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BPA-17-157 ADD 3 OFFICES c . V The Commonwealth of Massa e s Department of PuNQ-*ARy 3 WMassachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling v� (This Section For Official Use Only). Building Permit Number: Date Applied: Building Official: 1 SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not-available) 2? /fwrAae-^ c A • fe//`csw OIf�G tffZ*mf-i`c G'o�J1 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2•PROPOSED WORK. Edition of MA State Code used If New Co ruction check here❑or check all that apply in the two rows below Existing Building T1Repair❑ 1 Alteration Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy O 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 required? Yes ❑ No E3Brief Description of Proposed Work: 3 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 S.USE GROUP(Check as applicable) I A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 O A4❑ A-5 O B: Business ❑ TE: Educational 13j F: FactoF-1 E3F2[3H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ 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-20 U. Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IVO VA ❑ VB 13 SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Trench Permit: Debris Removal: Water Supply: Flood Zone information: Sewage Disposal: Licensed Disposal Site 13Public Check if outside Flood Zone❑ Indicate municipal A trench will not Po required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: NIA I listoric_Commission Keyitn...Pnxcs: 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: m a i Ltd q-O G.e,. 3 I L SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Xt ke _2,2- Name 2,2Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 57 Title Telephone No.(business) Telephone No. (cell) e-mail address Ifaplicable,the property owner hereby authorizes /1*0-4-eY J2>4 46�' W-- .sr'— s'a1/-cam ©l rr10 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. SECTION 10.CONSTRUCTION CONTROL(Please All out Appendix 2): buildingis less than 35,000 cu.ft of enclosed space and or not under Constmction Control then check here 0 and ski Section 10.1 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10:2 General Contractor Com any Name 5o4 r✓ /�`9�t�G LjJ' �0517 Name of Person Res risible for Construction License No. and Type if Applicable Street Address City/Town State Zip 92t `w,�O yc/-, _ Sc //02.,-�<�—;-) y1 0 r//,! e Telephone No.(business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPEN TION INSURANC.F Ai-'FIL)AVf 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 issuance of the building permit. Is a signed Affidavit submitted with this application? Yes O No O SECTION 12:.CONSTRUCTION COSTS.AND PERMIT FEE Item Estimated Costs:(Labor and Materials) otal Construction Cost(from Item 6)_$�r 1.Building $ Building Permit Fee=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 $ leo©Cl (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 t h my knowledge.and understanding. Please print and sign name Title Telephone No. Date 249 4-2dvr Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: 4t-"o None Dat