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BPA-17-162 UNIT 303 c.�--- 19o8 The Commonwealth of+� Department of Public Safety Massachusetts State Building CodedSI ' �� Building Permit Application for any Building other th a welling (rhis.Secdon For Official Use Only)' Building Permit Number. Date Applied: Builg Offficial: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) -AS 5 *303 .fie I No.and Street City/Town Zip Code Name of Building(if applicable) ISECTION 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❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No D Is an Independent Structural Engineering P r Review required? es D N ❑ Brief 1ption of Proposed Work: 41 l Viq..g `n Q� o t v-C l sur 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) 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 O 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 IBO IIA ❑ IIB ❑ IIIA0 1118 E3 IV E3 VA ❑ VB 13 SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information:: Sewage Disposal: Trench Permit: Debris Removal: A trench will not be Licensed Disposal Site❑ Public Check if outside Flood Zone❑ Indicate municipal❑ required❑or trench or specify: Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: 41A i listoric Commission Rtzyiew 1'nke±s: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION&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: rKa4 o(",) rflk4/0 SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner eL Name(Print) No.and Street 'City/Town ( Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes '' JJ -Sgi©S � 1t-7 GFSS s�i�' veI14 of 9/!�- Name Street Address City/To n State Zip to act on the property owner's behalf,in all matters relative to work authorized by thisbuilding rmit application. SECTION 10.CONSTRUCTION CONTROL(PIease fill out Appendix 2): budding is less than 35,000 cu.ft.of enclosedspaciand or not under Construction Control then check here O end skip 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 1Contractor n Company Name Name of Person Responsible for Cons ction License No. and Type if Applicable J1q Street Address city/T6wn State Zip qT-3-27- 840 in we 05 onQaw O'l 1-• co KA Telephone No.(business) Telephone No. cella-muiil address SECTION 11:W RKEh'S'C0MPENSA'1'101N INSURANCE AFFIDAVU M.G.L.c.152 9 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 Er'No E3 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ rs300 Building Permit Fee a Total Construction Cost x_(Insert here 2.Electrical $ 3.00 0" appropriate municipal factor)�$ 3.Plumbing $ OOO 1.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality 5.Mechanical Other $ Enclose check payable to , 6.Total Cost $ O�' (contact municipali )and write check number here` SECTI 13.SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below,I hereb t st under the pains and penalties of perjury that all of the information contained in this application is true and accurate to thtpe4t of my knowledge.and understanding. C.4re, _# Please print and sign na e � � �-- " ' p g 1 Title Telephone No. Date Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval• Name Dat