10 ABORN ST - BPA-15-1346 ROOF 11/29/2015 19:57 FAX 978 745 4822 ALLSTAR 20001/0004
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The CommonwealthS
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hfassachusetts$tite Buildinia44] E*CAR)A 10: 3b
Building Permit Application for any Building other than a On&or Two-FamUy Dwelling
r ,(This Section for Official Use Only)
VF— Building permit Number. Date Applied: Building Off clal 1Z
SECTION I-LOCATION(Please Indicate Block M and Lot A for locations for which a street adfilmu"Is not available)
No.and Street City/Town Zip Code Name of Budding(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here O or check all that apply in the Iwo rows below
Existing Building O Repair 13 1 Alteration ❑ 1 Addition 13 1 Demolition ❑ (Please fill out and submit Appendix 1)
ChangeofUse O Change of Occupancy ❑ 101her iySpecify: 6
Are building plans and/or construction documents being supplied as pan of this permit application? Yes ❑ No
Is an Ind. ndentStructuml Engineering Peer Review r�urn�i? Yes O No
Brief Description of Proposed Work• /L�llf-
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANCE IN USE OR OCCUPANCY
Check how If an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O
Existing Use Group(s): I Proposal Use Group(s):
SECTION 4.BUILDING HEIGHT AND AREA
Existing Prupawd
No.of Floors/Stories(include basement levels)6r Area Per Floor(sq.ft.) -
Total Area(sq.ft.)and Total Height(ft.) %O u�cKorle
SECTION 5:US9 CROUP(Check as app,Ikable)
A: Assembly A-1 O A-2 O Nightclub ❑ A-3 ❑ A-!O A-5 O e: Busimem E, Educational ❑
R Facto F-1 O F2❑ 1H: High Hazard H-1❑ H-2 O H-3 0 H-1❑ H-5 O
t: Institutional 1-1 O 1-2 O 1-3 O 1-4❑ M: Mercantile❑ ft, Residential R-1❑ R-2❑ R-30 R-40
S: Storage SI ❑ S-2❑ U: Utility O Spedal Use O and please describe below:
Special Use: 1
SECTION&CONSTRUCTION ,YPE(Check as applicable)
IAO 180 IIA ❑ 1180 111A r3 IIIB13 IVO I VA E3 Y80
SECTION 7:SITE INFORMATION(refer to 700 CMR 111.0 for detalls on each item)
Trench Permit Debris Remoxak
Water Supply: Flood Zone Information: Sewage Disposal• Licenxd Disposal A trench will not be per•'1 Site 0
Public O Check if outside Flood Zone O Indicate municipal❑ �
Private 0 or indenti Zane: or on site stem O required O or trench I or specify.
(Y system permit is enclosed O
Railroad rightrof-way: Hazards to Air Navigation: 1",a: �y..t��•��t!{•�xe 1'•���<
Not Applicable 0 Is Structure within airport apprw¢h area? Is their review complete j?
or Consent to Build enclosed O Yes O or No 0 Yes 0 Nu O '
SECTION 8:CONTENT OF CERTIFICATE OF( CCUPANCY
Edition of Code: Use Croup(s): Type of Construction: (k'copant LnaJ per FI~:
Does the buildingconlainan Sprinkler System?: Special Stipulations:
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11/29/2015 19:57 FAX 978 745 4822 ALLSTAR 0002/0004
SECTION 9: PROPERTY OWNER AUTHORIZATION
Nom and Addns of,PDro_perty Owner y�
CL rNeQ_ 6t-rL a .SOV /(
Name(Print) No.and Street City/Town Zip
Property Owner Contact Infonnalion:
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all natters relative to work authorized b this buildinpermit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building isle»than 35,000 cu.ft.of enclosed sPsm antiler not under Construction Control then check hen O and skip Section 10.1
1o.1 Registered Professional Responsible for Construction Control
4Registmnt42,M ) T•e h n o. mail a dr Registration Number
N7eant 3 .
Strret Address City/Town Slate Zip Discipline pirattun Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Tele hone No. ceB e-rna l address
SECTION 11:WORKERS'COhtl'E S 110 N5UKANAFFIUnvff MC.L c 1St 15C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be eompletel anJ
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the budding permit.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor -
Itemand Alntedals) Total Construction Cost(from Item 6)-5
t.Building 5 SfJ O Building Permit Fee-Total Construction Cost x_(Insert here
2.Electrical S appropriate municipal factor)
3.Plumbing $ Note:Minimum fee-S (contact municipality)
4.Mechanical (HVAC) 5T 0
S.Mechanical Other S Enclose check payable toy )J))
6.Total Cost S (contact munici all )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 pedury that all of the information containml in this
application is true.nd accurate to the best of my knowledge and understanding.
Pleue`ri and sign/�// '' Title Telephone No. Dare
Sireat Address City/Town /State Zip
Municipal Inspectorto fill out this section upon application approval•
Name �''�