0010 LINDEN STREET BPA-17-210The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)Ulf
Building Permit Application for any Building other than a One-or Two-Family Djelling
This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not awlable 4
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No.and Street City/Town Zip Code Name of Building(if applic>e) rr9
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here or check all that apply in the two rowd beloiw:'
Existing Building Q' Repair Alteration 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 11No
Is an Independent Structural Engineering Peer Review required? Yes No
Brief Description of Proposed Work: A- U l np 15, 1.,AC 4% e 3.*cz,ov- s-h-,fta-e—
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 1 B: Business E: Educational
F: Facto F-1 F2 H: High Hazard H-1 H-2 H-3 H-4 H-5
I: Institutional I-1 I-2 1-3 1-4 M: Mercantile R: Residential R-113 R-2 R-3 R-4
S: Storage S-1 S-2 U: Utility Special Use and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB IIA IIB IIIA IIIB IV VA VB
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:itPerm :Water Supply: Flood Zone Information:Sewage Disposal: TrenchLicensed Disposal Site
Public 11 Check if outside Flood Zone Indicate municipal
A trench will not be P
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 Historic 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 Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail adcMsi
If applicable,the property owner hereby authorizes
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 permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here and 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 Contractor
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Company Company Name
A s,luw,o C: S - Io6N62
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address V I
City/Town State Zip
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Telephone No. business Telephone No. cell e-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 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 15,a--f) 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 of m knowledge and understanding.
3
Please print and sign name Title Telephone No.Date
wL
MA
Street Address City/TownState Zip
9 IMunicipalInspectortofilloutthissectionuponapplicationapproval:
U , 3
Name Date