0005 NICHOLS STREET (1B COLONIAL TERR) BPA-17-172 S ' u?
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The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CjV�•R�
^ Building Permit Application for any Building other than-a4A` j'�yt�Fam�,welling
(This Section For Official Use Onl-) ,
Building Permit Number: Date Applied: Buildin i
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is n available)
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No.and Street City/Town Zip Code Name of Building(if applicable) I
SECTION 2 PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that aPPY�1 the two rows below
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Existing Building❑ Repair OvAlteration ❑ Addition❑ 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 W
Is an Independent Structural Engineering Peer Review required? Yes ❑ No RP
Brief Description of Pr posed Work:
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SECTION 3:COMPLETE THIS SECTION IF EXISTING 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 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❑ 11: High IIazard I I-1 ❑ IT n_1 ❑ 1 i-3 ❑ I I-4❑ I I-5❑
I: Institutional 1-1❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage 5-1 ❑ S-2❑ U: utility-u'l Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IIA ❑ AM❑ B ❑ IIV VVB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: I 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 indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Hiskiric Commission Review Process:
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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Pro erty Owner
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Name(Pr' t) No.and Street City/Town
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P operty wner on t Information:
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Title-
Telephone No.(business) Telephone No. (cell) -e-mail address
If applicable,the property owner hereby authorizes
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Name Street Address s City/Town State Zip
to act on the ro erty owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buddinR is less than 35,000 cu.ft.of enclosed ace and/or not under Construction Control then check here❑and Acip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
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Name(Registrant) I -
( g ) Tele hone No. a-mail address ReRS ' tration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Company Name -
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Name
me of Person Responsible for Construction License No. and Type Applicable
Street AdUress City/Town State Zip
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Telephone No. usiness) Telephone No. celle-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT 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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ U
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ (,. ) appropriate municipal factor)_$
3.Plumbing $ (r.)
4.Mechanical (HVAC) $ Note:Minimum fee=$ (cont ct municipality)
5.Mechanical (Other) $ Enclose check payable to
b.Total Cost $ S .F
(contact municipality)and wri4checumber ere
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.
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rint and sign name Tide Telephone No. Date
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Street Add ess City/Town State Zip
Municipal Inspector to fill out this section upon application approval: V'
Name Date