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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 it and Lot 0 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
Edition of MA State Code used if New Construction check here lE"or check all that apply in the two rows below
Existing Building 0 Repair 0 Alteration 0 Addition❑ Demolition 0 (Please fill out and submit Appendix])
Change of Use 0 Change of Occupancy 0 Other lir Specify: 7iti,4/41617i _
Are building plans and/or construction documents being supplied as part of this permit application? Yes ,Er No 0
Is an Independent Structural Engineering Peer Review required? Yes 0 No JR
Brief Description of Proposed Work: i�s�-//f7�C.'? �` 77vO 70:k d 7/i2(S.
De !r) o'V Tare c// " 1-/4.971:ry S1,eR Eew,4r/-41�_t'-S L✓;>✓<J
f e S ftc 1-i., ? s- - er c cr /-9.-77 T
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) D
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 0 A-2 0 Nightclub 0 A-3 0 A-4 0 A-5 0 B: Business 0 E: Educational 0
F: Factory F-1 0 F2 0 H: High Hazard H-1 O H-2 0 H-3 0 H4❑ H-5 0
I: Institutional 1-1 0 1-2 D I-3❑ f-4❑ M: Mercantile 0 R Residential R-1❑ R-2 0 R-3 0 R-4 0
S: Storage S-1 0 S-2 D U: Utility 0 Special Use 0 and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIAD MBD rv ❑ VAD 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:
A trench will not be Licensed Disposal Site 0
Public 0 Check if outside Flood Zone 0 Indicate municipal❑ required 0 or trench or specify:
Private 0 or indentify Zone: or on site system 0 permit is enclosed 0
Railroad right-of-way: Hazards to Air Navigation: MA Historic:Commissi,in Review Process:
•
Not Applicable 0 Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No D 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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1 7/s- 61,04 W ,709
tAc(- !- . 0 17 o �o
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
492/547e S.V4/4.s -
me(Print) No and Street City/Town Zip
Property Owner Contact Information
Title Telephone No.(business) Telephone No. (tell) e-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 aU matters relative to work authorized by this budding permit application.
SECTION ilk CONSTRUCTION CONTROL(Please fill out Appendix 2)
Of buildisjls lees than 36,000 cv ft,of enclosed space and/or not under Constnu tion Control then check here D and skip Section 10.1)
10.1 Registered Professional Responsible for Constructing Control
alit* I j[ap no,. 12L-F1S9 - /y>4 naura eAn @art 1 T ,9-8ota't
Name(Registrant) Telephone No. e-mail address ration Number
io$3 t/ fur �QlaivOr. irrs - ix s Slew
Street Address City/Town State Zip Discipline Exp
102 General Contractor
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Company Name woiPfW cyos/
. 2 f!Jyf'& 67„; T/Ile PSe Cs-0691Yv C'ONt-1--t 4b,1 ,Svf^itfv..ro,
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
-?2`L-6- g.'( - - FX RS Pip Co cnsr./I e r
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:11'ORKERS'COMPENSATION INSURANCE AFFIDAVIT`(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 tte issuance of the building permit.
Is a signed Affidavit"submitted with this application? Yes orNo 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FETE
Item Estimated Costs (Labor (pied ��
and Materials) Total Construction Cost(from Item 6)0 S
1.Buikii% S Building Permit Fee o Total Construction Cost x f1 .(Insert here
2.Electrical S appropriate municipal factor)O S (U--
3.Plumbing $
4.Mechanical (1IVAC) $ Note:Minimum fee-S (contact municipality)
5.Mechanical (Other) $ Enclose check payable to C1y OF 5,442/ / ,
•
6.Total Cost $�t3. Q )-2 (contact municipality)and write check timber here Y dCe(¢i ,
SECTION 12 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 an this
ap Ucation is true and accurate to the best of my knowledge and understanding.
Pei /- cis-y%.,A.�;✓is Q'./ef r� k6- J P- 4 6 /t/*
Please print and sign name rTitle Jelephone No. Date
Street Address City/Town State Zip
Munldpal Inspector to fill out this section upon application approval:
-:.‘*1 aevt.;,, /o/e/
Name Date