B-12-869 REPLACE ROOFTOP HVAC UNITS Fr..,
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The Commonwealth of Massachusetts
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Department of Public Safe • '
f` Massachusetts State Building Code Si)i CN R)
"'` Building Permit Application for any Building other th n a O, • q r'1'- Nat'l veiling
(This Section For Official Use Only)
~Building Permit Number: _.___-__ __ Date Applied: _ ____ Buiidin -i' a _
SEC PION 1:LOCATION(Please indicate Block M and Lot I fur locations f` vhich a street a dress i r ailab
•f No.and Street City/[own Zip Code Name of Building(if applicable)
f .
Via. SECT ION 2:PROPOSED WORK- — — __�_ 4:-
klition of NIA State C de used_____ If New Construction:heck here O or check all that apply in the two rows below....- • „ -
Existing Building l' Repair 0 , :Alteration ❑ i Addition 0 Demolition 0 (Please till out and submit:Appendix I) `" ••-_
Change of Use . 0 Change of Occupancy Cl Other 0 Specify: - _______
Are building plans and/or construction documents being supplied as part of this permit application? Yes C No 0
Is an Independent Structural Engineering Peer Review required? `/ Yes 0 No C
Brief Description of Proposed Work:.___- /Q6i1Jls-(p tt'ooi -rya //€'44- fRC‘wPA �s �y�
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here Ban Existing Building Investigation and Evaluation is enclosed(See 780 CNIR.34) 0
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-I❑ A-5❑A . B: Business 0 1 E: Educational ❑
I:: Factory rF-1 ❑ F2❑ II: High Haz.ud H-1 0 H-2 0 H-z 0 11-4 0 1-I-3 0
I: Institutional I-1 0 1-2 0 1-3❑ t--I O M: Mercantile 0 R: Residential R-1❑ R-2 O R-3❑ R-I O
S: Storage 5-1 0 S-2❑ U: Utility❑ I Special Use O and please describe below:
Special Use .
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA 0 IBO IIA ❑ 11B 0 WA BIB IV 0 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 0 Chock if outside Flood Zone 0 Indicate municipal❑
\trench will not beLicensed Disposal Site 0
required 0 or trunch or specify:.-...___.._. _
Private 0 or indentits tone: _.^_T or on site system O precool is enclosed 0
Railroad right-of-way: H.ttards to Air Navigation:
Not Applicable 0 Is Structure within airport approach area' Is their review completed'
or Consemtt to Budd enclosed 0 l es 0 or Non 1'e.0 No CI J
SECT ION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
I'd Mon of Code: . ._ , UseGrooip(>): _ . 1%peof Construction: l)iinpT.11lt Load per floor
I)ors the building;contain.an tipnnkler System'• . special Stipulations: . _
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i \441,L..._ 1761(4-1-1-4.i .
1 _ .
SI:C•I'lON 9: 1'ROI'l RTY OWNER AU'1•IIORIZA•rION
Name atop Address of I'rop t rty owner `
Nano(Print) No.and Street City/Town Lip
•
Properly Owner Contact Information:
rifle Telephone No.(business) Telephone No. (cell) • e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
toact 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)
L building is less than 35,0al cu.ft.of enclosed space and/or not under Constriction Control then check here 0 and skip Section IU.IL
r t0.1 Registered Professional Responsible for Construction Control
6',V.,6h Jp(✓Ifol' -;) set--nS. se/33
Name(Registrant) 14, pT�elcpho e No. e-mail address Registration Number
/14 Iv.,c6 tL'S�cs- 1 r.o /S Yt'r /�,t Ots1-3
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
//A C,66 S.Xr ..
Company Name
;m, des Ag G.,/ ^ ;7 9 a-q
Name of Person Responsible for Construction License No. and Type if Applicable
6.10 Ivor Cc..C"A WAS{ /moo.— ,tees p /58-3
Street Address City/Town State Zip
,Soc-/WI 9/33 Sob' .50`/_ SS 77
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:)n:(1.{(.ii:,14 c.)Nil �;.‘ru!�iy:.).11.�.\c t .‘i l II I,\V U (M.G.L.c.152.4 25C(6)1
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 wilt result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes 0 No 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)-
I. Building S Building Permit Fee-Total Construction Cost x (Insert here
2. Electrical S appropriate municipal factor)-`S
i, Plumbing
4. Nferh,mical (HVAC) S Note:Minimum fee-$ —(contact municipality)
3. Mechanical (Other) S
6.Total Cost 3 Enclose check payable to
PG o (contact municipalitti)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
liv entering my name below, I hereby attest under thy pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
Noose print and cign Haute ---- Title —�—_ Telephone No. Date-
titrret Address City/rows State Zip
Municipal Inspector to fill out this section upon application approval:
Date