1 KERNWOOD ST - BPA - TENT The Commonwealth of Massachusettsk'4'
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-FamiY`Ny AuRg,12.
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
( SECTION 1:LOCATION(Please indicate Block#and
dLLot#for locations for
which a street address is not available)
No.and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
L Edition of MA State Code used If New Construction check here O 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 0 Specify: Zell !G
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Rev' w requj�ed? Yes ❑ No ❑
Brief Description of Proposed Work:,/ �PfT �— .,7 lc'a7-5+ �- �.�X'-?j %em 0"?��Y
Sa nol /o i 1, Rrn /e 7271'A
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-3g--A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ 1-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage Sl❑ 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 ❑ 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:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disp a ❑
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad Light-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 O 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 Owner
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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) e-mail address
appl}}'cable,the pr erty owner here y authorizes /
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Name Street Address City/Town State Zip
to act on the propertv 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 Constmction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2,f.eneral Contractor
C„oWanyName
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Name off n Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
7p/ ;?I)- Vgzro _
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVITT 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 O No O
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 $ i- — Enclose check payable to
6.Total Cost $ ,S (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
a atio� is true and accurate to the best my wledge and understanding.� 2�2a
74e pritnt.,"e44� u,: itle �n Bleph o' Date
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Street Address City/Town i State Zip
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Municipal Inspector to fill out this section upon application approval: -'�> ��<�'
Name Date
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II(( 3 Imagery Date: 5/10/2015 42032'79.22" N 70054'16.19"W elev 53 ft