: Date Applied: I Budding Official:
SECTION 1:LOCATION rPinaca indiratp Block#and Lot#for locations for which a street address is not available)
� 1✓e2 t
No.and Street City/Town 1 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 ❑ Addition❑ I 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 ❑
Is an Independent Structural Engineering Peer Rgview required? Yes ❑ No ❑
Brief D iption of Pr posed Work:'
e.
S SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
eck here if an Existing Building Investi ation#nd Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s) Proposed Use Group(s):
SECTION 4:BUILDI G HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)k Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 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-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 111 13 IIA ❑ 118 C3 IIIA C3 11111 IV 13 1 VA 13 VB E3
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal-
Public
Permit.Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Disposal Site❑
Public C3Check if outside Flood Zone❑ Indicate municipal 13A trench will not be
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: :SIA l Iistoric Connnission Review Proceys:
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:
C L-9 13(0
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
009m4kWt -64�M, MA oil.-7-0
/ Name(Print) No.and Street City/Town Zip
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Z
ty Owner Contact Information:
— C1'tVCKfk SAIeMh .ORS.
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicab}e,the property owner hereby authorizes
(0A201 A. CCOWn) . Z17 Cbi Lem npo, 0I L7�7a
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 rmit application.
SECnON 10..CONSTRUCTION CONTROL(Please fm outAppettdlx2): .
buildingis less than 35000 cu.ft;of enclosed space end or not under Construction Control then check here D and skip Section 10.1
10.1 Re 'stared Professional Res onsible for Constructioli Control
Name(Registran) T le o e No. e-mail address Registration Number
le%&NA MA
Street Address City/Town State Zip Discipline Expiration Date
102 General Contractor
[kms e EVP I ,
ComRany Nam#
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Name of Person Responsible for Construction License No. and Type if Applicable
3 4GC.-) IULICASIde AA-,'. -s
Street Address City/Town State Zip
Telephone No.(business) Telephone No. cell e-nui l address
SECTION 11:AVOk'1 T.S'(7DAIPENSIA•1'ION IN' DANC''Af.Flll/A\V!•I' M.G.G c.152 S 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 D No C3
SECTION 12:.CONSTRUCTION COSTS.AND PERmff FEB
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee—Total Construction Cost x_(Insert here
Z Electrical $ appropriate municipal factor)a$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
ame $ � Enclose check payable to
Lb 6.Total Cost $ �L (contact municipality)and write check number here
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 my knowledge and understanding.
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Pleprint end sign n.me Title TelI CA VM 3 to a4 ephone t No. Date
Street Address City/Town State Zip
14 ,
Municipal Inspector to fill out this section upon application approval: cd 3
Name Dat