BPA-17-217 The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(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-available)
g°a' I_Inrl-n� Ave-,,, Safernlc� 9 7a
' 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❑or check all that apply in the two rows below
Existing Building❑ Repair K I Alteration ❑ Addition❑ I 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 UK
Is an independent Structural Engineerin eer Review requir ? Yes ❑ No
Brief Description of Proposed
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): IProposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) i
Total Area(sq.ft.)and Total Height(ft.)
SECTION S.USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A—1❑ A-5❑ 1 B: Business Wr 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❑ 14❑ M: Mercantile❑ 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 111 E3 IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV C3 VA ❑ VB 13
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Licensed Dis osal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ trench will not p
Private❑ or indentify Zone: or on site system 13ree trench
❑or trencc h or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA 1 Listoric Cominksion Review Vr ceis:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ 1 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:
t � R
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
n
ty Ow er Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-m d address
If aTa le,�erAoft,powner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owners behalf,in all matters relative to work authorized by this building permit application.
SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2). .
f buildi.ng is less than 35,000 cu.ft.of enclosed s 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) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
eneral Contractor
�g� I -t`-J
M
Name
►io-
Name of Person Responsibor Construction License No. and Type if Applicable
*,LdL — 1-w Q15 Z
Street Address Ci Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDA I'I' M.G.L.c.152 9 29C(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[3 No'M—
SECTION 11.CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor p
Item and Materials) Total Construction Cost(from Item 6)
1.Building $ °fid Building Permit Fee-Total Construction Cost x_(Insert here
Z Electrical $ appropriate municipal factor)s$
3.Plumbing $
4.NIechanical (HVAC) $ Note:Minimum fee $ (contact municipality
5.Mechanical Other $ Enclose check payable to �Y
4
6.Total Cost $ (contact municipality)and write check number here �Y^
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 6
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this
ation is true urate to the best o y owledge and understanding.
r-. IOC -�- � 3—zF)
Please print Kd sign name Title Telephone No. Date
Stibet Address City/Town AA tate Zip
Municipal Inspector to fill out this section upon application approval•
Name Date
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