B-17-380 - 0020 AMERICA WAY - Building Permit �7
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
J Y 0 (This Section For Official Use Only) _
Building Permit Number: Date Applied e Building,OffieiaL '
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SECTION 1:LOCATION(Please niiicate Block#arid Lot#for locations for'-whit-h a street address is of availabie)
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No.and Street \ ty/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 ❑ (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 Engineer Peer Review required? Yes ❑ No
Brief Descrip 'on of Proposed Work: I `�
`SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION;ADDITION;OR -
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CHANGE IN USE OR OCCUPANCYf,
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 AREAS,_" .
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
n SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I:. Institutional 1-1❑ I-2❑ I-3❑ I-4❑ M: 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:
3- SECTION 6:-CONSTRUCTION TYPE.(Check'as applicable)
IA IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 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 G or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-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❑ or No❑ Yes❑ No ❑
SECTION8: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
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 4ut'Appendix 2)
f 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 foi Construction Control`
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Name(Registrant) Telephone No. e-mail address Regis •ation Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Cojnpany Name
Name of Person 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 e-mail address
. . SECTION 11:WORKERS'<COMPENSATIOMN5uRANCE AFFIDAVLTr 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 oft e' suance 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 $ qU•0 u
Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ I appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (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 of my knowledge and understanding.
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Please print and si name Title Telephone No. Date
Street A dress City/Town State Zip
Municipal Inspector to fill out this section upon application approval: "'
Name `. Date