3 1/2 BECKET AVE - BPA-16-1110 ROOF IbS C-K
The Commonwealth of Massachusetts
Department of Public Safety 9
Massachusetts State Building Code(780 CNIR) 10lb' SEP Z8 A 8. 31
n Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
T Building Permit Number: Date Applied: Building Official:
19 SECTION 1:LOCATION (Please indicate Block#and Lot#for locations for which a street address is not available)
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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 Alteration ❑ Addition❑ Demolition 0 (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 Pee eview required? (( /� Yes ❑ No �
Brief Descri tion of Proposed bV- T i l i
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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)k-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❑ j B: Business ❑ E: Educational ❑
F: Factor F-1. ❑ F2❑ H: High Huard H-1 ❑ H-2❑ H-3 ❑ FI-4❑ FI-5 El
I: Institutional 1-1 El 1-2❑ 1-3❑ 1-4 11M: Mercantile ❑ R: Residential R-10 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 11 IIB ❑ IIIA ❑ IIIB ❑ IV 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:
Public ❑ Check if outside Flood Zone❑ Indicate municipal 11A trench will not be Licensed Disposal Site ❑
Private❑ or indentify Zone: or on site system❑ required 13 or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: NIA 1-fi,tone Commission Review Prow ,s:
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:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Oryner
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Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: / ]
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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 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 s ace and/or not under Construction Control then check here❑and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
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- Name egistrant Telepho ne No. e-mail address Registration Number
Street Address /City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Compal Name
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Name of P5von Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
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Telephone No. business Telephone No. (cell) a-mail address
SECTION 11:WORKERS'CONIPEIVSArFION NSL'RANCE ATFIDAVIT 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 ' uance 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 $ q 6 019.00 Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
-1. Mechanical (HVAC) $ Note: Minimum fee=$ (contact III umc nal ))
5. Mechanical (Other) $ Enclose check payable to M
6.Total Cost $ ) N) 6 O (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 tru�eand accurate to the best of my knowledge and understanding.
17 i a-�b i i1y1'/1 e/' Gam'- 300 47//
Please print and si n n,me Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: h • b O/U�ll
Name Date