BPA-17-168 REMODEL KITCHEN u` The Commonwealth of Massachug6 t$, F
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Department of Public Safety
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Massachusetts State Building Code(780 {{ l,�t� ' 1 :'?
Building Permit Application for any Building other than a One-or Two-Family Dwelling
Qo Building Permit Number:
(This Section For Official Use Only)Date Applied: I Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street 7 City/Town Sat/,eM Zip Code D r,17,0 Name of Building(if applicable) Al
SECTION 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 Alteration ❑ Addition❑ 1 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 ❑
Is an Independent Structural Engineering Peer Review required? , Yes ❑ No at"
Brief Descrip`ion of Proposed Work: t 0 cAC
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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❑ 1 B: Business ❑ E: Educational ❑
F. Facto F-1❑ F2❑ H: High Hazard H-1 13H-2 El H-3 ❑ H-4 13H-5 11I: Institutional 1-1 [3I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U. Utility❑ T Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable) Uj flq
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
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:
PublicA trench wil not be Licensed Disposal Site❑
Cain Check if outside Flood Zone❑ Indicate municipal
Private❑ or indentify Zone: or on site system 13 required or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic_Commission Ret-iew 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:
M ,%. -o( 1(,, TD Q7 L
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
vim .• r
Title Telephone No. (business) Telephone No. (cell) e-mail acgress
-I-ffaapplicable,the
jpropertow
ner hereby authorizes
Name Street Address City/ own State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building ern-it 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 O and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control /
Name(Registrant) ,Tjlephone No. e-mai addres Registration Number
Street Address City/Town State Zip Discipline Expiration ate
10.22 General Contractor
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Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/To n State Zip
97-9--.7t i'g-,Zi?
Telephone No. (business) Telephone No. (cell) e-mail addk4s
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 ince of the building permit.
Is a signed Affidavit submitted with this application? Yes 01 No 0
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 $ ��
S� appropriate municipal factor)_$
3.Plumbing $ C>t czv
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact i ity)
5.Mechanical (Other) $ �i�
Enclose check payable to
6.Total Cost $ :2 `�` (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 my knowledge and understanding/.
Please print and sign name �, Title Telephone No. Date
Street Address City own State Zip
Municipal Inspector to fill out this section upon application approval: (X'f
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Naive Date
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All dimensions-size designations This is an original design and must Designed: 12/7/2016
given are subject to verification on not be released or copied unless Printed: 12/9/2016
job site and adjustment to fit job � �^ applicable fee has been paid or job
conditions. 0 order placed.
KBelisle Kitchen Layout All Drawing#: 1 I No Scale.