BPA-17-155 RENOV. KIT & BATH; SIDING & DOORS 4.
The Commonwealth of Massachusetts `
Department of Public Safety
."i Massachuseytts Stag Building Cade(7801 C4fR}
Building Permit Application for any Building other than a tine-or Two-Family Dwelling
(This Section For Official I,s':se
Building Permit Number: Date Applied: Building Official:
3
i SECTION I:LOCATION(Please indicate Block#and Lot#for locations for which a sheet address is not available) i
p'
1 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 0 or check all that apply in the two rows below
Existing Building 0 Repair J9 Alteration 0 Addition 0 Demolition 0 (Please fill out and submit Appendix 1)
' Change of Use 0�- Change of C-kcupancy 0 Other 0 Specify:----
Are,
pecify.--Are building plans and;or construction documents being supplied a.part of this permit application? Yes O No'ISI..
Is an Independent Structural Engineering Peer Review required? Yes 0 No 0
Brief Description of Proposed Work � �� �s �
SECTIONS 3.COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADD1-nON„,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 COIR 34) O
Existing Use Group(s): --- Proposed Use,Group(s):
SECTION 4:BUILDIN3G 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-10 A-2 0 :nightclub 0 A-3 O A-4 0 A_5 0 B. Business 0 1 E: Educational. D
F: Facto F-1 0 F2 D H.- High hazard H-10 H-2 D H-3 D 1140 H-50
I: Institutional 1-10 1-2 0 1-3 0I-40 M; Mercantile d R- Residential R-10 R-213 R-3 R4 D
S: Storage S-1 0 S-20 - U: Utility 0 Special Use D and please describe below:
Special Use:
SECTION fx CONSTRUCTION TYPE(Check as applicable)
IA IB0 IIA0 IIB 13 IIIA0 IIIBO ND VA CI VB0
i
SECTION 7.SITE INFORMAT14DN(f°efer to 780 CMR 111.0 for details on each inn)
Water Supply: Flood Zone Information; Sewage Disposal: Trench Permit: Debris Removal-
Public D Cheek if outside Flood Zone❑ Indicate mons"eipai O A trench will nj- be Licensees T>isp al Site Ll
Private 0 or indentifv Zone: or on site system 0 required D or trench or specify.
permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: I �- , I.uL c i-hn,,n1st ca ige nkm,A---,
Not Applicable D is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes 0 or No❑
I Yes D No 0 i
SECTION S:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
4
Does the building contain an Sprinkler System?: Special Stipulations:
40
Serf' c.r�
3
l
G3
SECTION 9: PROPERTY OWNER AUTHORIZATION 3
Name and Address of Property Owner
x i f _ }� - r 5 5: 1 ro m..W I 1r(l
Nam (I rmt) No.and Street City/Town Zip �
Property Owner Contact Information:
i 14
Title Telephone No.(business) Telephone No. (cell) M A a d4 rem 14
If applicable,the property owner hereby authorizes
I
Name4^ 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)
y
i (if building is les,than 35,000 cu.ft.of enclosed space and/or not under Construction C'tmtral then check here C3 and skip Section 101)
10A Registered Professional Responsible for Construction Control
n E €
s
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Name (Registrant) 1 elephone No.
. e-mail address 1 Registration Number 1
Street Address City/ToA,,n State Zip j Discipline Exp tion Date
10,2 General Contractor
r
Company Name
I } q gav
Z,, 1 �d _a i c i A 4—rLA LA—,t 3 Qa � fit$ x� c' " . �
Name of Person Responsible for Construction License No. and Type V Applicable
Street Address City/Towyn State Zip
'relephone No.tbusiness) Telephone leo.(cell) e-mail address
t
SECTION 11:tom' €ZEz4#.G.L.c.152.§,25C(6)) _
€�Workers`Compensation Insurance Affidavit from the NIA 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 a lication? Yes 0 No EI
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs_(Labor ' 1
and Nfaterials Total Construction Cost(from Item 6)=
I
1.Building S 17 sem_®
Building Permit Fee=Total Construction C=ost x (Insert here
2.Electrical appropriate municipal factor)=S
i
3.Plumbing IS +
4.�I�echanical (HVAC) 0 Alli- e.Minimum fee=S (contact municipality47,10
) 3
5.Mechanical (Other) S
1 Enclose check payable to �
n.Total Cast St x Ia tt (contact municipali y)and write check number here
SECTION 13:SIGNATURE OF BUILDING PEIL41 T APPLICANT
By entering,my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this j
application is true and accurate to the best of my knowledge and understanding.
Please print d sign name Title Telephone No, at
% . _�.r_ Mme._ " C (
r
Street Address City/Town State Zip
i 3
Municipal inspector to fill out this section upon application approval.
f Name Late