120 SWAMPSCOTT RD - BUILDING INSPECTION � zs
h� 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)
( Budding Permit Number: Date Applied: _Building Official:
'n SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)_
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n No.and Street City/Town Zip Code Name of Building(if applicZ e) n
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�J SECTION •PROPOSED WORK o
I Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rs below,,�n
Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Ap ndix rn
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
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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 ❑ N gK m
Brief Description of Proposed Work:
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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): IProposed 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 a plicable) - -
A: Assembly A-1[3A-2 13Nightclub ❑ A-3 ❑ A=1 C3 A-5 C3B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑. H-3 13H-4 13H-5 131: Institutional I-1 ❑ 1-2❑ I-3❑ I-4❑ M: Mercantile C3 R: Residential R-113 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 18 ❑ IIA ❑ IIB ❑ IIIA ❑ . HIB ❑ 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 Disposal Site❑
Private❑ or indentify Zone: or on site system❑ required Cl or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: ;NIA I listorjy:_Conupicaiun Uoview Pnxc_s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Budd enclosed❑ 1 Yes❑ or No 0 1 1Yes❑- No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Coale: Use Group(s): Type of Construction: Occupant Load per Floor:
Dues the building contain an Sprinkler System?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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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)
Of building is less than 35,OW 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 - -
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O Name(Registrant) Telephone No.
e-mail address Registration Number
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Street Address City/Town 141( - �1-,;t to Zip Discipline E pita ion Date
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10.2 General Contractor-
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Company Name
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OName of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
Telephone No. business Telephone No. celle-mail address
SECTION 11:WORKERS'COnMENSAI10N INSURANCE.A1+11)AVr1' 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 Cl
- 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 $ Enclose check payable to
6.Total Cost $ ct/i (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 o knowledge an d s tndfng.
Please print and sign name Till Telephone No. Date
Street Address City/Town State Zip
OMunicipal Inspector to fill out this section upon application approval: '
Name Date