B-17-381 - 0020 AMERICA WAY - Building Permit The Commonwealth of Massachusetts
Department of Public Safety
���Q,• 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#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
I
^ SECTION 2:PROPOSED WORK
IV`1; Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building Repai 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 Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: ( X l Znn t L OC{1M C
t I-,(L. e C I t I tivn� h
&I c itifi.
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-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Factor F-1 ❑ F2❑ H: High Hazard FI-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ 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:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ IIB ❑ -T 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 Disposal Site❑
Private❑ or ind required ❑or trench or specify:entify Zone: or on site system ❑ permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: NIA 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 ❑
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:
SECTION 9:'PROPERTY OWNER AUTHORIZATION
_
Name and Address of Property Owner
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Name(Fruit) No.and Street City/Town Zip
Property Owner Contact Information:OWYl "DU _ 1�'Y� f e.+
Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the prope owner hereby authorizes
vwnrmW a fi y
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(I'lease fill out Appendix 2) s _
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If buildui is less than 35,000 cu.ft o enclosed s ace andJornot under Construction ControLthen checkhere❑and ski Section WA
10.1 Re stered Professional Res`onsible for Constriictiori
" Control �.w
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
� - - � � � d
10.2 General Contractor g
Company Name
Name of Person Responsible for Construction License No. and type if Applicable
Street Address City/Town State Zip
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Telephone No. business Telephone No. cell e-mail address
SECTION 11 WORKERS'-COMP, ON=LNSIJ RAN gE 1�FFIDA�IT<(M.G.L:
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? YeORP No ❑
f k wA427 SECTION 12:CONSTRUCTIONCOSTS:AND,PERMIT
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ I h l
Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ wo, appropriate municipal factor)_$
3.Plumbing $ To
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $
Enclose check payable to
6.Total Cost $ )L4 65 0 o DO (contact municipality)and write check number here
"SECTION 13:SIGNATURE OF BUILDING TERMIf PniCANT
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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lease tint and signpame. Title Telephone No. Date
Street Address City/Town State" Zip
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Municipal Inspector to fill out this section upon application approvalJf
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